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===Medical Therapy===
===Medical Therapy===


*The mainstay of therapy for ear pain in children over-the-counter drugs like Tylenol(acetaminophen) or ibuprofen (Advil, Motrin) and anesthetic drops, antibiotics for ear infections even its not effective treatment<ref name="urlEar infection (middle ear) - Diagnosis and treatment - Mayo Clinic">{{cite web |url=https://www.mayoclinic.org/diseases-conditions/ear-infections/diagnosis-treatment/drc-20351622 |title=Ear infection (middle ear) - Diagnosis and treatment - Mayo Clinic |format= |work= |accessdate=}}</ref>. DIY remedies <ref name="url3 Home Remedies for an Ear Infection – Health Essentials from Cleveland Clinic2">{{cite web |url=https://health.clevelandclinic.org/3-home-remedies-for-an-ear-infection/ |title=3 Home Remedies for an Ear Infection – Health Essentials from Cleveland Clinic |format= |work= |accessdate=}}</ref>
*The mainstay of therapy for ear pain in children over-the-counter drugs like Tylenol(acetaminophen) or ibuprofen (Advil, Motrin) and anesthetic drops, warm compresses for some kind of  bacterial ear infections<ref name="urlEar and Mastoid Disorders in Infants and Children | Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e | AccessMedicine | McGraw-Hill Medical">{{cite web |url=https://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109432406 |title=Ear and Mastoid Disorders in Infants and Children &#124; Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e &#124; AccessMedicine &#124; McGraw-Hill Medical |format= |work= |accessdate=}}</ref>, DIY remedies<ref name="url3 Home Remedies for an Ear Infection – Health Essentials from Cleveland Clinic2">{{cite web |url=https://health.clevelandclinic.org/3-home-remedies-for-an-ear-infection/ |title=3 Home Remedies for an Ear Infection – Health Essentials from Cleveland Clinic |format= |work= |accessdate=}}</ref> , antibiotics for ear infections even its not effective treatment<ref name="urlEar infection (middle ear) - Diagnosis and treatment - Mayo Clinic">{{cite web |url=https://www.mayoclinic.org/diseases-conditions/ear-infections/diagnosis-treatment/drc-20351622 |title=Ear infection (middle ear) - Diagnosis and treatment - Mayo Clinic |format= |work= |accessdate=}}</ref>. 
   
   
==='''Surgery'''===
==='''Surgery'''===

Revision as of 14:30, 26 January 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Eman Alademi, M.D.[2]

Synonyms and keywords: Ear pain in kids, earache, ear ache, ear infection, otitis, ear discomfort, ear sore, otalgia, otodynia.

Historical Perspective

  • In1840s , the first otoscope was invented by Anton von Troeltsh in Germany to treat/diagnose ear pain[1][2].

Classification

  • ear pain in children may be classified according to [classification method] into [number] subtypes/groups:[3]
  • primary
  • secondary
  • traumatic
  • Other variants of ear pain in children include[4] Diseases of the auricle , Diseases of the ear canal], Secondary otalgia, Diseases of the middle and inner ear, and Traumatic injuries to the ear.


Pathophysiology

  • The pathogenesis of ear pain in children is characterized by [5]Pain from the ear itself which called Primary ear pain[6] and Referred pain which called Secondary ear pain[7][8] .

Causes

The most common cause of ear pain in children[9] is Primary otalgia include otitis media and otitis externa[10] include:

1.Diseases of the auricle like: Cellulitis of the auricle, Perichondritis,Herpes zoster oticus, Local allergic reaction (bug bite), Contact dermatitis, Sunburn, Frostbite.

2.Diseases of the ear canal like:Otitis externa( Bacterial, Fungal,Malignant otitis externa), Furunculosis, Cerumen impaction, Foreign bodies, Granuloma,Malignant tumor, Contact dermatitis, Eczema.

3.Diseases of the middle and inner ear like: Acute otitis media, Eustachian tube dysfunction, Otitis media with effusion, Otitis media with perforation, Otitis media with tympanostomy tubes, Myringitis, Cholesteatoma, Malignant tumor, Complications of otitis media( Mastoiditis, Meningitis, Brain abscess, Venous sinus thrombosis, Inner ear infection, Facial nerve palsy).

Less common causes of [ear pain in children] is secondary otalgia include [11][temporomandibular joint syndrome],[ pharyngitis], stomatitis, Auricular lymphadenopathy or lymphadenitis, Sinusitis (maxillary),Parotitis,Facial nerve palsy, Psychogenic, cervical spine arthritis, and dental infections but its more common in adults than children[12]. or Traumatic injuries to the ear Abrasions or lacerations, Auricular hematoma, Traumatic perforation of the TM, Disruption of the ossicles, Hemotympanum (blunt or barotrauma), Basilar skull fracture, Associated intracranial injury, Inner ear injury (blunt or barotrauma).

Differentiating ear pain in children from other Diseases

Ear pain in children must be differentiated from:[13][14]

Auricle:[15]

  • Contusion (auricular hematoma).
  • Infection: Cellulitis, Perichondritis, Herpes zoster oticus (Ramsay Hunt syndrome)[16].
  • Allergic angioedema
  • Juvenile spring eruption (polymorphous light eruption)
  • Environmental injury

Ear canal:

  • Malignant otitis externa [18]
  • Contact dermatitis
  • Furuncle
  • Foreign body
  • Cerumen impaction
  • Tumor

Middle and inner ear:

  • Acute otitis media[19]
  • Complications of acute otitis media: Spontaneous rupture of the tympanic membrane , Mastoiditis, Facial palsy[20], Inner ear infection, Involvement of contiguous structures[21][22][23],
  • Otitis media with effusion
  • Eustachian tube dysfunction
  • Cholesteatoma
  • Blunt or penetrating trauma: Traumatic tympanic membrane perforation, Traumatic disruption of the ossicles or inner ear, [24], Basilar skull fracture.

Secondary otalgia: [25]

  • Auricular lymphadenopathy or lymphadenitis
  • Temporomandibular joint dysfunction syndrome,
  • Facial nerve (Bell's) palsy,
  • Oropharyngeal infections,
  • Sinusitis,
  • Cervical spine injury

Epidemiology and Demographics

  • The prevalence of ear pain in children of[30][31]:
  • acute otitis media is approximately 83% of children by 3 years of age.
  • Cerumen impaction occurs in 1 out of every 10 children

Age

  • ear pain in children especially primary otalgia of infection (acute otitis media) is more commonly observed among ages 6–24 months .
  • ear pain of Otitis externae is more commonly observed among patients aged 7-12 years old.

Gender

  • there is no genfer predilection for ear pain in children.

Race

  • There is no racial predilection for ear pain in children.

Risk Factors

  • Common risk factors in the development of ear pain in children are Allergies or asthma, ear infections[32](first ear infection before six months of age)[33]and family history of ear infections. , Coronary artery disease risk factors, Diabetes or immunocompromise, smoker or negative smoker(tobacco smoke exposure), Unilateral hearing loss, Superior tympanic membrane retraction pocket, otorrhea [34].

Natural History, Complications and Prognosis

  • The majority of patients with [disease name] remain asymptomatic for [duration/years].
  • Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
  • If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
  • Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
  • Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

Diagnosis

Diagnostic Criteria

  • The diagnosis of acute otitis media in children is made when at least one of the following criteria are met:[35]
  • pain (rubbing, tugging, or holding the ear may be a sign of pain)
  • fever
  • irritability
  • otorrhea
  • anorexia
  • sometimes vomiting or lethargy

Symptoms

  • ear pain in children is usually asymptomatic.
  • Symptoms of ear pain in children may include the following:[36]
  • Ear pain, especially when lying down
  • Tugging or pulling at an ear
  • Difficulty sleeping
  • Crying more than usual
  • Acting more irritable than usual
  • Difficulty hearing or responding to sounds
  • Loss of balance
  • Fever of 100 F (38 C) or higher
  • Drainage of fluid from the ear
  • Headache
  • Loss of appetite

Physical Examination

  • Patients of child with ear pain usually appear either stable with discomfort and holding their ear and crying, Younger infants or toddlers may be fussy and difficult to console. or with abnormal vital signs like ear pain, epidural hematoma, and abnormal mental status due to brain infection or traumatic injury.[37]
  • Physical examination may be remarkable for:[38]
  • abnormal vital signs due to serious infection, like meningitis, sepsis, or serious traumatic injury, like epidural hematoma.
  • holding their ear and crying in sever otitis media or externa.
  • moderate to severe hearing loss
  • traumatic injury like lacerations, ecchymoses, fluctuant hematomas, or swelling.
  • periorbital ecchymoses Signs of basilar skull fracture.
  • Battle sign (ecchymosis overlying the mastoid bone)
  • diffuse redness and swelling of the external ear due to indicate infection or local allergic reaction
  • Protrusion of the ear from the side of the head due to either allergic or infectious inflammation of the pinna or mastoiditis
  • Pre- or postauricular lymphadenopathy presence of any fluctuance and overlying redness or swelling

Laboratory Findings

imaging studies; and consultation with an otolaryngologist[39]

  • There are no specific laboratory findings associated with ear pain in children.
  • An elevated concentration of CBC, ESR, and CRP is diagnostic of serious or deep-seated infections, such as mastoiditis, malignant otitis externa, or bacterial meningitis .
  • Other laboratory findings consistent with the diagnosis of ear pain in children include [Bacterial or fungal culture of ear drainage], Blood culture, Lumbar puncture[40][41][42][43][44],and Audiometry.

Electrocardiogram

An ECG may be helpful in the diagnosis of carcinoma of the middle ear in children[45]. Findings on an ECG suggestive of carcinoma of the middle ear include Atrial dissociation.

X-ray

An x-ray may be helpful in the diagnosis of inner ear . Findings on an x-ray suggestive of microstructures defect or tumors include otoconia masses, most of the morphology studies of the inner ear[46][47].

Echocardiography or Ultrasound

Echocardiography may be helpful in the diagnosis of carcinoma of the middle ear in children. Findings on an echocardiography suggestive of carcinoma of the middle ear include Atrial dissociation[48][49].

CT scan

There are no CT scan findings associated with ear pain in children. However, a CT scan[50] may be helpful in the diagnosis of complications of otitis media in ear pain in children, which include altered mental status in conjunction with cardiovascular instability, fever, focal neurologic findings, meningismus, and/or severe headache, complications, such as venous sinus thrombosis, meningitis, or brain abscess should be suspected.

MRI

Ear MRI( Magnetic resonance imaging) and referral for nasolaryngoscopymay be helpful in the diagnosis of ear pain in childen in the setting of otalgia with normal ear examination findings and symptoms of or risk factors for tumor[51] . Findings on MRI[52] diagnostic of ear tumor include equal T1 and T2 signals with intensifying in tympanum, , and Long T1 or equal T1 and long T2 signal in mastoid showed obstructive inflammation.


Other Imaging Findings

There are no other imaging findings associated with ear pain in children.

Other Diagnostic Studies

  • Ear pain in children usually diagnosed using otoscope [53], or tympanometry can be helpful if there is suspicion of middle ear disease:[54]
  • Findings[55] on otoscopic examination include redness, flaking, swelling, or thick discharge[56] of ear canal, presence of masses, foreign bodies, bullae, or eczematous changes, and the TM appears thickened or cloudy, or if air bubbles are evident behind the TM, a middle ear effusion should be suspected, tense, pus-filled bullae may be seen in AOM(Auditory canal and middle ear), Redness or bullae of the TM without evident fluid in the middle ear suggests isolated myringitis, Perforations of the TM, inserted tympanostomy tube can see location and patency should be assessed, In cases of trauma, hemotympanum may be noted. Hemotympanum is characterized by a red or purple effusion, which may occupy the entire middle ear space or may appear as an air-fluid level.

Treatment

Medical Therapy

  • The mainstay of therapy for ear pain in children over-the-counter drugs like Tylenol(acetaminophen) or ibuprofen (Advil, Motrin) and anesthetic drops, warm compresses for some kind of bacterial ear infections[57], DIY remedies[58] , antibiotics for ear infections even its not effective treatment[59].

Surgery

  • Surgery is the mainstay of therapy for cholesteatoma (Abnormal squamous epithelium) polypoid disease, and infected bone must be removed in order to create a dry, safe ear that is free of infection[60].
  • [Surgical procedure] in conjunction with X-Ray radiation is the most common approach to the treatment of .
  • [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

  • Effective measures for the primary prevention of ear pain in children include Don’t smoke, and avoid secondhand smoke[61],Keep all foreign objects out of your ears always take time to carefully dry your ears after swimming, showering, or bathing, and You can also wear a bathing cap, earplugs, or use custom-fitted swim molds when swimming[62]. Hold a hair drier on a low heat setting at least 12 inches from the ear[63]

References

  1. ↑ Conover K (May 2013). "Earache". Emerg Med Clin North Am. 31 (2): 413–42. doi:10.1016/j.emc.2013.02.001. PMID 23601480.
  2. ↑ Altemeier WA (October 2000). "A pediatrician's view. A brief history of otitis media". Pediatr Ann. 29 (10): 599. doi:10.3928/0090-4481-20001001-03. PMID 11056932.
  3. ↑ "StatPearls". 2020. PMID 31751020 PMID: 31751020 Check |pmid= value (help).
  4. ↑ "UpToDate".
  5. ↑ "Earache - Ear, Nose, and Throat Disorders - MSD Manual Professional Edition".
  6. ↑ "Chapter 19. Ear | The Big Picture: Gross Anatomy | AccessMedicine | McGraw-Hill Medical".
  7. ↑ Scarbrough TJ, Day TA, Williams TE, Hardin JH, Aguero EG, Thomas CR (October 2003). "Referred otalgia in head and neck cancer: a unifying schema". Am J Clin Oncol. 26 (5): e157–62. doi:10.1097/01.coc.0000091357.08692.86. PMID 14528091.
  8. ↑ Earwood JS, Rogers TS, Rathjen NA (January 2018). "Ear Pain: Diagnosing Common and Uncommon Causes". Am Fam Physician. 97 (1): 20–27. PMID 29365233.
  9. ↑ Ely JW, Hansen MR, Clark EC (2008). "Diagnosis of ear pain". Am Fam Physician. 77 (5): 621–8. PMID 18350760 PMID: 18350760 Check |pmid= value (help).
  10. ↑ "Synonyms for EARACHE - Thesaurus.net".
  11. ↑ "UpToDate".
  12. ↑ Earwood JS, Rogers TS, Rathjen NA (2018). "Ear Pain: Diagnosing Common and Uncommon Causes". Am Fam Physician. 97 (1): 20–27. PMID 29365233 : 29365233 Check |pmid= value (help).
  13. ↑ "UpToDate".
  14. ↑ Bandúrová V, Plzák J, Bouček J (2019). "Differential diagnosis of ear pain". Cas Lek Cesk. 158 (6): 231–234. PMID 31931581 PMID: 31931581 Check |pmid= value (help).
  15. ↑ Ghanem T, Rasamny JK, Park SS (2005). "Rethinking auricular trauma". Laryngoscope. 115 (7): 1251–5. doi:10.1097/01.MLG.0000165377.92622.EF. PMID 15995516.
  16. ↑ Kansu L, Yilmaz I (2012). "Herpes zoster oticus (Ramsay Hunt syndrome) in children: case report and literature review". Int J Pediatr Otorhinolaryngol. 76 (6): 772–6. doi:10.1016/j.ijporl.2012.03.003. PMID 22445801.
  17. ↑ Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA; et al. (2014). "Clinical practice guideline: acute otitis externa". Otolaryngol Head Neck Surg. 150 (1 Suppl): S1–S24. doi:10.1177/0194599813517083. PMID 24491310.
  18. ↑ Rubin J, Yu VL, Stool SE (1988). "Malignant external otitis in children". J Pediatr. 113 (6): 965–70. doi:10.1016/s0022-3476(88)80564-x. PMID 3142986.
  19. ↑ Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA; et al. (2013). "The diagnosis and management of acute otitis media". Pediatrics. 131 (3): e964–99. doi:10.1542/peds.2012-3488. PMID 23439909.
  20. ↑ Mattos JL, Colman KL, Casselbrant ML, Chi DH (2014). "Intratemporal and intracranial complications of acute otitis media in a pediatric population". Int J Pediatr Otorhinolaryngol. 78 (12): 2161–4. doi:10.1016/j.ijporl.2014.09.032. PMID 25447953.
  21. ↑ Wu JF, Jin Z, Yang JM, Liu YH, Duan ML (2012). "Extracranial and intracranial complications of otitis media: 22-year clinical experience and analysis". Acta Otolaryngol. 132 (3): 261–5. doi:10.3109/00016489.2011.643239. PMID 22224578.
  22. ↑ Mattos JL, Colman KL, Casselbrant ML, Chi DH (2014). "Intratemporal and intracranial complications of acute otitis media in a pediatric population". Int J Pediatr Otorhinolaryngol. 78 (12): 2161–4. doi:10.1016/j.ijporl.2014.09.032. PMID 25447953.
  23. ↑ Zapalac JS, Billings KR, Schwade ND, Roland PS (2002). "Suppurative complications of acute otitis media in the era of antibiotic resistance". Arch Otolaryngol Head Neck Surg. 128 (6): 660–3. doi:10.1001/archotol.128.6.660. PMID 12049560.
  24. ↑ Hurtado TR, Zeger WG (2004). "Hemotympanums secondary to spontaneous epistaxis in a 7-year-old". J Emerg Med. 26 (1): 61–3. doi:10.1016/j.jemermed.2003.05.001. PMID 14751480.
  25. ↑ Conover K (2013). "Earache". Emerg Med Clin North Am. 31 (2): 413–42. doi:10.1016/j.emc.2013.02.001. Unknown parameter |*pmid= ignored (help)
  26. ↑ Battle S, Laudenbach J, Maguire JH (2007). "Influenza parotitis: a case from the 2004 to 2005 vaccine shortage". Am J Med Sci. 333 (4): 215–7. doi:10.1097/MAJ.0b013e31803b92c4. PMID 17435413.
  27. ↑ Francis CL, Larsen CG (2014). "Pediatric sialadenitis". Otolaryngol Clin North Am. 47 (5): 763–78. doi:10.1016/j.otc.2014.06.009. PMID 25128215.
  28. ↑ Stong BC, Sipp JA, Sobol SE (2006). "Pediatric parotitis: a 5-year review at a tertiary care pediatric institution". Int J Pediatr Otorhinolaryngol. 70 (3): 541–4. doi:10.1016/j.ijporl.2005.08.001. PMID 16154645.
  29. ↑ Tucci FM, Roma R, Bianchi A, De Vincentiis GC, Bianchi PM (2019). "Juvenile recurrent parotitis: Diagnostic and therapeutic effectiveness of sialography. Retrospective study on 110 children". Int J Pediatr Otorhinolaryngol. 124: 179–184. doi:10.1016/j.ijporl.2019.06.007. PMID 31202035.
  30. ↑ Rosa-Olivares J, Porro A, Rodriguez-Varela M, Riefkohl G, Niroomand-Rad I (November 2015). "Otitis Media: To Treat, To Refer, To Do Nothing: A Review for the Practitioner". Pediatr Rev. 36 (11): 480–6, quiz 487–8. doi:10.1542/pir.36-11-480. PMID 26527627.
  31. ↑ Earwood JS, Rogers TS, Rathjen NA (January 2018). "Ear Pain: Diagnosing Common and Uncommon Causes". Am Fam Physician. 97 (1): 20–27. PMID 29365233.
  32. ↑ "Risk Factors for Middle Ear Infections | Winchester Hospital".
  33. ↑ "www.lifespan.org".
  34. ↑ "Diagnosis of Ear Pain - American Family Physician".
  35. ↑ Gaddey HL, Wright MT, Nelson TN (September 2019). "Otitis Media: Rapid Evidence Review". Am Fam Physician. 100 (6): 350–356. PMID 31524361.
  36. ↑ "Ear Infection in Children : Symptoms & Risk Factors".
  37. ↑ "UpToDate".
  38. ↑ "UpToDate".
  39. ↑ Ely JW, Hansen MR, Clark EC (2008). "Diagnosis of ear pain". Am Fam Physician. 77 (5): 621–8. PMID 18350760 PMID: 18350760 Check |pmid= value (help).
  40. ↑ Chun CH, Johnson JD, Hofstetter M, Raff MJ (November 1986). "Brain abscess. A study of 45 consecutive cases". Medicine (Baltimore). 65 (6): 415–31. PMID 3784900.
  41. ↑ Schliamser SE, Bäckman K, Norrby SR (1988). "Intracranial abscesses in adults: an analysis of 54 consecutive cases". Scand J Infect Dis. 20 (1): 1–9. doi:10.3109/00365548809117210. PMID 3363298.
  42. ↑ Nielsen H (May 1983). "Cerebral abscess in children". Neuropediatrics. 14 (2): 76–80. doi:10.1055/s-2008-1059557. PMID 6877531.
  43. ↑ Patir R, Sood S, Bhatia R (1995). "Post-traumatic brain abscess: experience of 36 patients". Br J Neurosurg. 9 (1): 29–35. PMID 7786422.
  44. ↑ Tattevin P, Bruneel F, Clair B, Lellouche F, de Broucker T, Chevret S, Bédos JP, Wolff M, Régnier B (August 2003). "Bacterial brain abscesses: a retrospective study of 94 patients admitted to an intensive care unit (1980 to 1999)". Am J Med. 115 (2): 143–6. doi:10.1016/s0002-9343(03)00292-4. PMID 12893401.
  45. ↑ Brunner A, Kovacevic A (May 2020). "[Atrial dissociation in a boxer with a carcinoma of the middle ear]". Schweiz Arch Tierheilkd (in German). 162 (5): 319–323. doi:10.17236/sat00260. PMID 32369024 Check |pmid= value (help).
  46. ↑ Yin HX, Zhang P, Wang Z, Liu YF, Liu Y, Xiao TQ, Yang ZH, Xian JF, Zhao PF, Li J, Lv H, Ding HY, Liu XH, Zhu JM, Wang ZC (July 2019). "Investigation of inner ear anatomy in mouse using X-ray phase contrast tomography". Microsc Res Tech. 82 (7): 953–960. doi:10.1002/jemt.23121. PMID 30636063.
  47. ↑ "Earache & Ear Pain Causes, Treatment, Remedies & Symptoms".
  48. ↑ Brunner A, Kovacevic A (May 2020). "[Atrial dissociation in a boxer with a carcinoma of the middle ear]". Schweiz Arch Tierheilkd (in German). 162 (5): 319–323. doi:10.17236/sat00260. PMID 32369024 Check |pmid= value (help).
  49. ↑ Hao XP, Yang BT, Lei L, Wei XM, Li YX (November 2017). "[The characteristics of CT scan and MRI images of middle ear adenomas]". Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi (in Chinese). 31 (21): 1625–1629. doi:10.13201/j.issn.1001-1781.2017.21.001. PMID 29798114.
  50. ↑ Britt RH, Enzmann DR (December 1983). "Clinical stages of human brain abscesses on serial CT scans after contrast infusion. Computerized tomographic, neuropathological, and clinical correlations". J Neurosurg. 59 (6): 972–89. doi:10.3171/jns.1983.59.6.0972. PMID 6631519.
  51. ↑ "Diagnosis of Ear Pain - American Family Physician".
  52. ↑ Hao XP, Yang BT, Lei L, Wei XM, Li YX (November 2017). "[The characteristics of CT scan and MRI images of middle ear adenomas]". Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi (in Chinese). 31 (21): 1625–1629. doi:10.13201/j.issn.1001-1781.2017.21.001. PMID 29798114.
  53. ↑ Siddiq MA, Samra MJ (2008). "Otalgia". BMJ. 336 (7638): 276–7. doi:10.1136/bmj.39364.643275.47. PMC 2223060. PMID 18245001 PMID: 18245001 Check |pmid= value (help).
  54. ↑ "Diagnosis of Ear Pain - American Family Physician".
  55. ↑ "UpToDate".
  56. ↑ Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA, Huang WW, Haskell HW, Robertson PJ (February 2014). "Clinical practice guideline: acute otitis externa". Otolaryngol Head Neck Surg. 150 (1 Suppl): S1–S24. doi:10.1177/0194599813517083. PMID 24491310.
  57. ↑ "Ear and Mastoid Disorders in Infants and Children | Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8e | AccessMedicine | McGraw-Hill Medical".
  58. ↑ "3 Home Remedies for an Ear Infection – Health Essentials from Cleveland Clinic".
  59. ↑ "Ear infection (middle ear) - Diagnosis and treatment - Mayo Clinic".
  60. ↑ "UpToDate".
  61. ↑ "Health Effects of Secondhand Smoke | CDC".
  62. ↑ "www.cdc.gov" (PDF).
  63. ↑ "Earache & Ear Pain Causes, Treatment, Remedies & Symptoms".
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