Ear pain resident survival guide (pediatrics)

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

Synonyms and Keywords:

Ear pain resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Ear pain is the most common cause that affects children. Mortality rates are generally low, but the acute otitis media and otitis media with effusion have high morbidity. the child can come with fever, restless sleep, ear rubbing, irritability, excessive crying, decreased activity, poor appetite, rhinitis, nasal congestion, cough, hoarse voice, conjunctivitis, mucus vomiting.There are several causes divided into primary otalgia and secondary otologia .The primary otalogia including otitis externa (swimmer's ear), mechanical obstruction ,Otitis media ,otitis media with effusion, truma .The secondary otalgia including referred ear pain.

Causes

Life Threatening Causes

Ear pain is not life threatening[1]

Common Causes

primary otalgia [2]

Otitis externa (swimmer's ear)

Mechanical obstruction

Otitis media[8][9][10]

Otitis media with effusion[13][10][14]

Truma

secondary otalgia

Refered ear pain


Classification of otitis media

FIRE: Focused Initial Rapid Evaluation

Parents are considered as the most reliable proxy for assessing ear pain at young children[18] . If child come with restless sleep, ear rubbing, irritability, excessive crying, decreased activity, poor appetite and may be with fever we should think about ear pain .the help us to know the cause of ear pain is examination by otoscopy reveals the tympanic membrane if its bulging, retraction,fluid behind the eardrum o itf there is foreign body[19].

Ear pain[20]

  • Normal tympanic membrane examination(otoscopy).
    • secondary otalgia.
  • Imaging studies.

The IF Diagnosis is not clear from the history and physical examination.

Complete Diagnostic Approach

Treatment

Table

Key differences in the 2004 and 2013 American Academy of Pediatrics guidelines for the diagnosis and management of acute otitis media (AOM)[17]

 
 
 
 
 
 
 
 
 
 
 
 
Characterize the pain
  • Usually the parents use pain scales to detect pain in their young children .[19]
  • Ear-related symptoms: ear rubbing.
  • Non-specific symptoms: fever, irritability, excessive crying, decreased activity, poor appetite, and restless sleep.
  • Respiratory symptoms: rhinitis, cough, hoarse voice, conjunctivitis, mucus vomiting, and nasal congestion.
  • Gastrointestinal symptoms: vomiting, and diarrhea.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examination

It does not do for children who have been diagnosed on the basis of assessment in the clinic. [21] [10]

If the tympanic membrane is abnormal, the most likely cause of it by primary otalgia. The main causes of primary otalgia include

 
 
 
 
 
Subject 2004 2013 Rationale for 2013 Changes
Children <6 mo Treat with antibiotic therapy No recommendations

Diagnosis of AOM Acute onset of signs and symptoms Moderate to severe bulging of TM, or new-onset otorrhea not owing to acute otitis externa 2004 criteria allowed less precise diagnosis and provided treatment recommendation when diagnosis was uncertain.
Presence of MEE Mild bulging of TM and recent onset ear pain and intense TM erythema
Signs and symptoms of middle ear inflammationa Must have MEE

Uncertain diagnosis Expected and included in treatment guidelines Excluded Emphasized need for diagnosis of AOM for best management.

Initial observation option instead of the initial antibiotic therapy Option for observation:
  • 6 mo–2 y: Option if uncertain diagnosis or nonsevere illness
  • ≥2 y: Option if nonsevered and certain diagnosis
Option for observation:
  • 6 mo–2 y: Unilateral OM without otorrhea
  • ≥2 y: Unilateral or bilateral AOM without otorrhea
Favorable natural history overall.
Observation recommended:
  • ≥2 y and uncertain diagnosis
Observation recommended:
  • None
Evidence of the small benefits of antibiotics in recent trials that used stringent diagnostic criteria.

Initial antibiotic therapy recommended Antibiotics recommended:
  • <6 mo: All cases
  • 6 mo–2 y: Certain diagnosis, or uncertain diagnosis if severe illness
  • ≥2 y: Certain diagnosis and severe illness
Antibiotics recommended:
  • 6 mo–2 y: Otorrhea or severe illness or bilateral without otorrhea
  • ≥2 y: Otorrhea or severe illness
More stringent diagnostic guidelines in 2013 should lead to greater antibiotic benefit.
Antibiotics an option:
  • 6 mo–2 y: Uncertain diagnosis and non-severed illness
  • ≥2 y: Certain diagnosis and nonsevered illness
Antibiotics an option:
  • 6 mo–2 y: Unilateral without otorrhea
  • ≥2 y: Bilateral without otorrhea or unilateral without otorrhea
Greater antibiotic benefit for bilateral disease, AOM with otorrhea.
Two recent studies show small benefit of antibiotics for age 6–24 mo.

Recurrent AOM No recommendations Do not prescribe prophylactic antibiotics Minimal benefit for prophylaxis and antibiotics come with risks (antibiotic resistance and adverse effects).
May offer tympanostomy tubes Modest reduction in AOM with tubes.

Abbreviations: MEE, middle ear effusion; TM, tympanic membrane.

Signs and symptoms of middle ear inflammation include distinct erythema of TM or distinct otalgia (‘discomfort clearly referable to the ear's) that results in interference with or precludes normal activity or sleep’).

bRecent: <48 hours.

Ear pain may be indicated by holding, tugging, or rubbing of the ear in a nonverbal child.

non-severe illness was defined as mild otalgia and fever <39°C in the past 24 hours in the 2004 guideline; the 2013 guideline modifies this to “mild otalgia for less than 48 hours and temperature of less than 39°C.”

Severe signs or symptoms include moderate or severe otalgia or temperature ≥39°C in 2004 guideline; the 2013 guideline also includes otalgia for ≥48 hours.

Adapted from Lieberthal AS, Carroll AE, Chonmaitree T, et al. diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964–99; and American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113(5):1451–65


 
 
 
 
Treat the underlying causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fatigue due to Acut otitis media

❑In general,approximately 80% of children have spontaneous relief AOM within 2–14 days who absence of suspected complications follows initial treatment of symptomatic (analgesia and antipyretics) as fever and ear pain.If severe,recurrent infections or persistent give antibioticor if there is complication may offer tympanostomy tubes.[10]
❑If we use analgisic[17]Oral acetaminophen and ibuprofen are commonly used to treat pain in children.[26]
❑ If we use antibiotics.[17]

 
Fatigue due toAcute otitis externa[23]

❑American guidelines promote initial ototopical therapy without systemic antibiotics for uncomplicated acute otitis externa such as topical antibiotics with or without topical corticosteroids.

❑Oral antibiotics use for infection have spread beyond the ear canal.
 
Fatigue due to Otitis media with effusion.

❑Antibiotics, histamines or decongestants not effect at treatment[27] ❑In less sever case and without hearing problems, the effusion can resolve spontaneously or with autoinflation [28]

❑In sever case or persistent symptomatic cases, the treatment is by tympanostomy with or without adenoidectomy.[29][30]
 
Fatigue due to Tonsilitis

❑Treatment depends on to cause.
❑IF the cause is viral it is go by alone.[31] ❑Antibiotics.

  • If the cause is group A streptococcus, the first-line therapy antibiotics are using is penicillin or amoxicillin[32][33] .If there is alergic to pinicillin we can use a macrolide [34].If there is no response to penicillin therapy, we can use clindamycin or amoxicillin-clavulanate[35] .

❑Pain medication. ❑Surgery.

  • Tonsillectomy[36] . It is as a choice for treatment the chronic tonsillitis
 
Fatigue due to Ear wax

❑First-line treatmen is softening ear drops (oil or water).[37] [38]

❑Ear syringing.

Do's

Don'ts

  • Do not use antibiotics unless necessary because widespread use can lead to resistent.[10]
  • Do not let child sleep during takeoff or landing because when he awakes he can swallow more.[39]
  • Don not use aspirin.[41]
  • Do not smocking near the children because it incresase the ear infection.[41]


References

  1. 1.0 1.1 Earwood JS, Rogers TS, Rathjen NA (2018). "Ear Pain: Diagnosing Common and Uncommon Causes". Am Fam Physician. 97 (1): 20–27. PMID 29365233.
  2. 2.0 2.1 Neilan RE, Roland PS (2010). "Otalgia". Med Clin North Am. 94 (5): 961–71. doi:10.1016/j.mcna.2010.05.004. PMID 20736106.
  3. Zichichi L, Asta G, Noto G (2000). "Pseudomonas aeruginosa folliculitis after shower/bath exposure". Int J Dermatol. 39 (4): 270–3. doi:10.1046/j.1365-4362.2000.00931.x. PMID 10809975.
  4. Wang MC, Liu CY, Shiao AS, Wang T (2005). "Ear problems in swimmers". J Chin Med Assoc. 68 (8): 347–52. doi:10.1016/S1726-4901(09)70174-1. PMID 16138712.
  5. Schaefer P, Baugh RF (2012). "Acute otitis externa: an update". Am Fam Physician. 86 (11): 1055–61. PMID 23198673.
  6. Schwartz SR, Magit AE, Rosenfeld RM, Ballachanda BB, Hackell JM, Krouse HJ; et al. (2017). "Clinical Practice Guideline (Update): Earwax (Cerumen Impaction) Executive Summary". Otolaryngol Head Neck Surg. 156 (1): 14–29. doi:10.1177/0194599816678832. PMID 28045632.
  7. Conover K (2013). "Earache". Emerg Med Clin North Am. 31 (2): 413–42. doi:10.1016/j.emc.2013.02.001. PMID 23601480.
  8. Teele DW, Klein JO, Rosner B (1989). "Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective cohort study". J Infect Dis. 160 (1): 83–94. doi:10.1093/infdis/160.1.83. PMID 2732519.
  9. Leung AKC, Wong AHC (2017). "Acute Otitis Media in Children". Recent Pat Inflamm Allergy Drug Discov. 11 (1): 32–40. doi:10.2174/1874609810666170712145332. PMID 28707578.
  10. 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 Qureishi A, Lee Y, Belfield K, Birchall JP, Daniel M (2014). "Update on otitis media - prevention and treatment". Infect Drug Resist. 7: 15–24. doi:10.2147/IDR.S39637. PMC 3894142. PMID 24453496.
  11. 11.0 11.1 Worrall G (2011). "Acute earache". Can Fam Physician. 57 (9): 1019–21, e320–2. PMC 3173423. PMID 21918146.
  12. Sando I, Takahashi H (1990). "Otitis media in association with various congenital diseases. Preliminary study". Ann Otol Rhinol Laryngol Suppl. 148: 13–6. doi:10.1177/00034894900990s605. PMID 2140931.
  13. Kubba H, Pearson JP, Birchall JP (2000). "The aetiology of otitis media with effusion: a review". Clin Otolaryngol Allied Sci. 25 (3): 181–94. doi:10.1046/j.1365-2273.2000.00350.x. PMID 10944048.
  14. Owen MJ, Baldwin CD, Swank PR, Pannu AK, Johnson DL, Howie VM (1993). "Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life". J Pediatr. 123 (5): 702–11. doi:10.1016/s0022-3476(05)80843-1. PMID 8229477.
  15. Wright T (2015). "Middle-ear pain and trauma during air travel". BMJ Clin Evid. 2015. PMC 4298289. PMID 25599243.
  16. Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA; et al. (2019). "Clinical Practice Guideline: Tonsillectomy in Children (Update)". Otolaryngol Head Neck Surg. 160 (1_suppl): S1–S42. doi:10.1177/0194599818801757. PMID 30798778.
  17. 17.0 17.1 17.2 17.3 17.4 Rettig E, Tunkel DE (2014). "Contemporary concepts in management of acute otitis media in children". Otolaryngol Clin North Am. 47 (5): 651–72. doi:10.1016/j.otc.2014.06.006. PMC 4393005. PMID 25213276.
  18. American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health. Task Force on Pain in Infants, Children, and Adolescents (2001). "The assessment and management of acute pain in infants, children, and adolescents". Pediatrics. 108 (3): 793–7. doi:10.1542/peds.108.3.793. PMID 11533354.
  19. 19.0 19.1 Uitti JM, Salanterä S, Laine MK, Tähtinen PA, Ruohola A (2018). "Adaptation of pain scales for parent observation: are pain scales and symptoms useful in detecting pain of young children with the suspicion of acute otitis media?". BMC Pediatr. 18 (1): 392. doi:10.1186/s12887-018-1361-y. PMC 6302518. PMID 30572868.
  20. Ely JW, Hansen MR, Clark EC (2008). "Diagnosis of ear pain". Am Fam Physician. 77 (5): 621–8. PMID 18350760.
  21. Rovers MM, Schilder AG, Zielhuis GA, Rosenfeld RM (2004). "Otitis media". Lancet. 363 (9407): 465–73. doi:10.1016/S0140-6736(04)15495-0. PMID 14962529.
  22. Schilder AG, Chonmaitree T, Cripps AW, Rosenfeld RM, Casselbrant ML, Haggard MP; et al. (2016). "Otitis media". Nat Rev Dis Primers. 2: 16063. doi:10.1038/nrdp.2016.63. PMC 7097351 Check |pmc= value (help). PMID 27604644.
  23. 23.0 23.1 Schaefer P, Baugh RF (2012). "Acute otitis externa: an update". Am Fam Physician. 86 (11): 1055–61. PMID 23198673.
  24. Browning GG (2008). "Ear wax". BMJ Clin Evid. 2008. PMC 2907972. PMID 19450340.
  25. Michaudet C, Malaty J (2018). "Cerumen Impaction: Diagnosis and Management". Am Fam Physician. 98 (8): 525–529. PMID 30277727.
  26. Bertin L, Pons G, d'Athis P, Duhamel JF, Maudelonde C, Lasfargues G; et al. (1996). "A randomized, double-blind, multicentre trial of ibuprofen versus acetaminophen and placebo for symptoms of acute otitis media in children". Fundam Clin Pharmacol. 10 (4): 387–92. doi:10.1111/j.1472-8206.1996.tb00590.x. PMID 8871138.
  27. Griffin G, Flynn CA (2011). "Antihistamines and/or decongestants for otitis media with effusion (OME) in children". Cochrane Database Syst Rev (9): CD003423. doi:10.1002/14651858.CD003423.pub3. PMC 7170417 Check |pmc= value (help). PMID 21901683.
  28. Blanshard JD, Maw AR, Bawden R (1993). "Conservative treatment of otitis media with effusion by autoinflation of the middle ear". Clin Otolaryngol Allied Sci. 18 (3): 188–92. doi:10.1111/j.1365-2273.1993.tb00827.x. PMID 8365006.
  29. Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ (2010). "Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children". Cochrane Database Syst Rev (10): CD001801. doi:10.1002/14651858.CD001801.pub3. PMID 20927726.
  30. Atkinson H, Wallis S, Coatesworth AP (2015). "Otitis media with effusion". Postgrad Med. 127 (4): 381–5. doi:10.1080/00325481.2015.1028317. PMID 25913597.
  31. 31.0 31.1 [+https://medlineplus.gov/tonsillitis.html "Tonsillitis | Tonsillitis Symptoms | Tonsillitis Treatment | MedlinePlus"] Check |url= value (help).
  32. Bird JH, Biggs TC, King EV (2014). "Controversies in the review of acute tonsillitis: an evidence-based review". Clin Otolaryngol. 39 (6): 368–74. doi:10.1111/coa.12299. PMC 7162355 Check |pmc= value (help). PMID 25418818.
  33. Touw-Otten FW, Johansen KS (1992). "Diagnosis, antibiotic treatment and outcome of acute tonsillitis: report of a WHO Regional Office for Europe study in 17 European countries". Fam Pract. 9 (3): 255–62. doi:10.1093/fampra/9.3.255. PMID 1459378.
  34. Casey JR, Pichichero ME (2004). "Meta-analysis of cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis in children". Pediatrics. 113 (4): 866–82. doi:10.1542/peds.113.4.866. PMID 15060239.
  35. Brook I (2009). "The role of beta-lactamase-producing-bacteria in mixed infections". BMC Infect Dis. 9: 202. doi:10.1186/1471-2334-9-202. PMC 2804585. PMID 20003454.
  36. Burton MJ, Glasziou PP, Chong LY, Venekamp RP (2014). "Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis". Cochrane Database Syst Rev (11): CD001802. doi:10.1002/14651858.CD001802.pub3. PMC 7075105 Check |pmc= value (help). PMID 25407135. Review in: Evid Based Med. 2015 Apr;20(2):64
  37. Aaron K, Cooper TE, Warner L, Burton MJ (2018). "Ear drops for the removal of ear wax". Cochrane Database Syst Rev. 7: CD012171. doi:10.1002/14651858.CD012171.pub2. PMC 6492540. PMID 30043448.
  38. Poulton S, Yau S, Anderson D, Bennett D (2015). "Ear wax management". Aust Fam Physician. 44 (10): 731–4. PMID 26484488.
  39. 39.0 39.1 "Traveling with children: MedlinePlus Medical Encyclopedia".
  40. "Swimmer's Ear (External Otitis) (for Teens) - Nemours KidsHealth".
  41. 41.0 41.1 41.2 41.3 41.4 "Earache: MedlinePlus Medical Encyclopedia".