Chapter 30 Ear Pain/Otitis Media
ETIOLOGY
What Causes Ear Pain?
Ear pain is a frequent and persistent symptom of acute otitis media (AOM), the most common illness prompting a visit to a physician. Ear pain often develops without AOM in a child who has an upper respiratory infection with obstructed or poorly functioning eustachian tubes or during air travel when pressure change within the middle ear causes acute retraction or bulging of the tympanic membrane. Pain that worsens when the external ear is touched or moved usually reflects otitis externa, which often has an associated purulent discharge (“swimmer’s ear”). An adolescent may have an inflammatory acne lesion within the ear canal that causes pain. Trauma to the ear canal or tympanic membrane by a cotton-tipped applicator or another foreign object can cause pain. Pain can be referred from teeth, a parotid gland, lymph nodes, or the temporomandibular joint and cause a child to describe “ear” pain or to rub or tug at the ear. Caries and dental abscesses are particularly common in children who have poor dental hygiene. Eruption of the first primary molars also can cause referred pain to the area of the ear. Mastoiditis is a rare but dangerous cause of ear pain and fever.
What Is Acute Otitis Media?
AOM represents infection of the middle ear cavity, usually before age 6 years, most often in the first 2 years of life. AOM is usually preceded or accompanied by viral upper respiratory infection. Children in daycare, preschool, play groups, school, or even large families have the highest risk for AOM. Rates of AOM are higher among children who live in homes where exposure to cigarette smoke occurs. Formula-fed infants have higher rates of AOM than do breast-fed infants, but any protective effect of breast-feeding is partial and lasts only as long as the infant is exclusively breast-fed. Other risk factors for AOM include prior episodes of AOM, antibiotic use in the previous 30 days, prolonged bottle feeding (especially beyond age 12 months), frequent use of a pacifier, and lower socioeconomic status. Children with Down syndrome and cleft palate have high rates of AOM, likely because of structural problems with the eustachian tubes. Immune deficiency may be first identified because of excessive or complicated episodes of AOM.
What Infectious Agents Cause Acute Otitis Media?
Viral infections produce inflammation, mucosal edema, and eustachian tube obstruction and dysfunction that promote bacterial infection of the middle ear and development of symptomatic AOM. Bacterial pathogens can be detected in 70% to 90% of children who have physical examination findings consistent with AOM. Bacteria identified include Streptococcus pneumoniae (∼40%), nontypeable strains of Haemophilus influenzae (∼30%), Moraxella catarrhalis (10% to 20%), and, much less commonly, Streptococcus pyogenes and Staphylococcus aureus. The precise bacterial cause of AOM for an individual patient must be inferred from community data because routine cultures are not recommended. The conjugate pneumococcal vaccine (PCV-7) has been shown to reduce the nasal carriage of S. pneumoniae and the incidence of AOM caused by the strains covered by this vaccine. H. influenzae type B is not a common cause of AOM, so the Hib vaccine has had little impact on AOM incidence.
How Often Does Antibiotic Resistance Occur?
Resistance to commonly used antibiotics has been increasing at an alarming rate worldwide for all of the major bacterial causes of AOM. Thirty percent to 50% of S. pneumoniae show resistance to one or more antibiotics, including penicillins, cephalosporins, macrolides, and trimethoprim-sulfamethoxazole. Up to 50% of H. influenzae are resistant to beta-lactam antibiotics, as are almost all isolates of M. catarrhalis, depending on the geographic region. Hence, resistant organisms have markedly altered treatment recommendations and have prompted reappraisal of the use of antibiotics for uncomplicated AOM.
EVALUATION
Does Ear Pain Always Mean Acute Otitis Media?
Ear pain is often overinterpreted by parents and physicians as indicating AOM. The diagnosis of AOM should only be made after careful assessment. AOM is a likely diagnosis when ear pain occurs in a child younger than 6 during an upper respiratory infection, especially when accompanied by fever. Occasionally a child will have ear pain followed by rapid resolution of pain at the time that a purulent drainage appears in the ear canal. This usually represents tympanic membrane rupture caused by AOM.
How Does History Help Identify the Cause of Ear Pain?
Ear pain is most evident when a verbal child tells you which ear hurts, when the pain started, and provides a description of the pain and what elicits it. The preverbal infant or toddler may cry, whimper, or rub and tug at the involved ear. Parents can describe the behavioral and sleep changes that they interpret as indicative of pain, especially if these symptoms have accompanied previous episodes of AOM in the child or a sibling. You need to identify details of the pain: onset, location, duration, and change over time. Ask about associated symptoms and signs, especially fever, upper respiratory infection, and otorrhea. It is important to document immunization status, as widespread use of the conjugate vaccine for S. pneumoniae has reduced the rates of AOM. Inquire about risk factors such as exposure to tobacco smoke, attendance at daycare, any known trauma to the ear, and specific inciting causes such as swimming, air travel, acne, and insertion of cotton swabs in the ear canal. An “otitis-prone” child may have a past history of frequent AOM or of chronic middle ear effusion with accompanying conductive hearing loss and delayed language development. Listening to the child’s speech will allow you to assess language development. You must understand development to interpret language skills, identify behaviors that might cause injury, and look for dental eruption as a cause of pain. Knowledge of risks associated with structural abnormalities (e.g., cleft palate) or syndromes will ensure that you consider appropriate issues during patient evaluation.
How Should I Examine a Child with Ear Pain?
Measure body temperature and look for “toxicity” (see Chapter 33). Identify patients who have high rates of AOM, including those with cleft palate, Down syndrome, and Treacher Collins syndrome. In addition, examine the nose, mouth, teeth, and lymph nodes. Finally, examine the ears. A successful examination of the ear requires assistance from the parent or caregiver to help stabilize the child’s head and body (Figure 30-1). You must have experience with examination of the healthy ear, especially the examination of the tympanic membrane using a pneumatic otoscope (see Chapter 5). Use a checklist to guide your examination of the ears (Table 30-1).
Figure 30-1 Three ways to position the infant or child for examination of the ear.
From Berkowitz CD: Pediatrics: a primary care approach, Philadelphia, 2000, WB Saunders, p 220.
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