Ear pain resident survival guide (pediatrics)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Amira Albawri M.D.
Ear pain resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Ear pain is the most common cause that affects in children. The mortality rates are generally low but the 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 refered ear pain.

Causes

Life Threatening Causes

Ear pain is not life threatening[1]

Common Causes

primary otalgia [2]

Otitis externa (swimmer's ear)

Mechanical obstruction

Otitis media[8][9][10]

  • 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]

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

Truma

secondary otalgia

Refered ear pain

  • Toothaches.
  • Sorethroat.
  • Mumps
  • dental infections
  • Temporomandibular joint disorder (TMJ) [17]

Classification of otitis media

  • Acute otitis media (AOM).[18]
  • Recurrent acute otitis media (RAOM).
  • Otitis media with effusion (OME).
  • Chronic otitis media with effusion (COME)

FIRE: Focused Initial Rapid Evaluation

Parents are considered as most reliable proxy for assessing ear pain at young children[19] . 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 or there is foreign body[20].

Ear pain[21]

  • Abnormal tympanic membrane examination(otoscopy).
    • primary otalgia.
  • Normal tympanic membrane examination(otoscopy).
    • secondary otalgia.
  • imaging studies.

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

Complete Diagnostic Approach

Characterize the pain

  • Usually the parents use pain scales to detect pain in their young children .[20]
  • 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.

History

  • Enter into group child care and amounts of time spent.
  • Exposure of smoking.
  • Peroid 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 aroud the ear (mastoiditis)
  • Myringotomy

It dose not do for children who have been diagnosed on the basis of assessment in the clinic. [22] [10]

  • Tympanic membrane.

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

  • Acut 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.
    • 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 on screening of asymptomatic children.[23] [10]
    • Affects children between 3 and 7 years old.
  • Chronic otitis media with effusion.
    • Persiste of acute otitis media for ≥3 mo from the date of onset.
    • Tympanic membrane perforation and associated middle ear discharge.
  • Recurrent acute otitis media.
    • Child has three episodes of acute otitis media within a 6-month period, or four in one year.
  • Otitis externa (swimmer's ear). [24]
    • Inflammation at the external ear canal,erythema and edema this lead to narrow it also may be involve the pinna or tympanic membrane.
    • Ear pain,hearin loss, itching, and otorrhea.
  • Ear wax.[25]
    • See wax.
    • Hearing loss, itching, pain, tinnitus. [26]

Table

Key differences in the 2004 and 2013 American Academy of Pediatrics guidelines for the diagnosis and management of acute otitis media (AOM)[18]

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

  • Acut otitis media.
    • In general,approximately 80% of children have spontaneous relief of AOM within 2–14 days who absence of suspected complications it follow 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.[18]
      • Oral acetaminophen and ibuprofen are commonly used to treat pain in children.[27]
    • If we use antibiotics.[18]
      • 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.
  • Acute otitis externa.[24]
    • American guidelines promote initial ototopical therapy without systemic antibiotics for uncomplicated acute otitis externa such as topical antibiotics with or witout topical corticosteroids.
    • Oral antibiotics use for infection has spread beyond the ear canal.
  • Ear wax
    • First-line treatmen is softening ear drops (oil or water).[28] [29]
    • Ear syringing.

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • Vaccine
    • Pneumococcal vaccine prevent otitis media.[10]
  • Breastfeeding.[18]
  • When travel[30]
    • (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)[31]
    • 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.[32]
  • Use pain relievers such as acetaminophen or ibuprofen.[32]
  • The upright position can reduce pressure in the middle ear. [32]

Don'ts

  • 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 awake he can swallow more.[30]
  • Don not use aspirin.[32]
  • Do not smocking near the children because it increase the ear infection.[32]


References

  1. ↑ 1.0 1.1 Earwood JS, Rogers TS, Rathjen NA (2018). "Ear Pain: Diagnosing Common and Uncommon Causes". Am Fam Physician. 97 (1): 20–27. PMID 29365233.
  2. ↑ 2.0 2.1 Neilan RE, Roland PS (2010). "Otalgia". Med Clin North Am. 94 (5): 961–71. doi:10.1016/j.mcna.2010.05.004. PMID 20736106.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  17. ↑ Gauer RL, Semidey MJ (2015). "Diagnosis and treatment of temporomandibular disorders". Am Fam Physician. 91 (6): 378–86. PMID 25822556.
  18. ↑ 18.0 18.1 18.2 18.3 18.4 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.
  19. ↑ 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.
  20. ↑ 20.0 20.1 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.
  21. ↑ Ely JW, Hansen MR, Clark EC (2008). "Diagnosis of ear pain". Am Fam Physician. 77 (5): 621–8. PMID 18350760.
  22. ↑ 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.
  23. ↑ 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.
  24. ↑ 24.0 24.1 Schaefer P, Baugh RF (2012). "Acute otitis externa: an update". Am Fam Physician. 86 (11): 1055–61. PMID 23198673.
  25. ↑ Browning GG (2008). "Ear wax". BMJ Clin Evid. 2008. PMC 2907972. PMID 19450340.
  26. ↑ Michaudet C, Malaty J (2018). "Cerumen Impaction: Diagnosis and Management". Am Fam Physician. 98 (8): 525–529. PMID 30277727.
  27. ↑ Bertin L, Pons G, d'Athis P, Duhamel JF, Maudelonde C, Lasfargues G; et al. (1996). "A randomized, double-blind, multicentre controlled 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.
  28. ↑ 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.
  29. ↑ Poulton S, Yau S, Anderson D, Bennett D (2015). "Ear wax management". Aust Fam Physician. 44 (10): 731–4. PMID 26484488.
  30. ↑ 30.0 30.1 "Traveling with children: MedlinePlus Medical Encyclopedia".
  31. ↑ "Swimmer's Ear (External Otitis) (for Teens) - Nemours KidsHealth".
  32. ↑ 32.0 32.1 32.2 32.3 32.4 "Earache: MedlinePlus Medical Encyclopedia".


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