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 , otalgia , ear sore , otitis , ear infection , ear discomfort and ear aches.

Ear pain resident survival guide (pediatrics) Microchapters


Ear pain is the most common cause that affects children. Mortality rates are generally low, but 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.


Common Causes

Primary otalgia

The following are the causes of primary otalgia:[1][2]

Otitis externa (swimmer's ear)

Mechanical obstruction

Otitis media[8][9][10]

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


Secondary otalgia

Referred 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



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.

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 non-severe 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 a temperature of less than 39°C.”

Severe signs or symptoms include moderate or severe otalgia or temperature ≥39°C in 2004 guidelines; 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 the 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 used 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 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]


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