Ear pain resident survival guide (pediatrics)

| Resident
Survival
Guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Amira Albawri

Synonyms and keywords: Ear pain , otalgia , ear sore , otitis , ear infection , ear discomfort and ear aches.

Ear pain resident survival guide (pediatrics) Microchapters

Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

## Overview

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Ear pain is the most common cause that affects children. Mortality rates are generally low, but acute otitis media and otitis media with effusion have high morbidity. the child can come with fever, restless sleep, ear rubbing, irritability, excessive crying, decreased activity, poor appetite, rhinitis, nasal congestion, cough, hoarse voice, conjunctivitis, mucus vomiting.There are several causes divided into primary otalgia and secondary otologia .The primary otalogia including otitis externa (swimmer's ear), mechanical obstruction ,Otitis media ,otitis media with effusion, truma .The secondary otalgia including referred ear pain.

## Causes

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### Common Causes

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#### Primary otalgia

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The following are the causes of primary otalgia:[1][2]

#### Otitis externa (swimmer's ear)

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* Pseudomonas.[3]
* Staph aureus.[4][5]

#### Mechanical obstruction

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* Earwax[6]
* Foreign body[7]

#### Otitis media[8][9][10]

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* Common cold or upper respiratory tract infection, common cold, or upper respiratory tract infection [11]
* Streptococcus pneumoniae
* Nontypable Haemophilus influenzae
* Moraxella catarrhalis
* Congenital ear anomalies(cleft palate)[12]

#### Otitis media with effusion[13][10][14]

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* Enter into group child care (Amounts of time spent)
* Exposure of smoking
* Period of breastfeeding

#### Truma

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* Air travel[15]

### Secondary otalgia

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#### Referred ear pain

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* Tonsillitis and Tonsillectomy[16][1][2]

* Toothaches.

* Mumps
* Dental infections

## Classification of otitis media

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* Otitis media can be classified as the following:[17]
* Acute otitis media (AOM).
* Recurrent acute otitis media (RAOM).
* Otitis media with effusion (OME).
* Chronic otitis media with effusion (COME)

## FIRE: Focused Initial Rapid Evaluation

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Parents are considered as the most reliable proxy for assessing ear pain at young children[18] . If child come with restless sleep, ear rubbing, irritability, excessive crying, decreased activity, poor appetite and may be with fever we should think about ear pain .the help us to know the cause of ear pain is examination by otoscopy reveals the tympanic membrane if its bulging, retraction,fluid behind the eardrum o itf there is foreign body[19].

Ear pain[20]

* Abnormal tympanic membrane examination(otoscopy).
* primary otalgia.

* Normal tympanic membrane examination(otoscopy).
* secondary otalgia.

* Imaging studies.

The IF Diagnosis is not clear from the history and physical examination.

## Complete Diagnostic Approach

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## Treatment

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# Table

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Key differences in the 2004 and 2013 American Academy of Pediatrics guidelines for the diagnosis and management of acute otitis media (AOM)[17]

Characterize the pain

* Usually the parents use pain scales to detect pain in their young children .[19]
* Ear-related symptoms: ear rubbing.
* Non-specific symptoms: fever, irritability, excessive crying, decreased activity, poor appetite, and restless sleep.
* Respiratory symptoms: rhinitis, cough, hoarse voice, conjunctivitis, mucus vomiting, and nasal congestion.
* Gastrointestinal symptoms: vomiting, and diarrhea.

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History

* Enter into group child care and amounts of time spent.
* The exposure of smoking.
* Period of breastfeeding.
* Swimming
* Recurrent ear pain.
* Skills developmental delay like (language delay) due to hearing loss.

Examination

* Face (lymph node, mastoids, temporomandibular joints, and maxillary sinuses), mouth, and throat.[11]
* Skin especially around the ear (mastoiditis)
* Myringotomy

It does not do for children who have been diagnosed on the basis of assessment in the clinic. [21] [10]

* Tympanic membrane.

If the tympanic membrane is abnormal, the most likely cause of it by primary otalgia. The main causes of primary otalgia include

* Acute otitis media.
* Cloudy, bulging PMID: 22459064 erythema of the tympanic membrane.[10]
* Acute onset symptoms and signs fever, otalgia also see irritability, otorrhea, anorexia, and vomiting.
* It usually affects children aged under 2 years,
* Otitis media with effusion.
* Retracted/concave tympanic membrane with change colour of tympanic membrane (yellow,amber,blue) , and air–fluid levels.[10]
* Absence of signs and symptoms (asymptomatic).
* Hearing loss.This is lead to speech delays.It is detected during screening of asymptomatic children.[22] [10]
* Affects children between 3 and 7 years old.
* Chronic otitis media with effusion.
* Persistent of acute otitis media for ≥3 mo from the date of onset.
* Tympanic membrane perforation and the associated middle ear discharge.
* Recurrent acute otitis media.
* A child has three episodes of acute otitis media within a 6-month period or four in one year.
* Otitis externa (swimmer's ear). [23]
* Inflammation at the external ear canal,erythema and edema this lead to narrow it also may involve the pinna or tympanic membrane.
* Ear pain ,hearing loss, itching, and otorrhea.
* Ear wax.[24]
* See wax.
* Hearing loss, itching, pain, tinnitus. [25]

Subject  | 2004  | 2013  | Rationale for 2013 Changes

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Children <6 mo  | Treat with antibiotic therapy  | No recommendations  |

* * *

Diagnosis of AOM  | Acute onset of signs and symptoms  | Moderate to severe bulging of TM, or new-onset otorrhea not owing to acute otitis externa  | 2004 criteria allowed less precise diagnosis and provided treatment recommendation when diagnosis was uncertain.
Presence of MEE  | Mild bulging of TM and recent onset ear pain and intense TM erythema
Signs and symptoms of middle ear inflammationa  | Must have MEE

* * *

Uncertain diagnosis  | Expected and included in treatment guidelines  | Excluded  | Emphasized need for diagnosis of AOM for best management.

* * *

Initial observation option instead of the initial antibiotic therapy  | Option for observation:

* 6 mo–2 y: Option if uncertain diagnosis or non-severe illness
* ≥2 y: Option if nonsevered and certain diagnosis

| Option for observation:

* 6 mo–2 y: Unilateral OM without otorrhea
* ≥2 y: Unilateral or bilateral AOM without otorrhea

| Favorable natural history overall.
Observation recommended:

* ≥2 y and uncertain diagnosis

| Observation recommended:

* None

| Evidence of the small benefits of antibiotics in recent trials that used stringent diagnostic criteria.

* * *

Initial antibiotic therapy recommended  | Antibiotics recommended:

* <6 mo: All cases
* 6 mo–2 y: Certain diagnosis, or uncertain diagnosis if severe illness
* ≥2 y: Certain diagnosis and severe illness

| Antibiotics recommended:

* 6 mo–2 y: Otorrhea or severe illness or bilateral without otorrhea
* ≥2 y: Otorrhea or severe illness

| More stringent diagnostic guidelines in 2013 should lead to greater antibiotic benefit.
Antibiotics an option:

* 6 mo–2 y: Uncertain diagnosis and non-severed illness
* ≥2 y: Certain diagnosis and nonsevered illness

| Antibiotics an option:

* 6 mo–2 y: Unilateral without otorrhea
* ≥2 y: Bilateral without otorrhea or unilateral without otorrhea

| Greater antibiotic benefit for bilateral disease, AOM with otorrhea.
|  | Two recent studies show small benefit of antibiotics for age 6–24 mo.

* * *

Recurrent AOM  | No recommendations  | Do not prescribe prophylactic antibiotics  | Minimal benefit for prophylaxis and antibiotics come with risks (antibiotic resistance and adverse effects).
May offer tympanostomy tubes  | Modest reduction in AOM with tubes.

Abbreviations: MEE, middle ear effusion; TM, tympanic membrane.

Signs and symptoms of middle ear inflammation include distinct erythema of TM or distinct otalgia (‘discomfort clearly referable to the ear's) that results in interference with or precludes normal activity or sleep’).

bRecent: <48 hours.

Ear pain may be indicated by holding, tugging, or rubbing of the ear in a nonverbal child.

non-severe illness was defined as mild otalgia and fever <39°C in the past 24 hours in the 2004 guideline; the 2013 guideline modifies this to “mild otalgia for less than 48 hours and a temperature of less than 39°C.”

Severe signs or symptoms include moderate or severe otalgia or temperature ≥39°C in 2004 guidelines; the 2013 guideline also includes otalgia for ≥48 hours.

Adapted from Lieberthal AS, Carroll AE, Chonmaitree T, et al. diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964–99; and American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113(5):1451–65

Treat the underlying causes

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Fatigue due to Acut otitis media

❑In general,approximately 80% of children have spontaneous relief AOM within 2–14 days who absence of suspected complications follows initial treatment of symptomatic (analgesia and antipyretics) as fever and ear pain.If severe,recurrent infections or persistent give antibioticor if there is complication may offer tympanostomy tubes.[10]
❑If we use analgisic[17]Oral acetaminophen and ibuprofen are commonly used to treat pain in children.[26]
❑ If we use antibiotics.[17]

* Amoxicillin (90 mg/kg per day) is the recommended first-line agent in the 2013 guidelines.
* Amoxicillin with beta-lactamase coverage the patient has concurrent purulent conjunctivitis or recurrent acut otitis media unresponsive to amoxicillin.
* If there is penicillin-sensitive patients we can use second- or third-generation cephalosporins, including intramuscular ceftriaxone or if penicillin-sensitive patients or amoxicillin failures we can use second- and third-generation cephalosporins and clindamycin.
* Tympanocentesis use for drainage (theraby) and culture in difficult cases

Fatigue due toAcute otitis externa[23]

❑American guidelines promote initial ototopical therapy without systemic antibiotics for uncomplicated acute otitis externa such as topical antibiotics with or without topical corticosteroids.

❑Oral antibiotics use for infection have spread beyond the ear canal.

Fatigue due to Otitis media with effusion.

❑Antibiotics, histamines or decongestants not effect at treatment[27] ❑In less sever case and without hearing problems, the effusion can resolve spontaneously or with autoinflation [28]

❑In sever case or persistent symptomatic cases, the treatment is by tympanostomy with or without adenoidectomy.[29][30]

Fatigue due to Tonsilitis

❑Treatment depends on the cause.
❑IF the cause is viral it is go by alone._Tonsillitis_Symptoms_|_Tonsillitis_Treatment_|_MedlinePlus-31|[31] ❑Antibiotics.

* If the cause is group A streptococcus, the first-line therapy antibiotics are used is penicillin or amoxicillin[32][33] .If there is alergic to pinicillin we can use a macrolide [34].If there is no response to penicillin therapy, we can use clindamycin or amoxicillin-clavulanate[35] .

❑Pain medication. ❑Surgery.

* Tonsillectomy[36] . It is as a choice for treatment the chronic tonsillitis

Fatigue due to Ear wax

❑First-line treatmen is softening ear drops (oil or water).[37] [38]

❑Ear syringing.

## Do's

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* Otitis media
* Vaccine
* Pneumococcal vaccine prevents otitis media.[10]
* Breastfeeding.[17]
* When travel[39]
* (For child)Chew gum or suck candy or give your child acetaminophen or ibuprofen about 30 minutes before takeoff or landing.
* (For infant ) breastfeeding, or sucking on pacifiers.
* Otitis externa ( swimmer's ear )[40]
* Keep your ear drying by use a clean towel after swimming, or showering.
* Use a cotton ball as an earplug while take a shower or swimming to protect the ear during healing.
* Use a cold pack outside the ear to reduce pain for 20 minutes.[41]
* Use pain relievers such as acetaminophen or ibuprofen.[41]
* The upright position can reduce pressure in the middle ear. [41]
* tonsilitis._Tonsillitis_Symptoms_|_Tonsillitis_Treatment_|_MedlinePlus-31|[31]
* Drink more water.
* If there is pain during swallowing, eat smooth foods like soups.
* Wash your hands.
* Gargles with saltwater.
* Stay away from things that cause irritation in the throat like smoke.

## Don'ts

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* Do not use antibiotics unless necessary because widespread use can lead to resistent.[10]
* Do not let child sleep during takeoff or landing because when he awakes he can swallow more.[39]
* Don not use aspirin.[41]
* Do not smocking near the children because it incresase the ear infection.[41]

## References

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1. ↑ 1.0 1.1 Neilan RE, Roland PS (2010). "Otalgia". Med Clin North Am. 94 (5): 961–71. doi:10.1016/j.mcna.2010.05.004. PMID 20736106.
2. ↑ 2.0 2.1 Earwood JS, Rogers TS, Rathjen NA (2018). "Ear Pain: Diagnosing Common and Uncommon Causes". Am Fam Physician. 97 (1): 20–27. PMID 29365233.CS1 maint: Multiple names: authors list (link)
3. ↑ Zichichi L, Asta G, Noto G (2000). "Pseudomonas aeruginosa folliculitis after shower/bath exposure". Int J Dermatol. 39 (4): 270–3. doi:10.1046/j.1365-4362.2000.00931.x. PMID 10809975.CS1 maint: Multiple names: authors list (link)
4. ↑ Wang MC, Liu CY, Shiao AS, Wang T (2005). "Ear problems in swimmers". J Chin Med Assoc. 68 (8): 347–52. doi:10.1016/S1726-4901(09)70174-1. PMID 16138712.CS1 maint: Multiple names: authors list (link)
5. ↑ Schaefer P, Baugh RF (2012). "Acute otitis externa: an update". Am Fam Physician. 86 (11): 1055–61. PMID 23198673.
6. ↑ Schwartz SR, Magit AE, Rosenfeld RM, Ballachanda BB, Hackell JM, Krouse HJ; et al. (2017). "Clinical Practice Guideline (Update): Earwax (Cerumen Impaction) Executive Summary". Otolaryngol Head Neck Surg. 156 (1): 14–29. doi:10.1177/0194599816678832. PMID 28045632.CS1 maint: Multiple names: authors list (link)
7. ↑ Conover K (2013). "Earache". Emerg Med Clin North Am. 31 (2): 413–42. doi:10.1016/j.emc.2013.02.001. PMID 23601480.
8. ↑ Teele DW, Klein JO, Rosner B (1989). "Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective cohort study". J Infect Dis. 160 (1): 83–94. doi:10.1093/infdis/160.1.83. PMID 2732519.CS1 maint: Multiple names: authors list (link)
9. ↑ Leung AKC, Wong AHC (2017). "Acute Otitis Media in Children". Recent Pat Inflamm Allergy Drug Discov. 11 (1): 32–40. doi:10.2174/1874609810666170712145332. PMID 28707578.
10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 Qureishi A, Lee Y, Belfield K, Birchall JP, Daniel M (2014). "Update on otitis media - prevention and treatment". Infect Drug Resist. 7: 15–24. doi:10.2147/IDR.S39637. PMC 3894142. PMID 24453496.CS1 maint: Multiple names: authors list (link)
11. ↑ 11.0 11.1 Worrall G (2011). "Acute earache". Can Fam Physician. 57 (9): 1019–21, e320–2. PMC 3173423. PMID 21918146.
12. ↑ Sando I, Takahashi H (1990). "Otitis media in association with various congenital diseases. Preliminary study". Ann Otol Rhinol Laryngol Suppl. 148: 13–6. doi:10.1177/00034894900990s605. PMID 2140931.
13. ↑ Kubba H, Pearson JP, Birchall JP (2000). "The aetiology of otitis media with effusion: a review". Clin Otolaryngol Allied Sci. 25 (3): 181–94. doi:10.1046/j.1365-2273.2000.00350.x. PMID 10944048.CS1 maint: Multiple names: authors list (link)
14. ↑ Owen MJ, Baldwin CD, Swank PR, Pannu AK, Johnson DL, Howie VM (1993). "Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life". J Pediatr. 123 (5): 702–11. doi:10.1016/s0022-3476(05)80843-1. PMID 8229477.CS1 maint: Multiple names: authors list (link)
15. ↑ Wright T (2015). "Middle-ear pain and trauma during air travel". BMJ Clin Evid. 2015. PMC 4298289. PMID 25599243.
16. ↑ Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA; et al. (2019). "Clinical Practice Guideline: Tonsillectomy in Children (Update)". Otolaryngol Head Neck Surg. 160 (1_suppl): S1–S42. doi:10.1177/0194599818801757. PMID 30798778.CS1 maint: Multiple names: authors list (link)
17. ↑ 17.0 17.1 17.2 17.3 17.4 Rettig E, Tunkel DE (2014). "Contemporary concepts in management of acute otitis media in children". Otolaryngol Clin North Am. 47 (5): 651–72. doi:10.1016/j.otc.2014.06.006. PMC 4393005. PMID 25213276.
18. ↑ American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health. Task Force on Pain in Infants, Children, and Adolescents (2001). "The assessment and management of acute pain in infants, children, and adolescents". Pediatrics. 108 (3): 793–7. doi:10.1542/peds.108.3.793. PMID 11533354.CS1 maint: Multiple names: authors list (link)
19. ↑ 19.0 19.1 Uitti JM, Salanterä S, Laine MK, Tähtinen PA, Ruohola A (2018). "Adaptation of pain scales for parent observation: are pain scales and symptoms useful in detecting pain of young children with the suspicion of acute otitis media?". BMC Pediatr. 18 (1): 392. doi:10.1186/s12887-018-1361-y. PMC 6302518. PMID 30572868.CS1 maint: Multiple names: authors list (link)
20. ↑ Ely JW, Hansen MR, Clark EC (2008). "Diagnosis of ear pain". Am Fam Physician. 77 (5): 621–8. PMID 18350760.CS1 maint: Multiple names: authors list (link)
21. ↑ Rovers MM, Schilder AG, Zielhuis GA, Rosenfeld RM (2004). "Otitis media". Lancet. 363 (9407): 465–73. doi:10.1016/S0140-6736(04)15495-0. PMID 14962529.CS1 maint: Multiple names: authors list (link)
22. ↑ Schilder AG, Chonmaitree T, Cripps AW, Rosenfeld RM, Casselbrant ML, Haggard MP; et al. (2016). "Otitis media". Nat Rev Dis Primers. 2: 16063. doi:10.1038/nrdp.2016.63. PMC 7097351 Check `|pmc=` value (help). PMID 27604644.CS1 maint: Multiple names: authors list (link)
23. ↑ 23.0 23.1 Schaefer P, Baugh RF (2012). "Acute otitis externa: an update". Am Fam Physician. 86 (11): 1055–61. PMID 23198673.
24. ↑ Browning GG (2008). "Ear wax". BMJ Clin Evid. 2008. PMC 2907972. PMID 19450340.
25. ↑ Michaudet C, Malaty J (2018). "Cerumen Impaction: Diagnosis and Management". Am Fam Physician. 98 (8): 525–529. PMID 30277727.
26. ↑ Bertin L, Pons G, d'Athis P, Duhamel JF, Maudelonde C, Lasfargues G; et al. (1996). "A randomized, double-blind, multicentre trial of ibuprofen versus acetaminophen and placebo for symptoms of acute otitis media in children". Fundam Clin Pharmacol. 10 (4): 387–92. doi:10.1111/j.1472-8206.1996.tb00590.x. PMID 8871138.CS1 maint: Multiple names: authors list (link)
27. ↑ Griffin G, Flynn CA (2011). "Antihistamines and/or decongestants for otitis media with effusion (OME) in children". Cochrane Database Syst Rev (9): CD003423. doi:10.1002/14651858.CD003423.pub3. PMC 7170417 Check `|pmc=` value (help). PMID 21901683.
28. ↑ Blanshard JD, Maw AR, Bawden R (1993). "Conservative treatment of otitis media with effusion by autoinflation of the middle ear". Clin Otolaryngol Allied Sci. 18 (3): 188–92. doi:10.1111/j.1365-2273.1993.tb00827.x. PMID 8365006.CS1 maint: Multiple names: authors list (link)
29. ↑ Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ (2010). "Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children". Cochrane Database Syst Rev (10): CD001801. doi:10.1002/14651858.CD001801.pub3. PMID 20927726.CS1 maint: Multiple names: authors list (link)
30. ↑ Atkinson H, Wallis S, Coatesworth AP (2015). "Otitis media with effusion". Postgrad Med. 127 (4): 381–5. doi:10.1080/00325481.2015.1028317. PMID 25913597.CS1 maint: Multiple names: authors list (link)
31. ↑ _Tonsillitis_Symptoms_|_Tonsillitis_Treatment_|_MedlinePlus_31-0|31.0 _Tonsillitis_Symptoms_|_Tonsillitis_Treatment_|_MedlinePlus_31-1|31.1 [+https://medlineplus.gov/tonsillitis.html "Tonsillitis | Tonsillitis Symptoms | Tonsillitis Treatment | MedlinePlus"] Check `|url=` value (help).
32. ↑ Bird JH, Biggs TC, King EV (2014). "Controversies in the review of acute tonsillitis: an evidence-based review". Clin Otolaryngol. 39 (6): 368–74. doi:10.1111/coa.12299. PMC 7162355 Check `|pmc=` value (help). PMID 25418818.CS1 maint: Multiple names: authors list (link)
33. ↑ Touw-Otten FW, Johansen KS (1992). "Diagnosis, antibiotic treatment and outcome of acute tonsillitis: report of a WHO Regional Office for Europe study in 17 European countries". Fam Pract. 9 (3): 255–62. doi:10.1093/fampra/9.3.255. PMID 1459378.
34. ↑ Casey JR, Pichichero ME (2004). "Meta-analysis of cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis in children". Pediatrics. 113 (4): 866–82. doi:10.1542/peds.113.4.866. PMID 15060239.
35. ↑ Brook I (2009). "The role of beta-lactamase-producing-bacteria in mixed infections". BMC Infect Dis. 9: 202. doi:10.1186/1471-2334-9-202. PMC 2804585. PMID 20003454.
36. ↑ Burton MJ, Glasziou PP, Chong LY, Venekamp RP (2014). "Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis". Cochrane Database Syst Rev (11): CD001802. doi:10.1002/14651858.CD001802.pub3. PMC 7075105 Check `|pmc=` value (help). PMID 25407135.CS1 maint: Multiple names: authors list (link)  Review in: Evid Based Med. 2015 Apr;20(2):64
37. ↑ Aaron K, Cooper TE, Warner L, Burton MJ (2018). "Ear drops for the removal of ear wax". Cochrane Database Syst Rev. 7: CD012171. doi:10.1002/14651858.CD012171.pub2. PMC 6492540. PMID 30043448.CS1 maint: Multiple names: authors list (link)
38. ↑ Poulton S, Yau S, Anderson D, Bennett D (2015). "Ear wax management". Aust Fam Physician. 44 (10): 731–4. PMID 26484488.CS1 maint: Multiple names: authors list (link)
39. ↑ 39.0 39.1 "Traveling with children: MedlinePlus Medical Encyclopedia".
40. ↑ "Swimmer's Ear (External Otitis) (for Teens) - Nemours KidsHealth".
41. ↑ 41.0 41.1 41.2 41.3 41.4 "Earache: MedlinePlus Medical Encyclopedia".