Otalgia is one of the most common complaints that physicians caring for children encounter. Furthermore, examination of the pediatric patient to identify the source of ear pain can be challenging. The external canal may be narrow and obstructed with cerumen, especially in young children. Visualization and cleaning of the ear canal and the tympanic membrane may be attempted initially with a cerumen loop and an open-head otoscope. If this is not successful, referral to an otolaryngologist for binocular microscopic cleaning may be necessary. Accurate diagnosis is often elusive due to the number of potential causes for otalgia. To confound matters further, both the outer and the middle ear receive sensory innervation from a variety of nerves that also innervate other areas in the head and the neck. This fact requires one to search for referred causes of otalgia when the results of the otologic examination are unrevealing.
An examination of the head and the neck should include an inspection and palpation of the oral cavity, the oral pharynx, and the neck when evaluating otologic pain of obscure origin. In assessing the painful ear, the relevant history includes 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 aural discharge may be present and suggest primary ear disease. Audiologic investigations are essential, and the timing of these tests is based on the disease process. Radiologic studies such as computerized tomography are indicated in special cases when a malignancy is suspected.
EXTERNAL AUDITORY CANAL
A variety of disorders can affect the skin of the pinna, the external auditory canal, and the lateral aspect of the tympanic membrane. Otalgia due to an external ear process is often accompanied by aural fullness, hearing loss, or discharge. The differential diagnosis of external ear otalgia is usually made without difficulty based on a thorough physical examination and history. The challenge arises when trying to determine concomitant middle ear involvement because the tympanic membrane is obscured. Before an otoscopie examination is performed, the pinna should be inspected and palpated. Careful inspection of the external auditory canal with an otoscope, from its meatus to the tympanic membrane, may reveal small lesions mat would have been overlooked because of the impulse to look directly at the tympanic membrane first. Common causes of otalgia in the pediatric patient are listed in the table.
Otitis externa is an inflammation of the external auditory canal skin. It may be exacerbated by cerumen impaction, bony narrowing of the canal called exostosis, or other foreign objects. Trauma, however trivial, such as from scratching the canal with a paper clip, can become a nidus for severe infection. Otitis externa is more frequent in areas of the country with high humidity and during the summer months in those who engage in water sports. Uncommonly, an ill-fitting hearing aid may also be a focus for infection.
The patient with otitis externa will often complain of otalgia, decreased hearing, aural fullness, and aural discharge. Examination reveals pain with pinna or tragal manipulation. Otoscopy will demonstrate a mildly to severely edematous external canal. The tympanic membrane, if visible, may be thickened and erythematous. A thick, fetid discharge is usually present. Preauricular and postauricular lymph nodes may be enlarged and tender to palpation. The most common causative organism is Pseudomonas species, often associated with both staphylococci and proteus.
The first line of therapy is a thorough, gentle debridement of all squamous debris and purulent material. The superficial layers of the canal skin are shed laterally in a healthy ear; this mechanism is disrupted in otitis externa, causing a buildup of keratin debris. In the acute form of the illness, cleaning of the canal may be challenging because of otalgia. When edema of the canal does not allow topical medications to be instilled, a wick is placed to provide delivery. If a wick is used, it should be removed every 24 to 48 hours and the external canal should be inspected and cleaned.
Topical antibiotic drops alone are all that is required in the majority of cases (ofloxacin otic solution 0.3% is a good choice because it covers Pseudomonas well). Oral antibiotics are added for patients who have a concurrent middle ear infection, who are improving too slowly with local treatment, or who are immunocompromised. One should suspect fungal infection or an underlying eczematous disorder in the patient who has a protracted or relapsing course and should change treatment appropriately.
Causes of Otalgia In the Pediatric Patient
Cultures are appropriate if initial therapy has been instituted and resolution has not occurred after 10 to 14 days of frequent aural toilet and topical otologic drops. Cultures may show mixed flora with a predominance of one bacterial organism or fungus, and this will help direct therapy. Referral to an otolaryngologist is appropriate if the external canal edema or debris does not allow topical drops to enter, if there is a failure of topical therapy, or if the patient is immunocompromised.
Symptoms of ear pain often precede the formation of vesicles when the causative agent is herpes zoster. These vesicles occur in clusters and primarily involve the external canal and the pinna. As a neurotropic virus, herpes simplex can cause partial to complete facial paralysis as well as hearing loss and vestibular disturbance. Cranial nerve testing, especially nerves V, VTI, IX, and X, should be performed serially. Treatment involves pain management, acyclovir, and steroids.
Perichondritis is usually incited by blunt trauma to the external ear. It presents with marked auricular tenderness and overlying soft tissue edema. The blood supply to the auricular cartilage is somewhat tenuous, and bacterial infections, usually staphylococci, can spread rapidly. If perichondritis is not aggressively treated, cartilage necrosis with subsequent long-term auricular deformity may occur. Recurring infections and subsequent cartilage thickening are common to pugilists and is known as a "cauliflower ear." Treatment includes intravenous antibiotic therapy and local aural toilet.
Erythema, edema, and tenderness of the auricular skin heralds this bacterial infection, which is most commonly caused by streptococcal organisms. This process can progress rapidly, and therapy requires immediate institution of antibiotics. Erysipelas can be confused with perichondritis. However, involvement of the ear lobule (at the bottom of the auricle) generally implies erysipelas as the cause of infection because the lobule does not contain cartilage.
The outer one-third of the external canal is cartilaginous and contains hair follicles, sebaceous glands, and ceniminous glands. Bacterial infection of the external canal hair appendages is often secondary to microtrauma of the canal. Symptoms of moderate auricular discomfort with palpation and mastication are seen early with furunculosis. Upper neck adenopathy is seen later. In contrast to otitis externa, there is usually limited canal edema and no aural discharge. Relief and resolution are aided by unroofing the furuncle. Cultures of the purulent discharge will often yield staphylococcal species. Treatment is antibiotic therapy directed at these organisms and analgesics.
Auricular Burns and Frostbite
Diagnosis of these injuries is readily obtained with a brief history and physical examination, with treatment and prognosis based on the severity of injury. Thermal injuries producing erythema of the skin only are first-degree burns. Erythema and blistering are second-degree burns, and charring and necrosis are third-degree burns. Treatment must be directed at the prevention of perichondritis. Some mechanisms of injury, such as sparks from a fire or welding slag, require that middle ear damage be ruled out.
At the other end of the spectrum, frostbite presents acutely as painless pallor. But with warming, the auricle can become particularly painful. Hyperemia, vesiculation, and necrosis categorize first-degree, second-degree, and third-degree frostbite, respectively.
Tumors of the external ear may ulcerate and cause pain as they progress, particularly in the latter stages of the disease. Most common in this area are rhabdomyosarcoma, lymphoma, eosinophilic granuloma, and Wegener's granulomatosis. Malignancy should be suspected in any nonhealing lesion of the ear. A pathologic examination is required to confirm the diagnosis.
Children have a propensity for placing small objects, such as beads and vegetable matter, in the external auditory canal. Symptoms include otalgia, aural fullness, and hearing loss. Most foreign bodies can be removed in the office. An operating microscope may be needed and general anesthesia may be required if the object is tightly lodged in the canal or if the patient cannot cooperate with the examination. Hearing aid batteries can cause extensive caustic skin and bony damage in a short period of time. Removal of this foreign body is considered an otologic emergency and is performed as soon as possible after detection. Otologic drops should be avoided if the object is not clearly identified because, in a moist environment, batteries can cause increased damage and vegetable matter can swell, causing increased discomfort and added difficulty in removal. An examination of the opposite ear and the nose is appropriate to rule out other occult foreign objects.
Cerumen impaction typically presents with fullness, pruritus, and hearing loss; however, mild otalgia may be present if there is a concurrent otitis externa. Impaction of the wax against the tympanic membrane occurs with inappropriate cotton swab usage and can cause discomfort. Removal is required to make the diagnosis and to provide relief. The use of topical ceruminolytics or irrigation of the canal should occur only if an intact tympanic membrane can be determined.
Diagnosis of middle ear disease can be challenging in the pediatric patient due to the inherent difficulty in performing the otologic examination. The most common cause of otalgia originates in the middle ear as otitis media. Dysfunction of the normal middle ear ventilation system (ie, the mastoid and the eustachian tube) can also cause otalgia.
Acute Suppurative Otitis Media
Acute suppurative otitis media typically presents with mild to severe otalgia, hearing loss, fever and malaise, and occasional tinnitus or vestibular disturbance. It is certainly the most common cause of otalgia in infants and children. The most common infectious agents are viruses (adenovirus and enterovirus) and bacteria (Haemophilus influenza, Streptococcus pneumoniae, and Branhamella catarrhalis). Pain results from inflamed mucosa in the middle ear. Spontaneous resolution of otalgia may occur with tympanic membrane perforation and subsequent otorrhea, or by therapeutic myringotomy if there is pressure from exudate in the middle ear. The institution of antibiotic therapy and analgesics should be associated with resolution of the fever and otalgia within 48 to 72 hours. If this does not occur, reexamination of the ear and use of another class of antibiotics to cover resistant organisms is indicated.
Otoscopie findings depend on the stage of the disease. Early findings include tympanic membrane hyperemia and dullness and are not very reliable. Middle ear fluid may cause a bulging of the tympanic membrane due to extensive fluid accumulation. Decreased drum motility demonstrated by pneumatic otoscopy is key in determining the presence of middle ear effusion. The examiner may also note an air-fluid interface.
Chronic Suppurative Otitis Media
By definition, chronic suppurative otitis media occurs through a perforation in the tympanic membrane or through a previously placed ventilation tube. As with acute serous otitis media that spontaneously drains, pus that is not "under pressure" usually causes little or no otalgia. However, investigation into the cause of the chronic discharge is needed to rule out persistent infection, cholesteatoma, foreign bodies, or malignancy.
Traumatic injury to the middle ear can be caused by direct penetrating physical injury to the tympanic membrane and ossicles, or from the trauma of a slap injury to the ear or a fall while waterskiing. Initial symptoms are severe pain with varying degrees of hearing loss and vestibular symptoms. A physical examination demonstrates a fresh, ragged perforation of the tympanic membrane. Otomicroscopic examination is required to evaluate for ossicular discontinuity, and an audiogram is obtained to evaluate potential hearing loss. Treatment is dictated by the severity of injury and includes preventing water from entering the middle ear space.
Acute severe otalgia with possible hearing loss and tinnitus in the patient who has been recently flying or scuba diving usually indicates barotrauma to the middle ear. Otoscopy may reveal a thickened, hemorrhagic tympanic membrane and a middle ear effusion. 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 for the otalgia.
A typical scenario for this disease is a patient who was diagnosed with acute otitis media and correctly given oral antibiotic therapy with initial improvement of symptoms. Relapse occurs secondary to the emergence of resistant organisms or insufficient antibiotic therapy. Symptoms of otalgia and otorrhea, with the additional findings of a tender protruding auricle and doughy swelling behind the ear, are diagnostic. Particular to this entity is the finding of marked posterior external canal edema and lack of anterior canal edema. Treatment includes myringotomy for culture, ventilation tube placement, possible mastoidectomy, and intravenous antibiotics.
Tumors of the middle ear are extremely rare, but must be considered in patients with unremitting, deep-seated otalgia. Polypoid or friable middle ear tissue prolapsing into the external auditory canal is suspicious for malignancy and should be referred for biopsy.
Otalgia can be referred from distant sites secondary to inflammatory processes, tumors, or mechanical disturbances. These can all mimic primary ear disease. Pain is referred from distant sites, primarily via cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and X (vagus), and cervical nerves C-2 and C-3. Distant sources of otalgia must be searched for by physical examination when the otologic examination is unrevealing.
Periauricular lymphadenitis may occur secondary to local skin or scalp infection and may cause mild otalgia. Treatment is directed to the cause of the infection.
Temporomandibular Ioint Dysfunction
Typically, the patient with temporomandibular joint dysfunction will present with episodes of acute, unilateral otalgia followed by a continual dull ache in the area. Palpation over the joint while the patient opens and closes his or her mouth allows the examiner to diagnose this by finding a clicking or grinding action within the joint. Pain may be temporally related to chewing and jaw motion, and may be worse in the morning if bruxism is the cause. Headaches are also a common accompanying symptom. Otalgia may be caused by nerve irritation, muscle spasm, or degenerative changes in the joint. Treatment is directed at reducing the inflammation and pain, primarily with local heat therapy, soft diet, and analgesics. Long-term therapy is directed at correcting the underlying causes, which are typically trauma, orthodontic procedures, malocclusion, or bruxism.
The trigeminal nerve branches into three divisions to provide sensory innervation to the face, the sinuses, the nasal cavity, and the oral cavity. Pain from erupting teeth or gingival irritation commonly causes referred otalgia in young children.
Distal Causes of Otalgia
Otalgia secondary to diseases in the oral cavity, the pharynx, the paranasal sinuses, and the esophagus includes both inflammatory and malignant etiologies. In children, infectious causes such as pharyngitis, tonsillitis, and sinusitis are most common. Treatment is directed to the most likely organisms involved.
Otalgia is a common symptom in the pediatric patient, but its cause can be elusive. A thorough history and physical examination can usually provide a diagnosis. However, when a visible reason for the otalgia is not present, one must search carefully for a referred cause of pain.
Causes of Otalgia In the Pediatric Patient