Ear pain resident survival guide (pediatrics)

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

Ear pain resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

Life Threatening Causes

Ear pain is not life threatening

Common Causes

primary otalgia

Otitis externa (swimmer's ear)

• Pseudomonas.
• Staph aureus.

Mechanical obstruction

• Earwax
• Foreign body

Otitis media

• common cold or upper respiratory tract infection

• Streptococcus pneumoniae
• nontypable Haemophilus influenzae
• Moraxella catarrhalis

Otitis media with effusion

• Enter into group child care(Amounts of time spent)
• Exposure of smoking
• Peroid of breastfeeding

Truma

• Air travel

secondary otalgia

Refered ear pain

• Tonsillitis and Tonsillectomy

• Toothaches.

• Sorethroat.
• Mumps
• dental infections
• Temporomandibular joint disorder (TMJ)

FIRE: Focused Initial Rapid Evaluation

Ear pain

• Abnormal ear examination(otoscopy).
  • primary otalgia.

• Normal ear examination(otoscopy).
  • secondary otalgia.

• imaging studies.

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

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the [...] guidelines.

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

Subject	2004	2013	Rationale for 2013 Changes
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, provided treatment recommendation when diagnosis was uncertain.
	Presence of MEE	Mild bulging of TM and recentb onset ear painc or 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 initial antibiotic therapy	Option for observation: 6 mo–2 y: Option if uncertain diagnosis and nonsevere illnessd ≥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 small benefit 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 severee illness ≥2 y: Certain diagnosis and severee illness	Antibiotics recommended: 6 mo–2 y: Otorrhea or severee illness or bilateral without otorrhea ≥2 y: Otorrhea or severee illness	More stringent diagnostic guidelines in 2013 should lead to greater antibiotic benefit.
	Antibiotics an option: 6 mo–2 y: Uncertain diagnosis and nonsevered 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.

aSigns 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.

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

dNonsevere illness 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 temperature less than 39°C.”

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

Adapted from Lieberthal AS, Carroll AE, Chonmaitree T, et al. The 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.

 

 

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

DO NOT block any drainage coming from the ear. DO NOT try to clean or wash the inside of the ear canal. DO NOT put any liquid into the ear. DO NOT attempt to remove the object by probing with a cotton swab, a pin, or any other tool. To do so will risk pushing the object farther into the ear and damaging the middle ear. DO NOT reach inside the ear canal with tweezers.

References

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