Introduction
Earache (otalgia) is pain that arises from a pathologic process in the external, middle, or inner ear or that is referred to the ear from another structure. Acute otitis media (AOM) is the most common cause of otalgia in children ( Tables 4.1 and 4.2 ). At least 80% of children will experience one or more episodes of AOM in the first three years of life. The second most common cause of ear pain is otitis externa, followed by dermatitis and infections of the pinna (see Table 4.1 ). Other causes of otalgia are rare ( Table 4.3 ). A careful examination of the pinna, external auditory canal, and tympanic membrane can help the clinician identify most causes of ear pain. When the findings are normal, the clinician should consider referred pain ( Table 4.4 ).
| Disorder | Clinical Features |
|---|---|
| Acute otitis externa | Diffuse redness, swelling, and pain of the canal with greenish to whitish exudate; often very tender pinna |
| Malignant otitis externa | Rapidly progressive, severe swelling and redness of pinna; pinna may be laterally displaced |
| Dermatitis | |
| Eczema | History of atopy, presence of lesions elsewhere; lesions are scaly, red, pruritic, and weeping |
| Contact | History of cosmetic use or irritant exposure; lesions are scaly, red, pruritic, and weeping |
| Seborrhea | Scaly, red, papular dermatitis; scalp may have thick, yellow scales |
| Psoriasis | History or presence of psoriasis elsewhere; erythematous papules that coalesce into thick, white plaques |
| Cellulitis | Diffuse redness, tenderness, and swelling of the pinna |
| Furuncles | Red, tender papules in areas with hair follicles (distal third of the ear canal) |
| Infected periauricular cyst | Discrete, palpable lesions; history of previous swelling at same site; cellulitis may develop, obscuring cystic structure |
| Insect bites | History of exposure; lesions are red, tender papules |
| Herpes zoster | Painful, vesicular lesions in the ear canal and tympanic membrane in the distribution of cranial nerves V and VII |
| Perichondritis | Inflammation of the cartilage, usually secondary to cellulitis |
| Tumors | Palpable mass, destruction of surrounding structures |
| Foreign body | Foreign body may cause secondary trauma to the ear canal or become a nidus for an infection of the ear canal |
| Trauma | Bruising and swelling of external ear; there may be signs of basilar skull fracture (cerebrospinal fluid otorrhea, hemotympanum) |
| Disorder | Clinical Features |
|---|---|
| Acute otitis media | Immobile tympanic membrane that may appear bulging, red, and/or opaque |
| Bullous myringitis | Hemorrhagic or serous bullae on the tympanic membrane; more severe pain than AOM |
| Mastoiditis | Tenderness and erythema over mastoid with periostitis process; no destruction of bone trabeculae |
| Acute mastoid osteitis | Destruction of bone trabeculae; tenderness and erythema over mastoid process coupled with outward displacement of pinna |
| Granulomatosis | Severe necrotizing vasculitis; ulcerative and destructive granulomatous lesions of upper and lower respiratory tract with polyangiitis |
| Histiocytosis | Pituitary dysfunction, exophthalmos, seborrheic dermatitis, and bone lesions; if bone lesions involve the ear, patient presents with mastoid tenderness and otorrhea |
| Intrinsic |
| I. External Ear |
|
| II. Middle Ear, Eustachian Tube, and Mastoid |
|
| Extrinsic |
| I. Trigeminal Nerve |
|
| II. Facial Nerve |
|
| III. Glossopharyngeal Nerve |
|
| IV. Vagus Nerve |
|
| V. Cervical Nerves |
|
| VI. Miscellaneous |
|
| Neck |
| Cervical lymphadenitis |
| Infected cervical cysts |
| Subluxation of the atlantoaxial joint (torticollis and otalgia) |
| Salivary Glands |
| Parotitis |
| Thyroid |
| Thyroiditis |
| Teeth and Gums |
| Dental caries |
| Dental abscess |
| Impacted teeth |
| Gingivitis |
| Temporomandibular Joint |
| Temporomandibular disorder |
| Arthritis, juvenile idiopathic arthritis |
| Spasm from bruxism or dental malocclusion |
| Tonsils |
| Tonsillitis |
| Peritonsillar abscess |
| Post-tonsillectomy neuralgia |
| Pharynx |
| Pharyngitis |
| Paranasal Sinuses |
| Maxillary sinusitis |
| Other |
| Herpes zoster (Ramsey-Hunt syndrome: postherpetic neuralgia, migraine) Bell palsy |
| Migraine |
| Tumors (e.g., of facial nerve) |
History
Older, verbal children with ear pain are often able to localize and accurately describe their symptoms. Younger children often cannot localize their pain and may present with a variety of nonspecific symptoms, including fever, irritability, rhinorrhea from an associated upper respiratory tract illness (URI), and ear pulling. Even though ear pulling is associated with ear pain, it is neither specific nor sensitive in the diagnosis of ear disease . In addition, infants with AOM may occasionally be afebrile and present with various degrees of irritability, such as sleep disturbances and/or eating or drinking inadequately. The clinician should be highly suspicious of ear disease in infants during the first year of life or in any preschool child with fever, irritability, or a URI.
In taking a history from a child who presents with ear pain, the clinician must distinguish between true ear pain and the sensation of fullness and discomfort that children experience when they have an effusion or retracted tympanic membrane secondary to a dysfunctional eustachian tube. The clinician should review the child’s history for factors placing the child at risk for infection such as craniofacial (cleft palate) abnormalities, immunodeficiencies, autoimmune disease, diabetes, previous ear infections, placement of tympanostomy tubes, and recent dental procedures, trauma, and air travel. Immunization status should also be reviewed. A careful review of systems should elicit associated fevers, sore throat, reflux symptoms, otorrhea, neurologic symptoms, and symptoms of sinusitis. Children with a middle ear effusion may have decreased hearing acuity.
Acute otitis media presents with abrupt onset of otalgia associated with middle ear fluid, signs and symptoms of inflammation, and local or systemic infection. Risk factors for AOM include a family or personal history of recurrent AOM, trisomy 21, household cigarette smoke exposure, lack of breastfeeding, lower socioeconomic status, male gender, cleft palate, immunodeficiency, and group daycare attendance or siblings in the household.
Children with otitis externa (“swimmer’s ear”) present with either ear pain, purulent otorrhea, or both. Manipulating the tragus and pinna causes extreme pain. On otoscopic exam, the external canal is erythematous and there is typically drainage. Relapsing polychondritis also involves swelling and redness of the pinna; this condition is usually bilateral and recurrent, and other cartilaginous structures are affected.
With referred ear pain, such as from tooth decay or teething, there are often additional symptoms associated with the respective head and neck structures (see Table 4.4 ). Patients with ear pain secondary to maxillary sinusitis may also complain of headaches and purulent rhinorrhea.
Physical Examination
In a child presenting with a chief complaint of ear pain, the general examination includes the temperature, the respiratory rate, and a determination of whether the infant or child has a toxic appearance. Then the clinician proceeds with the complete head, eyes, ears, nose, oral cavity, and throat examination and with an appropriately focused physical examination of other pertinent systems.
The examination of the ear begins with the less symptomatic ear. The clinician should inspect the pinna and adjacent tissues for dermatitis, redness, and edema. The pinna, including the cartilaginous portions, and the mastoid process are palpated for any tenderness. Erythema, swelling, and tenderness over the mastoid process suggest mastoiditis ; whereas localization of these findings to the external auditory canal and the pinna suggests otitis externa. In both conditions, the swelling may be so severe that the pinna is laterally displaced. The opening of the external ear canal is also examined for the presence of discharge or exudate. Most disorders of the external ear can be detected through this examination (see Tables 4.1 and 4.3 ).
Otoscopy provides an opportunity to indirectly view the middle ear through the tympanic membrane. The middle ear is normally an air-filled cavity that transmits sound from the eardrum to the ossicle and then into the internal ear ( Fig. 4.1 ). Otoscopy begins by properly positioning and, if necessary, restraining the patient. Both shoulders and hips need to be stabilized so that the patient cannot roll during the examination. Infants are best examined on an examining table in the prone position, with a parent or an attendant firmly holding the patient’s shoulders, thus preventing the patient from moving. Toddlers should sit on a parent’s lap, with the examiner sitting in a chair opposite them. The child is held against the parent’s chest, with one of the parent’s hands and arms holding the child’s arms and the other around the child’s head so that one ear is exposed. To avoid trauma with movement, the otoscope should be held in the examiner’s hand making direct contact with the patient’s head, allowing the otoscope to move with the head.
Cerumen (ear wax) is a waxy substance consisting of glandular discharge from cells in the outer external canal mixing with exfoliated epithelial cells. Cerumen can both obscure visualization of the eardrum leading to diagnostic errors and be a cause of otalgia if impaction occurs. To view the eardrum properly, the examiner should remove the wax by irrigating the ear canal gently with lukewarm water, lift the wax out with a blunt curette, or dissolve the wax by placing 1-2 drops of docusate sodium liquid in the canal for 10-15 minutes. Contraindications for irrigation or use of a cerumenolytic solution are the presence of a tympanostomy tube, a perforated tympanic membrane, or an organic foreign body (e.g., legumes swell in contact with fluids).
During the insertion of the speculum, the clinician should note any redness, edema, tenderness, exudate, furuncles, or vesicles that may be present in the external auditory canal. In some illnesses (otitis externa), the ear canal may be so edematous that the speculum cannot be inserted and the eardrum cannot be seen. In addition, in neonates and in some children with craniofacial anomalies such as trisomy 21, the external canal may be so small that it precludes an accurate assessment of the tympanic membrane.
Pneumatic otoscopy allows evaluation of the tympanic membrane’s mobility. Because it is more accurate than otoscopy alone in detecting middle ear effusion, pneumatic otoscopy should be part of every ear examination. In performing pneumatic otoscopy, the examiner should select a speculum that fits snugly in the external auditory canal. The examiner then partially depresses the rubber bulb of the pneumatic otoscope and inserts the otoscope into the ear canal ( Fig. 4.2 ). Once the eardrum is seen, the examiner should observe the color, appearance, position, bony landmarks, and mobility of the tympanic membrane ( Table 4.5 , Fig. 4.3 ). If the eardrum is not perforated, the clinician observes its mobility by alternating positive and negative pressure by gently depressing and releasing the bulb of the pneumatic otoscope. Poor mobility of the eardrum may be secondary to middle ear effusion, a perforated tympanic membrane, or lack of an airtight seal ( Fig. 4.4 ).
| Characteristic | Normal Findings | Acute Otitis Media | Otitis Media With Effusion | Comments |
|---|---|---|---|---|
| Color | Gray to pink | Often red from inflammation; yellow to white from purulent fluid behind tympanic membrane | Usually gray to pink, but may still be yellow or white; not red | Interobserver variation of color is high; redness can occur from crying alone |
| Appearance | Translucent | Opaque | Translucent or opaque | Opacity is caused by opaque fluid or by scarring of tympanic membrane |
| Position | Neutral | Fluid under pressure produces bulging of tympanic membrane; bony landmarks may be distorted and the light reflex lost | Not bulging; may be retracted | |
| Mobility | Tympanic membrane moves freely | Mobility to positive and negative pressure reduced | Mobility to positive and negative pressure reduced | |
| Other findings | Perforation with otorrhea |
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