Paediatric medicine - The child with ear pain and infection

Consider referred stalgia as more common causes in children with these symptoms.

In acute otitis media the ear drum will become red and bulging and may rupture to allow pus to discharge
In acute otitis media the ear drum will become red and bulging and may rupture to allow pus to discharge

The child with a painful ear is a common problem. While acute otitis media (AOM) and otitis externa dominate, failure to consider the possibility of referred otalgia is the most common error seen when dealing with this symptom.

A full history is extremely important. The nature of the pain and the duration of symptoms are helpful indicators. Toothache or thermal sensitivity is suggestive of referred pain.

Examination of the ear begins with inspection of the pinna followed by examination with an auriscope. Careful examination of the skin of the ear canal must not be forgotten in a haste to visualise the tympanic membrane.

Acute otitis media
AOM is acute infection within the middle ear space. This is extremely common and accounts for 12 per cent of all GP consultations with children and 14 per cent of all antibiotic prescriptions.

The peak incidence is between six and 15 months and becomes increasingly unusual after six years. The illness is more common in winter. Viruses are commonly the causing pathogens, especially respiratory syncytial virus. Streptococcus pneumoniae, S pyogenes, Haemophilus influenzae and Moraxella catarrhalis are the most commonly isolated bacterial pathogens.

The classical picture is of a preceding URTI followed by irritability, malaise, pyrexia and otalgia. Older children may complain of hearing loss. In the acute phase the drum is red and bulging (see image above).

AOM is a self-limiting illness with 80 per cent of episodes resolving spontaneously without antibiotics. In the first instance, analgesia with paracetamol and ibuprofen is recommended.

The decision to commence antibiotic therapy remains contentious with a wide variation in prescribing practices worldwide. In the US and Australia, where prescribing rates are high, antibiotic resistance is an increasing problem. In the Netherlands where prescribing rates are low, complications such as mastoiditis are higher, although this still remains uncommon.

Current recommendations, according to SIGN guidelines, are to treat children under two years, especially those with bilateral AOM or with discharge as this group seems to gain maximal benefit. The antibiotic of choice is amoxicillin for five days at the dosages recommended. For children over two years with a febrile illness, a 'wait and see' approach is advocated.

A prescription may be issued and the parents advised to collect antibiotics if the child has not started to improve after 72 hours. This will usually result in only about one in four prescriptions being filled. The advantages of avoiding antibiotics can be stressed to the parents.

There is no evidence that delayed treatment in this way results in higher rates of complications.There is no evidence that nasal decongestion is helpful.

Co-amoxiclav is recommended as second-line therapy in unresponsive children. Co-trimoxazole, trimethoprim or erythromycin may be used in patients with penicillin allergy. Recurrent AOM should prompt referral to ENT to assess hearing and consideration for antibiotic prophylaxis or insertion of grommets.

Otitis externa
Otitis externa is infection of the skin of the ear canal. It is characterised by discomfort and discharge. There may be pruritus. It is often triggered by irritants such as chlorine from swimming pools. On examination the ear canal may have debris and canal oedema. Gentle traction to the ear may produce discomfort.

The most common pathogen is Pseudomonas spp. and Staphylococcus aureus. If the debris is scanty without much canal oedema then topical aminoglycoside and steroid ear drops are usually effective.

If fungal otitis externa is present then clotrimazole ear drops may be used. The patient is advised to dry mop the meatus with cotton wool. The drops must be instilled with the patient lying on their side. The patient is then instructed to gently massage the tragal cartilage.

The patient should be counselled against use of cotton buds. Drying ears with a towel after washing should be discouraged. Underlying eczema may be treated with a mild steroid ointment. If there is significant canal stenosis or debris then the patient should be referred to ENT for specialist aural toilet.

Furunculosis
A furuncle is a staphylococcal infection of a hair follicle and its surroundings in the ear canal. It may be seen as a distinct pointing abscess and will require incision. More commonly, there may simply be subtle redness of a discrete area of the ear canal. The patient is also usually very sensitive to examination.

The treatment is analgesia and oral flucloxacillin.

Referred otalgia
Referred otalgia occurs because of the large number of nerves supplying sensation to the ears. In children the most common source of referred pain is dental via the trigeminal nerve.

Examination of the teeth may easily be done with a wooden tongue depressor and a light source. Teething is a well recognised cause of otalgia in children. Pulpitis, apical periodontitis and inflammation of the gum around a partially erupted wisdom tooth can cause otalgia.

Palpation around the temporomandibular joint should also be performed. Temporomandibular joint dysfunction is more common in teenagers.

  • Mr Thevasagayam is consultant ENT surgeon, Sheffield Children's Hospital

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