Ear pain resident survival guide (pediatrics)

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 in children. The 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 refered ear pain.

Causes

Life Threatening Causes

Ear pain is not life threatening

primary otalgia

Otitis externa (swimmer's ear)

• Pseudomonas.
• Staph aureus.

Mechanical obstruction

• Earwax
• Foreign body

Otitis media

• Common cold or upper respiratory tract infection
• Streptococcus pneumoniae
• Nontypable Haemophilus influenzae
• Moraxella catarrhalis
• Congenital ear anomalies(cleft palate)

Otitis media with effusion

• Enter into group child care(Amounts of time spent)
• Exposure of smoking
• Peroid of breastfeeding

Truma

• Air travel

secondary otalgia

Refered ear pain

• Tonsillitis and Tonsillectomy

• Toothaches.

• Sorethroat.
• Mumps
• Dental infections
• Temporomandibular joint disorder (TMJ)

Classification of otitis media

• Acute otitis media (AOM).
• Recurrent acute otitis media (RAOM).
• Otitis media with effusion (OME).
• Chronic otitis media with effusion (COME)

FIRE: Focused Initial Rapid Evaluation

Parents are considered as most reliable proxy for assessing ear pain at young children . 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 or there is foreign body.

Ear pain

• Abnormal tympanic membrane examination(otoscopy).
  • primary otalgia.

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

• imaging studies.

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

Table

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

Characterize the pain Usually the parents use pain scales to detect pain in their young children . 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 Enter into group child care and amounts of time spent. Exposure of smoking. Period of breastfeeding. Swimming Recurrent ear pain. Skills developmental delay like (language delay) due to hearing loss.

Examination Face (lymph node, mastoids, temporomandibular joints, and maxillary sinuses), mouth, and throat. Skin especially around the ear (mastoiditis) Myringotomy It does not do for children who have been diagnosed on the basis of assessment in the clinic. Tympanic membrane. If the tympanic membrane is abnormal the most cause of it by primary otalgia. The most cause of primary otalgia include Acute otitis media. Cloudy, bulging PMID: 22459064 erythema of the tympanic membrane. Acute onset symptoms and signs fever, otalgia also see irritability, otorrhea, anorexia, and vomiting. Usually affects children aged under 2 years, Otitis media with effusion. Retracted/concave tympanic membrane with change colour of tympanic membrane (yellow,amber,blue) , and air–fluid levels. Absence of signs and symptoms (asymptomatic). Hearing loss.This is lead to speech delays.It is detected on screening of asymptomatic children. Affects children between 3 and 7 years old. Chronic otitis media with effusion. Persiste of acute otitis media for ≥3 mo from the date of onset. Tympanic membrane perforation and associated middle ear discharge. Recurrent acute otitis media. Child has three episodes of acute otitis media within a 6-month period, or four in one year. Otitis externa (swimmer's ear). Inflammation at the external ear canal,erythema and edema this lead to narrow it also may be involve the pinna or tympanic membrane. Ear pain ,hearing loss, itching, and otorrhea. Ear wax. See wax. Hearing loss, itching, pain, tinnitus.

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, provided treatment recommendation when diagnosis was uncertain.
	Presence of MEE	Mild bulging of TM and recentb onset ear painc or 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 initial antibiotic therapy	Option for observation: 6 mo–2 y: Option if uncertain diagnosis and nonsevere illnessd ≥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 small benefit 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 severee illness ≥2 y: Certain diagnosis and severee illness	Antibiotics recommended: 6 mo–2 y: Otorrhea or severee illness or bilateral without otorrhea ≥2 y: Otorrhea or severee illness	More stringent diagnostic guidelines in 2013 should lead to greater antibiotic benefit.
	Antibiotics an option: 6 mo–2 y: Uncertain diagnosis and nonsevered 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.

aSigns 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.

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

dNonsevere illness 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 less than 39°C.”

eSevere 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. The 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.

Treatment

Condition	Management
Acute Otitis Media	cx
Chronic Otitis Media
Acute Otitis externa
Malignant Otitis externa

• Acut otitis media.
  • In general,approximately 80% of children have spontaneous relief of AOM within 2–14 days who absence of suspected complications it follow 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.
  • If we use analgisic.
    • Oral acetaminophen and ibuprofen are commonly used to treat pain in children.
  • If we use antibiotics.
    • Amoxicillin (90 mg/kg per day) is the recommended first-line agent in the 2013 guidelines.
    • Amoxicillin with beta-lactamase coverage the patient has concurrent purulent conjunctivitis or recurrent acut otitis media unresponsive to amoxicillin.
    • If there is penicillin-sensitive patients we can use second- or third-generation cephalosporins, including intramuscular ceftriaxone or if penicillin-sensitive patients or amoxicillin failures we can use second- and third-generation cephalosporins and clindamycin.
    • Tympanocentesis use for drainage (theraby) and culture in difficult cases.
• Acute otitis externa.
  • American guidelines promote initial ototopical therapy without systemic antibiotics for uncomplicated acute otitis externa such as topical antibiotics with or witout topical corticosteroids.
  • Oral antibiotics use for infection has spread beyond the ear canal.
• Tonsilitis.
  • Treatment depends on to cause.
  • IF the cause is viral it is go by alone.
  • Antibiotics.
    • If the cause is group A streptococcus the first-line therapy antibiotics are useing is penicillin or amoxicillin .If there is alergic to pinicillin we can use a macrolide .If there is not response to penicillin therapy we can use clindamycin or amoxicillin-clavulanate .
  • Pain medication.
    • Paracetamol or ibuprofen.
  • Surgery.
    • Tonsillectomy . It is as a choice for treatment the chronic tonsillitis
• Ear wax
  • First-line treatmen is softening ear drops (oil or water).
  • Ear syringing.

Do's

• Otitis media
  • Vaccine
    • Pneumococcal vaccine prevent otitis media.
• Breastfeeding.
• When travel
  • (For child)Chew gum or suck candy or give your child acetaminophen or ibuprofen about 30 minutes before takeoff or landing.
  • (For infant ) breastfeeding, or sucking on pacifiers.
• Otitis externa ( swimmer's ear )
  • Keep your ear drying by use a clean towel after swimming, or showering.
  • Use a cotton ball as an earplug while take a shower or swimming to protect the ear during healing.
• Use a cold pack outside the ear to reduce pain for 20 minutes.
• Use pain relievers such as acetaminophen or ibuprofen.
• The upright position can reduce pressure in the middle ear.
• tonsilitis.
  • Drink more water.
  • If there is pain during swallow eat smooth foods like soups.
    • Wash your hands.
    • Gargles with saltwate.
    • Stay away from things cause irritation the throat like smoke.

Don'ts

• Do not use antibiotics unless necessary because widespread use can lead to resistent.
• Do not let child sleep during takeoff or landing because when he awake he can swallow more.
• Don not use aspirin.
• Do not smocking near the children because it increase the ear infection.