1 Ear pain.pptx

CLINICAL OBJECTIVES
 List the most common infectious and noninfectious causes of pain in the ear.
 Discuss the reliability of the diagnostic tests for otitis media.
 Describe the optimal management of acute suppurative otitis media.
 Compare and contract strategies that are most effective for preventing recurrence of otitis media
in children with frequent infections

Ear Pain
 Ear pain is one of the most common reasons why parents seek care for their children from
primary care physicians.
 Otitis media was the third most common reason for visiting a physician in a study of community
practices .
 Ear wax, serous otitis media, and otitis externa also ranked in the top 50 most common
diagnoses . Although these problems are infrequently life-threatening, they commonly cause a
significant amount of anxiety and suffering in primary care patients as well as posing significant
costs to the health care system /

APPLIED ANATOMY
 The ear is innervated by three different neural pathways : The external ear, conchae, and
external auditory canal receive primary sensory innervation from somatic sensory fibers of
the facial nerve (7th cranial nerve).
 Parts of the external auditory canal also receive sensory innervation from the auricular
branch of the vagus (Arnold nerve), which contains nerve fibers from the 7th cranial nerve
as well as the 9th and 10th nerves.
 The stimulation of the Arnold nerve in the external auditory canal sometimes produces
cough through vagal stimulation. The Arnold nerve also is involved in herpes zoster
infections of the external ear canal. On the other hand, the middle ear receives its neural
innervation through branches of the glossopharyngeal nerve (9th cranial nerve) only.
 because this nerve innervates the throat and tongue, it is common for throat pain to be
referred to the middle ear.
 The separate innervation of the middle and external ears can be useful in differentiating the
source of pain.

APPLIED ANATOMY
 Retraction of the conchae or pressure on the tragus (the tragus sign) in the case of external
otitis or trauma to the external auditory canal will cause pain because of local inflammation of
the 7th cranial nerve. However, stimulation of the external ear typically will not produce pain
with otitis media.
 The inner ear, on the other hand, is innervated by the 8th cranial nerve, the vestibulocochlear
nerve. The nerve is made up of two large divisions (the vestibular and cochlear nerves) that
transmit information relating to balance and sound to the medulla. Dysfunction in the
vestibulocochlear nerve results in symptoms such as hearing loss, vertigo, or tinnitus

APPLIED ANATOMY
 The function and integrity of the Eustachian tube is a major factor influencing the likelihood
of a child developing middle ear infections. The role of the eustachian tube is to ventilate the
middle ear and provide mucociliary clearance for bacteria and other materials that migrate
from the nasopharynx. Ventilation is controlled by the tensor veli palatini muscle, which
opens and closes the eustachian canal to normalize pressures in the middle ear. Mucociliary
clearance is performed primarily in the lower half of the eustachian tube that is provided with
many mucous glands.
 Dysfunction of the eustachian tube disrupts proper ventilation of the middle ear and can
result in a negative pressure that pulls fluid into the middle ear space. Stasis of this fluid
(middle ear effusion) combined with colonization with nasopharyngeal organisms can result
in otitis media.

APPLIED ANATOMY
 Conditions that are associated with poor eustachian tube function or occlusion of the lower
eustachian tube such as allergic rhinitis or upper respiratory tract infections increase the risk
of otitis media. Additionally, poor function of the tensor veli palatini muscle which is seen in
some families as well as in patients with Trisomy 21 (Down syndrome) also increase the risk
of otitis media. Finally, patients with craniofacial abnormalities that may involve the
eustachian tube also have higher incidences of otitis media.

DIFFERENTIAL DIAGNOSIS
 The most common cause of inflammation in the middle or external ears is infection.
Additionally, some pain may accompany the impaction of the external ear by foreign bodies or
with excessive cerumen due to excessive pressure in the auditory canal causing mucosal
irritation. Generally, cerumen impaction or foreign body presence does not produce pain, but
rather results in hearing loss.
 Infections of the external ear and auditory canal are defined primarily by their location:
Perichondritis is used to describe infection of the pinna. These infections usually produce a
red painful, swollen external ear. Furunculosis refers to infection of the hair follicles in the
outer third of the auditory canal. Both perichondritis and furunculosis are usually caused by
staphylococcal species or, occasionally, streptococcal species.

DIFFERENTIAL DIAGNOSIS
 Otitis externa refers to infection of the fibrocartilaginous inner two-thirds of the auditory canal,
which is devoid of hair follicles and glands and has a very friable, thin skin layer.
 The most common organism cultured from the auditory canal in otitis externa is
Pseudomonas, which can be found in association with other bacteria such as Staphylococcus
and Proteus . Infection causes edema of the ear canal and disrupts the normal squamous cell
shedding that occurs on a regular basis. This leads to the accumulation of a keratin layer in
the canal along with exudate and necrotic debris.
 Patients with repetitive trauma to any of these areas are at highest risk for the development of
an infection.

Differential Diagnosis of Ear Pain
Diagnosis Frequency in Primary Care
Acute otitis media Very common
Cerumen impaction Very common
Otitis externa common
Referred pain from throat or temporal bone common
Acoustic trauma Less common
External ear dermatitis Less common
Perichondritis Less common
Foreign body in the canal Less common
Furunculosis Rare
Mastoiditis Rare
Ear tumors (eosinophilic granulomas,
rhabdosarcomas
Rare

CLINICAL EVALUATION
 History- Decreased hearing, pain, and associated systemic signs of infections such as
fever or malaise characterize middle ear infections. The peak onset of middle ear infections
is in the first 6 years of life. About one-third of children have their first episode of otitis media
in the first year of life and often have repetitive episodes throughout their childhood.
Another third of children have only a small number of ear infections in their childhood. The
remaining third of children do not have any ear infections.

Risk Factors for Development of
Acute Otitis Media
 Age 2 years
 Male
 Genetic predisposition
 Previous episode(s) of otitis media
 Cigarette smoking in household
 Attendance at day care
 Recent upper respiratory infection

History
 In general, the most useful elements of the history in a patient with ear pain are: the location of the
pain, type of pain and actions that make the pain worse.
 Outer ear infections are sensitive to touch of the ear as described above.
 Otitis media is a deeper pain that is unaffected by movement of the outer ear.
 The most predictive symptoms for otitis media are ear pain and rubbing of the ear
 The degree of accompanying hearing loss also can be a useful historical sign.
 Complete hearing loss can occur with foreign bodies or complete canal occlusion with cerumen.
 Severe otitis externa may totally obstruct the auditory canal as well.
 Middle ear infections generally cause a dulling of sound, but hearing is still present.

History
 It is important to ask about : dental problems, pain with chewing, throat pain, or other problems that
are affecting the throat and jaw.
 Referred pain to the ear is common and other sources of the problem should be sought.
 Temporomandibular disorders are particularly prone to ear pain . In patients with temporomandibular
disorders, the prevalence of otalgia without infection varies between 12 and 16% . Patients with
suspected temporomandibular disorders should generally be referred to a dentist for further
assessment.

Physical Examination
 The first step in evaluating ear pain is differentiating middle ear pain, external ear pain, and referred
pain.
 Manipulation of the external ear will exacerbate most pain located in the external ear or the
auditory canal.
 Referred pain and middle ear pain will be unaffected by this maneuver.
 Inspection of the outer ear and auditory canal will confirm the presence of foreign bodies or
inflammation

 If manipulation of the outer ear fails to reproduce or worsen the pain, the source is more likely to be
the middle ear or referred pain.
 The presence of an earache along with night restlessness and a fever increase the likelihood of an
otitis media
 The next step in the evaluation is visualization of the tympanic membrane (TM) plus possible
ancillary testing such as pneumatic otoscopy and tympanometry to determine if the membrane is
mobile.
 A mobile TM suggests that no fluid is present in the middle ear and that the diagnosis of otitis media
cannot be made.

 When examining the TM when AOM is suspected, the most useful positive findings for otitis media
include a bulgin or cloudy TM.
 These findings are caused by effusion which is a necessary component to diagnose AOM and a
much better predictor than observing redness of the TM
 A TM that is only slightly red is not useful .
 The combination of a cloudy effusion, bulging membrane, and loss of mobility has a predictive value
for AOM in the mid-90th percentile .
 Note if the tympanic membrane is perforated as this will allow purulent material to exude into the
auditory canal.

 To improve diagnostic accuracy, pneumatic otoscopy can be used as an adjunctive maneuver. In
this test, air is introduced into the auditory canal while the TM is being visualized.
 Movement of the TM with increased air pressure is believed to indicate that no middle ear effusion
is present.
 This test does not improve the positive predictive value of clinical otoscopy significantly . Other
ancillary tests are described

Key Elements in the History, Physical Examination,
and Diagnostic Testing for Ear Pain
Diagnosis Diagnostic Maneuvers Reliability of Diagnostic Test
Otitis externa Pain on manipulation of outer
ear
Not tested
Acute otitis media Pneumatic otoscopy Sensitivity: 74–93%; specificity:
58–60%
Tympanometry in cooperative
children
Tympanometry in uncooperative
children
Sensitivity: 78–95%; specificity:
79–93%
Sensitivity: 71%; specificity: 38%
Acoustic reflectometry Sensitivity: 79–90%; specificity:
79–86%

Red Flags Signaling Problems
Red Flag Diagnosis Suggested
Ear lobule erythema Erysipelas
Seventh cranial nerve palsy Malignant otitis externa (Pseudomonas infection)
Ulceration in external ear canal Auditory canal tumor or tumor eroding into the
canal such as myosarcoma or
lymphoma
Nonhealing lesion in the auditory canal
Tenderness over the mastoid
Auditory canal tumor or tumor eroding into the
canal such as rhabdomyosarcoma
or lymphoma
Mastoiditis

 External ear infection (perichondritis) is generally located in the body of the auricle, but spares the
noncartilaginous lobule Involvement of the lobule of the auricle, which does not contain cartilage, is
an ominous sign that suggests a more virulent infection such as erysipelas.
 If the lobule is involved in infection, rapid initiation of antistreptococcal antibiotics is imperative to keep
the infection from rapidly progressing into the surround neck tissue.
 In otitis externa, invasion into adjoining tissue occurs most frequently in infections caused by
Pseudomonas aeruginosa. Infection with this organism, termed malignant otitis externa, can cause
widespread local invasion and bacteremia with sepsis and death. The hallmark warning signs of
Pseudomonas malignant otitis include a seventh nerve palsy on the affected side.
 Other infections, in particular, herpes zoster of the ear, also can produce a seventh nerve palsy and
must be differentiated from malignant otitis externa.

 Other warning signs in the auditory canal include an ulcerated or nonhealing lesion in the canal.
Either of these signs can indicate erosion of an adjoining tumor into the canal. If these lesions are
seen, biopsies of the ulcerated or nonhealing area are indicated.
 A final red flag seen in otitis media is tenderness over the mastoid process of the temporal bone. This
could signal mastoiditis, a chronic osseous infection that in the preantibiotic era was a significant
cause of morbidity and usually will not resolve without surgical debridement of the mastoid

Diagnostic Testing
 Tympanometry improves the sensitivity and specificity of the diagnosis of middle ear effusion
necessary to diagnose AOM.
 Tympanometry measures the amount of a test sound that transverses the TM at given positive and
negative auditory canal pressures.
 The tympanometer forms an airtight seal around the auditory canal, and a sound wave is introduced
by pushing a button on the instrument. The machine monitors the amount of the sound reflected back
from the TM. This procedure is repeated as various positive and negative pressures and the results
are plotted based on the amount of sound transmitted: usually a bellshaped curve reflects normal TM
movement.
 The reliability of the test is influenced by the level of cooperation by the patient. In poorly cooperative
children, the predictive value drops substantially
 Acoustic reflectometry, another adjunctive test, measures reflected sound off the TM. The amount of
sound reflected Is measured in decibels

Recommended Diagnostic Strategy
 A combination of history, physical examination, and diagnostic testing to diagnose otitis media
is recommended by the Agency for Healthcare Research and Quality . A 2004 American
Academy of Pediatrics and American Academy of Family Physicians (AAP/AAFP) guideline
defined AOM as:
 1) the presence of middle ear effusion (based on either diagnostic tests or physical examination
findings of opacification or a full or bulging tympanic membrane or otorrhea) plus
 2) an acute onset of signs and symptoms, together with
 3) signs and symptoms of middle ear inflammation such as erythema, otalgia, and systemic
unwellness such as fever or irritability in an infant or toddler. All three elements should be
present before AOM is diagnosed.

MANAGEMENT
Patient with ear pain
Painful outer ear?
Pain on ear movement?
Other oropharyngeal or
jaw problems?
Otitis media likely
New infection
Resistant infection?
Multiple recurrences
YES Probably outer ear infection
YES Probably auditory canal infection
YES Consider referred pain
YES
Consider antibiotic therapy
YES
Change to second line agent
YES
Treat current infection and
consider long-term chemoprophylaxis
or tube placement
F

Cerumen Impaction
 Disimpaction of cerumen is usually achieved by irrigation of the auditory canal with either water or
a 50:50 water-peroxide solution. Water temperature should be tepid and as close to body
temperature as possible. This is important both for the comfort of the patient and because the use
of water that is either too cold or too hot can precipitate a strong vestibular nerve reaction with
nystagmus and dizziness.
 Topical cerumen softening agents can be used either before irrigation (to first soften the wax) or
for cerumen that persists after irrigation, but prolonged use may cause irritation of the canal with
subsequent edema, which worsens the cerumen entrapment.
 As a last resort, cerumen can be removed with direct suction under direct microscopic
visualization, which is usually performed by an otolaryngologist.

Cerumen Impaction
 Cerumen impaction that does not impair hearing probably does not require removal and efforts
should generally be directed at avoiding total canal occlusion rather than a patient becoming reliant
on frequent irrigations.
 Patients should be advised not to insert foreign objects such as cotton-tipped swabs or other
paraphernalia into the ear canal because this is likely to push cerumen further into the canal and
result in an impaction.

Perichondritis and Furunculosis
 Broad spectrum antibiotics effective against staphylococcal and streptococcal species, such as
cephalosporins, are necessary. Because blood flow to the outer ear cartilage is scanty cartilage
necrosis with long-term ear deformity (cauliflower ear) can occur if treatment is delayed or
inadequate.
 Infection of the outer ear also is common after trauma, especially injuries such as frostbite. Close
attention to tissue healing and protection against infection is an important aspect of managing outer
ear frostbite or other traumas such as bites or scratches

Otitis Externa
 Treatment includes debridement of necrotic tissue through gentle rinsing followed by the application
of a broad-spectrum antibiotic topical solution that will cover the most common organisms in what is
usually a polymicrobial infection. For patients whose canal is obliterated by edema, the insertion of a
gauze wick may be necessary to draw antibiotics into the infected canal.
 The choice of topical antibiotic for otitis externa has not been studied extensively .
Neomycin/polymyxin B
 ear drops and ofloxacin ear drops are both popular because of their ability to eradicate
Pseudomonas. Because of ototoxicity associated with aminoglycosides, neomycin should be
avoided when the tympanic membranes is ruptured or cannot be visualized well. The addition of
corticosteroids is popular in some ear drops, although there is little evidence that this speeds healing
or prevents recurrences. Based on a clinical practice guideline , oral antibiotics such as ciprofloxacin
should be added to topical therapy for severe or recurrent cases along with aggressive aural toileting
usually performed under direct microscopic observation by an otolaryngologist.

Otitis Externa
 “Swimmers ear” is a form of recurrent or chronic otitis externa caused by chronic irritant fluid
accumulation in the acoustic canal, such as can occur in competitive swimmers.
 This is more of an inflammatory etiology than infective and the use of topical astringent drops, such
as acetic acid, sometimes combined with topical steroids such as hydrocortisone are effective along
with efforts to clear water from the ear canal when drying off.
 Prevention of recurrent otitis externa includes maneuvers to reduce the intrusion of fluids or other
materials into the ear. Cleaning of the ear by sticking instruments into the ear canal should be
avoided.
 Finally, some suggest rinsing the ear with alcohol following bathing or swimming to flush out
water that may pool in the canal. Although probably harmless, this technique has not been evaluated to
determine if it reduces recurrences.

Acute Otitis Media (AOM)
 What constitutes the most appropriate management of AOM has sparked debate for many years.
For example, in the United States, routine use of 10 days of oral antibiotics for AOM has been the
traditional treatment without evidence of superiority to other strategies . But in other countries, most
notably the Netherlands, antibiotic use for AOM is reserved for high-risk children between ages 6
months and 2 years, and not for most children older than age of 2.
 However, early use of antibiotics also has some harm: patients with AOM treated with antibiotics
early in their course are more likely to become colonized with resistant bacteria .
 It has been noted in a Dutch study that children initially treated with amoxicillin had more episodes of
recurrent AOM than those not treated with antibiotic further emphasizing the need for judicious
prescribing of antibiotics .

 To help guide clinicians, the AAP and the AAFP published an evidence-based guideline for
treatment in 2004 that remains in effect.
 For children younger than 6 months of age diagnosed with AOM, the guideline recommends
routine antibiotic administration starting with amoxicillin at a dose of 80–90 mg/kg per day .
 For children older than age 6 months, the AAP/AAFP recommendations include the option to
observe selected children without antibiotic treatment. This option should be based on the
certainty of diagnosis, the child’s age, the severity of illness, and the assurance that the patient
will be able to follow up if the symptoms do not improve in 48–72 hours. If the child is otherwise
healthy, the diagnosis is uncertain, the illness not severe, and the child’s caregiver can reliably
follow-up if symptoms do not improve, then observation and symptom treatment alone is a
reasonable strategy. If the child returns with a more definitive examination or worsening of
symptoms within 72 hours, then antibiotic therapy should be started. Another useful strategy is a
“wait and see” approach where an antibiotic is provided but parents are instructed not to fill the
prescription unless the child has persistent pain and fever. I

 Antibiotics used for 5 days or less showed equal effectiveness with longer durations of therapy .
 In addition to a cost benefit of shorter durations of therapy, reports have noted fewer drug-related
side effects in patients taking short courses of antibiotics. One study estimated that the number
needed to treat with short-duration therapy to avoid one gastrointestinal adverse effect was eight
children.
 In addition to short-duration therapy compared to long-duration therapy with oral antibiotics, a
single intramuscular dose of ceftriaxone was just as effective as a longer duration of other
antibiotics
 Because of the emergence of multiple drug resistant strains of Streptococcus pneumoniae, there
has been some concern that standard doses of medications might not be sufficient to cover
strains that are intermediately resistant. Higher dose regimens of beta-lactam resistant antibiotics,
such as amoxicillin-clavulanate have been suggested to deal with this potential problem

 The treatment of recurrent otitis media after a previous resistant episode is another area of
controversy. Some physicians treat a second episode of AOM with a second-line drug after a
previous treatment failure. However, recurrences several weeks after an initial episode are
usually produced by a new organism and do not necessarily have the same resistance pattern as
previous infections.
 One nonrandomized study that investigated the effectiveness of a second-line drug versus a first-
line agent (amoxicillin or trimethoprim-sulfamethoxazole) showed no benefit of the broader
spectrum second-line agent in a recurrent infection after a previously resistant episode . To
reduce the development of resistance, new episodes should be treated with narrower spectrum
agents, such as amoxicillin or sulfamethoxazole/trimethoprim.

 Non-antibiotic treatments for AOM include autoinflation steroids, or antihistamines. Autoinflation
refers to having children “pop” their ears by blowing out with a closed airway and nose. Modest
improvements at short and longer intervals (more than a month) have been demonstrated with
autoinflation although the number of studies is small. Based on the low risk from this activity, a
Cochrane review stated that this maneuvre is reasonable to consider. the use of oral or nasal
steroid during AOM has also shown quicker clearing of effusion
 Antihistamine-decongestant combination medication were shown to result in no greater clearing of
effusion than placebos but were associated with a greater incidence of side effects
 Antihistamine-decongestants are not recommended for AOM.

 Children who have ear perforations may experience persistent ear drainage with AOM. These
conditions can be treated with oral antibiotics, but a Cochrane review found that
fluoroquinolone-containing ear drops were superior at clearing discharge compared to oral
antibiotics .
 During episodes of AOM, management of ear pain can be accomplished with either an oral
analgesic such as acetaminophen or ibuprofen or with topical ear drops containing mild
anesthetics.

Antibiotics commonly used in Ear Infections
Drug Dosage Contraindications/Cautions/Ad
verse Effects
Otitis Externa
Neomycin solutions 3–4 drops QID 7 day Rupture of tympanic membrane,
potential
ototoxicity with ruptured tympanic
membrane
Ofloxacin solution Children 1–12 years: 5 drops
BID 10 days
Patients 12 years: 10 drops
BID 10 days
Warm bottle in hands to avoid
dizziness

verse Effects
First Line
Amoxicillin 80 mg/kg split at least
BID at least 5 days
Penicillin allergy, diarrhea (2%)
Sulfamethoxazole (SMX
trimethoprim (TMP)
40 mg/kg SMX/8 mg/kg TMP
divided BID 10 day
avoid in patients with glucose-
6-phosphatase deficiency; avoid
in folate deficiency; light
sensitivity, skin reactions (2%)
with severe reactions in (0.1%);
may cause bone
marrow suppression possible with
chronic use

verse Effects
Second Line
Ceftriaxone
Amoxicillin-clavulanate
50 mg/kg up to 1 g
20–45 mg/day of amoxicillin
component in 2 or 3 dose
Cross-reactivity with penicillin
allergy; pain at
injection site, diarrhea (5–6%)
Penicillin allergy; history of
jaundice; select appropriate
concentration; diarrhea (up to
40%)
Azithromycin
Other second- or third-genera
cephalosporins (e.g., cefaclor,
cefuroxime, cefixime)
30 mg/kg as a single dose
OR 10 mg/kg QD 3 days (3%),
abdominal pain (3%)
OR 10 mg/kg 1 day then
5 mg/kg on days 2 through 5
Varies with drug
Macrolide allergy; diarrhea (5%),
nausea
Caution in penicillin allergy,
diarrhea (3–5%), rash

verse Effects
Prophylaxis for recurrent AOM
Amoxicillin
Half daily dosage at bedtime Penicillin allergy, diarrhea 2%
Sulfamethoxazole-Trimethopri 40 mg/kg SMX/8 mg/kg
TMP QHS
Sulfa allergy, skin reactions (2%)
with severe reactions in <0.1%)

Long-Term Monitoring and Prevention
 In children with multiple, recurrent episodes of AOM, prevention of recurrent infections may be
necessary.
 Recurrent otitis is defined as three or more episodes of AOM in a 6-month period or four episodes
in a year with a normal examination documented between each infection .
 The first approach in preventing recurrences is to identify conditions that predispose children to
Eustachian tube dysfunction. Most commonly, this is an upper respiratory infection that cannot be
prevented. However, some children have chronic allergic rhinitis that results in eustachian tube
dysfunction. Treatment of these children with antihistamines or nasal steroids may reduce their risk
of a recurrent infection

Long-Term Monitoring and Prevention
 For children with no evidence of allergy, options include chronic antibiotic prophylaxis or surgical
ventilation of the inner ear through the placement of tubes.
 Tympanostomy tubes and antibiotic prophylaxis have nearly equal effectiveness for the prevention
of recurrence , but medication use is associated with fewer side effects. Antibiotic prophylaxis can
be achieved with either amoxicillin or sulfamethoxazole given as a single dose at bedtime. The
usual dose is half of the total daily treatment dose.
 For patients with tubes in place, families often are told to limit children’s exposure to water such as
swimming. One study examining the validity of this restriction showed that children allowed to
participate in surface swimming had no higher rate of ear pain or complications such as recurrent
AOM than those who were not allowed to swim.

KEY POINTS
 AOM can only be diagnosed in the presence of a middle ear effusion.
 Tympanography is a useful test if clinical exam cannot confirm the presence of a
middle ear effusion.
 AOM will resolve spontaneously in some children without antibiotics.
 High dose amoxicillin is indicated to treat intermediately resistant S. pneumonia.
 Otitis media with effusion can be treated with ventilation tubes but early insertion of
tubes offers no advantage to speech development over watchful waiting.

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