- Sometimes identifying the source of ear pain can be challenging.
- Injury to the middle ear can be from direct or indirect trauma.
- Even trivial trauma from a cotton bud can precipitate otitis externa.
- Perichondritis needs aggressive treatment to avoid ear deformity.
- Never irrigate wax without being sure the tympanic membrane is intact.
1. THE ASSESSMENT OF EAR PAIN
Ear pain is a common complaint in children. Usually it is a simple matter, but at times identifying the source of ear pain can be challenging.
Most earaches in children are due to local pathology, but infants and young children often resent examination. This makes obtaining a view of the tympanic membrane difficult. A narrow external canal and the presence of wax can compound the problem.
Assessing ear pain
In assessing the painful ear, consider the site, quality and timing of pain, radiation of pain to other sites, and aggravating or relieving factors.
Sudden lancing pain may suggest a neuralgia, whereas pain with mastication suggests a temporomandibular joint disorder. Associated features such as vertigo, tinnitus, hearing loss or ear discharge suggest primary ear disease.
Audiology can help, and the timing of testing depends on the suspected disease process. Radiology, including computerised tomography, is indicated where conditions such as mastoiditis or malignancy are suspected. Examine the head, neck, oral cavity and pharynx when evaluating ear pain with no obvious cause.
The middle ear
The most common cause of earache is otitis media. Dysfunction of the normal middle ear ventilation system - the mastoid and the eustachian tube - contributes to the pain.
Acute suppurative otitis media
All GPs are familiar with this common cause of earache in infants and children. Young infants may present with just fever or irritability, while older children complain of pain in the ear and hearing loss, and have fever and malaise. There is occasionally tinnitus or vestibular disturbance.
The most common infectious agents are viruses (adeno- and enteroviruses) and bacteria (such as Streptococcus pneumoniae and Branhamella catarrhalis).
Haemophilus influenza infection is rare if the child has been vaccinated.
Early findings on otoscopy include redness and dullness of the tympanic membrane. Accumulation of fluid in the middle ear may cause a bulging of the membrane and a fluid level may be seen.
Pain results from stretching of the tympanic membrane, the inflammation of the mucosa in the middle ear and pressure changes. Rapid and spontaneous resolution of earache may occur if the tympanic membrane perforates. Antibiotics are no longer recommended for routine use, but in children who are unwell with fever and vomiting, amoxicillin, co-amoxiclav or erythromycin may help in bacterial infections. Analgesics can be given in all cases to help fever and earache. Most cases settle within 48 to 72 hours. Re-check any case that does not settle after this time.
Chronic suppurative otitis media
Chronic suppurative otitis media can occur when there is a persistent perforation of the tympanic membrane or a grommet is in situ. As the pus is not under pressure, there is usually little or no ear pain. Investigation should exclude persistent infection, cholesteatoma, foreign bodies or even malignancy. Cases that do not resolve should be referred for ENT specialist opinion.
- Most earaches in children are due to local pathology.
- Infants and young children often resent examination, making this difficult.
- Rapid and spontaneous resolution of earache may occur if the tympanic membrane perforates.
- Chronic suppurative otitis media that does not resolve should be referred.
2. TRAUMA, BAROTRAUMA AND MASTOIDITIS
Injury to the middle ear can be caused by direct penetrating physical injury to the tympanic membrane and ossicles, or from the indirect trauma of a slap injury to the external ear, or from a fall.
Initial symptoms are severe pain with varying degrees of hearing loss and vestibular symptoms. A fresh, ragged perforation of the tympanic membrane can be seen.
Treatment is dictated by the severity of the injury and includes the prevention of water from entering the middle ear.
If there is any suspicion of severe damage, referral for an audiogram and otomicroscopy is required to check for ossicular discontinuity.
Barotrauma is suggested by acute severe earache with possible hearing loss and tinnitus, occurring in patients who have recently experienced significant pressure fluctuations after having, for example, flown or been scuba diving.
Diving is an increasingly popular sport and is now permitted from the age of 10 so more children are affected. A thickened, haemorrhagic tympanic membrane and a middle ear effusion may be seen.
Barotrauma is caused by the inability of the eustachian tube to equilibrate a sudden air pressure difference between the environment and the middle ear space. Treatment is largely supportive with analgesics.
Symptoms of earache and discharge, plus a tender protruding auricle and doughy swelling behind the ear, are diagnostic. A feature of this condition is the marked posterior external canal oedema and absence of anterior canal oedema.
The tympanic membrane may appear normal, thickened, or have a small central perforation. Neurological changes may be seen with intracranial complications.
Perforation of the mastoid tip produces a deep abscess in the neck, known as a Bezold's abscess.
Treatment of an ill child with mastoiditis requires urgent referral to an ENT department. The child may require myringotomy for culture, ventilation tube placement, possibly a mastoidectomy and intravenous antibiotics.
- Trauma to the ear drum can be caused by a slap on the ear.
- If severe damage is suspected, refer for otomicroscopy and an audiogram.
- Barotrauma follows flying or scuba diving most commonly.
- Treatment of barotrauma is usually supportive with analgesics.
- Earache with a tender protruding auricle and doughy swelling behind the ear suggests mastoiditis.
- The ill child with mastoiditis needs an urgent ENT opinion.
3. OTITIS EXTERNA
Ear ache due to an external ear problem is often accompanied by a feeling of fullness, hearing loss or discharge.
Causes and findings
Otitis externa is an inflammation of the skin of the external auditory canal. It may be exacerbated by wax impaction or foreign objects. Trauma, however trivial, such as inappropriate use of cotton buds or scratching, can result in an infection. It is aggravated by humidity.
An ill-fitting hearing aid may be implicated, and this is not uncommon in children with severe learning disabilities.
Otitis externa will cause earache, decreased hearing, fullness in the ear and ear discharge. Pain may also occur with any movement of the pinna or the tragus.
If pain occurs on pressing the tragus, otitis externa is more likely than otitis media. If otoscopy is possible, a mild to severely oedematous external canal may be seen.
If the tympanic membrane is obscured, it can be difficult to exclude middle ear involvement. The tympanic membrane, if visible, may be thickened and erythematous. A thick, smelly discharge is usually present.
Preauricular and postauricular lymph nodes may be enlarged and tender.
Pseudomonas species are frequently responsible, often associated with staphylococci and proteus organisms.
Investigations and treatment
Swab for cultures whenever possible before starting treatment. Cultures may show mixed flora with a predominance of one bacterial organism or a fungus. This will help direct therapy.
Topical antibiotic drops alone are all that is required in most cases, preferably active against pseudomonas.
When oedema prevents the instillation of eardrops, a wick can be used to deliver treatment. It should be removed every 24 to 48 hours for inspection and to clean the canal.
Oral antibiotics may be added if response is slow, if a concurrent middle ear infection is suspected, or in those patients who are immunocompromised.
Suspect fungal infection or underlying eczema if a patient has a protracted or relapsing problem.
Refer to an ENT specialist if external canal oedema or debris prevents adequate topical therapy, if there is treatment failure, or the patient is immunocompromised.
Thorough cleaning, including gentle debridement of all squamous debris and purulent material, is the mainstay of treating refractory cases.
Shedding of the canal skin lining is disrupted in otitis externa, causing a build-up of keratin debris. When acute, pain may limit cleaning of the canal.
- Otitis externa may be exacerbated by wax impaction or foreign objects.
- If pain occurs on pressing the tragus, otitis externa is more likely than otitis media.
- If oedema prevents use of eardrops, a wick can be used to deliver treatment.
- Refer if external canal oedema or debris prevents adequate topical therapy.
4. A MISCELLANY OF PAINFUL EAR CONDITIONS
A number of unrelated conditions can cause pain in the ear.
Ear pain often precedes shingles affecting the facial nerve (the Ramsay Hunt Syndrome). Vesicles occur in clusters in the external canal and the pinna.
Herpes zoster can cause partial or complete facial paralysis, hearing loss and vestibular disturbance. Treatments are pain management, acyclovir and steroids.
Perichondritis is an unusual infection of the pinna usually due to external blunt trauma. Features are auricular tenderness and overlying soft tissue oedema.
As blood supply to auricular cartilage is poor, infections spread rapidly.
If not treated with IV antibiotics and local hygiene, cartilage necrosis and auricular deformity may result.
Erysipelas is accompanied by erythema, oedema and tenderness of auricular skin. Commonly caused by a streptococcus, it can progress rapidly and antibiotics are needed immediately. It can be confused with perichondritis, but if the ear lobe is involved, erysipelas is more likely.
The outer third of the external canal contains hair follicles, sebaceous glands and ceruminous glands. Bacterial infection of a hair follicle with a staphylococcus is often secondary to microtrauma of the canal. Increasing ear discomfort on palpation and mastication, and cervical lymphadenopathy occur. Unlike otitis externa, there is usually little oedema in the canal and no discharge. If the child will permit it, de-roofing the furuncle can bring relief and aid resolution. Treatment is with antibiotic therapy active against staphylococci, such as flucloxacillin or co-amoxiclav, together with analgesics.
Burns and frostbite
Treatment and prognosis of burns is based on the severity of the injury.
Treatment must involve avoiding perichondritis. Frostbite presents in the acute phase as painless pallor.
On warming, the auricle becomes painful. Hyperaemia, vesiculation and necrosis occur with first-, second- and third-degree frostbite, respectively.
- Herpes zoster can cause partial or complete facial paralysis.
- Perichondritis is usually due to blunt trauma to the external ear.
- Furunculosis in the external ear is often secondary to microtrauma of the canal.
- Treatment of burns to the pinna must involve avoiding perichondritis.
5. FOREIGN BODIES AND WAX
Children have a propensity for placing small objects, such as beads and vegetable matter, in the external auditory canal. Symptoms include earache, fullness of the ear and hearing loss.
Most foreign bodies can be removed in the A&E department, but tight impaction or an uncooperative patient may mean that general anaesthesia and an operating microscope are needed. Leaking hearing aid batteries can cause rapid, extensive caustic skin and bony damage. Consider battery removal an emergency.
Ear drops should be avoided if the object is not clearly identified because moisture can result in batteries causing more damage and make vegetable matter swell. Check the nose and the other ear - the child may have stuck something in there as well.
Wax impaction causes fullness, itching and hearing loss, but mild earache may occur if there is a concurrent otitis externa. Use of cotton buds can cause wax to be impacted against the tympanic membrane. Topical ceruminolytics can be tried.
Irrigation of the canal in a child (or an adult) should only be done if there can be certainty that the tympanic membrane is intact.
Earache can be referred from distant sites, secondary to inflammatory processes, tumours or mechanical disturbances, and mimic primary ear disease.
Pathology affecting the trigeminal, facial, glossopharyngeal, vagus nerves and cervical nerves C2 and C3 can all be responsible. In particular, check for distant causes for earache when the ear appears normal. Pain from erupting teeth or gingival irritation commonly causes referred earache in young children.
Temporomandibular joint dysfunction
The pain of temporomandibular joint dysfunction is unilateral, and could relate to chewing. On palpation over the joint, a clicking or grinding action when the patient opens and closes his or her mouth suggests the diagnosis. Treatment involves reducing inflammation and pain, primarily with heat therapy, soft diet, and analgesics.
- Leaking hearing aid batteries in the auditory meatus constitute an emergency.
- Cotton buds can cause wax to be impacted against the tympanic membrane.
- Referred pain can mimic primary ear disease.
- Temporomandibular joint dysfunction is unilateral, and may be related to chewing.
AK Leung, JH Fung, AG Leong. Otalgia in children J Natl Med Assoc. 2000; 92 (5): 254-60.