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

Synonyms and keywords:

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]

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

Truma

secondary otalgia

Refered ear pain

Classification of otitis media

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]

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

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

Complete Diagnostic Approach

Table

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

 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examination

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

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

 
 
 
 
 
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

Condition Management
Acute Otitis Media cx
Chronic Otitis Media
Acute Otitis externa
Malignant Otitis externa

Do's

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.[36]
  • Don not use aspirin.[38]
  • Do not smocking near the children because it increase the ear infection.[38]


References

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