UBC Objective: Care of Children + Adolescents & Priority Topic: Earache

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Manage common paediatric problems in an office setting

Key Feature 1: Make the diagnosis of otitis media (OM) only after good visualization of the eardrum (i.e., wax must be removed), and when sufficient changes are present in the eardrum, such as bulging or distorted light reflex (i.e., not all red eardrums indicate OM).
Skill: Clinical Reasoning, Psychomotor Skills/Procedure Skills
Phase: Diagnosis, Physical

Key Feature 2: Include pain referred from other sources in the differential diagnosis of an earache (ex: tooth abscess, trigeminal Neuralgia, TMJ dysfunction, pharyngitis, etc.).
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 3: Consider serious causes in the differential diagnosis of an earache (ex: tumours, temporal arteritis, mastoiditis).
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 4: In the treatment of otitis media, explore the possibility of not giving antibiotics, thereby limiting their use (ex: through proper patient selection and patient education because most otitis Media is of viral origin), and by ensuring good follow-up (ex: reassessment in 48 hours).
Skill: Selectivity, Communication
Phase: Treatment

Key Feature 5: Make rational drug choices when selecting antibiotic therapy for the treatment of otitis media. (Use first-line agents unless given a specific indication not to.)
Skill: Selectivity, Professionalism
Phase: Treatment

Key Feature 6: In patients with earache (especially those with otitis media), recommend appropriate pain control (oral analgesics).
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 7: In a child with a fever and a red eardrum, look for other possible causes of the fever (i.e., do not assume that the red ear is causing the fever).
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 8: Test children with recurrent ear infections for hearing loss.
Skill: Clinical Reasoning
Phase: Investigation

According to the UpToDate article Evaluation of earache in children, "The diagnosis of acute otitis media (AOM) requires bulging of the tympanic membrane or other signs of acute inflammation and middle ear effusion. The importance of accurate diagnosis is crucial to avoidance of unnecessary treatment." Thus, if the view of the tympanic membrane is obstructed, one cannot make a diagnosis of acute otitis media. If there is cerumen impaction, this must first be disimpacted so that the tympanic membrane can be visualized. This can be done using cerumenolytics, +/- irrigation, +/- mechanical removal. And then, when the tympanic membrane is visualized, it is important to look for signs of inflammation suggestive of AOM. The most specific finding is a bulging membrane, which bulges from the increased quantity of inflammatory fluid in the middle ear space. Although a red tympanic membrane can be in keeping with an AOM, there other reasons that can cause the eardrum to become red (such as fever and crying, which are both common findings in children who are being brought in for assessment of possible ear infection but that may very well be occurring for reasons other than an ear infection). This means that a red eardrum in isolation is not a sufficient finding on otoscopy to make a diagnosis of AOM, and other sources of infection should be sought in a child with a fever.

Although the most common reason for a child to present with ear pain is AOM, there is a big differential for ear pain that must be considered. My general DDx for ear pain is as follows:

1. External ear pain 
   1. Infections 
      1. Otitis externa (ex: fungal, bacterial) 
      2. Auricular cellulitis 
      3. Perichondritis
      4. External canal abscess 
   2. Trauma (ex: frostbite, piercings) 
   3. Other (ex: foreign body, cerumen impaction) 
2. Middle and inner ear pain 
   1. Infections or inflammation 
      1. Acute otitis media 
      2. Serous otitis media 
      3. Mastoiditis 
      4. Myringitis
   2. Trauma (ex: perforation, barotrauma) 
   3. Neoplasms 
3. Referred pain 
   1. Infections (ex: sinusitis, dental disease) 
   2. Trigeminal neuralgia 
   3. Other (ex: temporomandibular joint dysfunction, thyroiditis) 

If a patient does indeed have evidence of AOM then a decision needs to be made about whether or not to prescribe antibiotics. UpToDate recommends that children less than 2 years old with evidence of AOM on examination be given antibiotics, while being more conservative about antibiotic prescribing in children 2 years and up. They suggest that antibiotics in this latter age group should be prescribed based on the presence of any of the following features:

• Toxic appearance
• Persistent otalgia for >48 hours
• Temperature ≥39°C in the past 48 hours
• Bilateral AOM
• Otorrhea
• Uncertain access to follow-up

In on other words, initial observation may be appropriate in a child 2 years of age or older with evidence of AOM on exam, if the caretakers are reliable to follow-up if indicated (for any of the above-listed features).

First-line treatment for AOM, according to Bugs & Drugs, is penicillin 40 mg/kg/d PO divided TID for 5-10 days in an otherwise healthy child, or 1 g PO TID x 5 days in an otherwise healthy adult (an uncommon disease process in adults). And whether or not antibiotics are prescribed, it is recommended that the ear pain be treated with oral ibuprofen or acetaminophen. 

If a child has recurrent AOM (defined as at least 3 episodes in 6 months or at least 4 episode in 12 months) with middle ear effusions, consider sending them to see an ENT Surgeon in consideration of tympanostomy tube insertion. The reason this would be done would be to prevent hearing loss and subsequent delay in language development in the child. If there are concerns about hearing loss that is ongoing after an AOM has been treated, consider that there may be persistent otitis media with effusion, and send the child for audiometry testing. If this is remarkable, an ENT referral would also be warranted.