Evaluation of earache in children
- David Greenes, MD
David Greenes, MD
- Clinical Assistant Professor of Pediatrics
- Harvard Medical School
- Section Editor
- Gary R Fleisher, MD
Gary R Fleisher, MD
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Pediatric Signs and Symptoms
- Egan Family Foundation Professor
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Ear pain (or otalgia) ranks as one of the leading complaints among children evaluated in the primary care or emergency setting. Most patients will have one of three common diagnoses (acute otitis media, otitis externa, or otitis media with effusion) which are generally not serious. The rare cases of more serious disease associated with ear pain usually result from extension of ear infection to adjacent anatomic structures (eg, mastoiditis, meningitis, malignant otitis externa, venous sinus thrombosis). Basilar skull fracture or epidural hematoma after head trauma may also present with ear pain.
The differential diagnosis of ear pain can be categorized by the anatomic site from which the pain originates (table 1). Patients with primary otalgia have pain originating from the ear itself. Secondary otalgia is referred pain, originating in another anatomic site but causing the sensation of arising from the ear.
Contusion (auricular hematoma) — Blunt trauma to the external ear may result in contusions of the auricle. Physical findings may include swelling, ecchymosis, and tenderness overlying the auricle. Lacerations to the ear may also occur. Care should be taken to evaluate for lacerations involving the perichondrium or cartilage itself, which will require a layered repair and present an increased risk of infection.
Auricular hematomas are localized collections of subperichondrial blood that typically result either from blunt impact or from friction, as commonly occurs during wrestling . Shearing of the perichondrium away from the underlying cartilage results in rupture of the subperichondrial blood vessels. The hematomas are typically found in the anterior superior part of the auricle and present as a fluctuant, purple or red, mildly tender mass. Hematoma drainage followed by careful pressure bandaging of the auricle to prevent reaccumulation of the hematoma is essential to optimal cosmetic outcome.
Cellulitis — Cellulitis of the auricle frequently develops after trauma, an insect bite, or an ear piercing. Patients present with fairly rapid onset and progression of pain, redness, swelling, tenderness, and induration. In some cases, the swollen auricle will appear to protrude outward.
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- DIFFERENTIAL DIAGNOSIS
- - Contusion (auricular hematoma)
- - Cellulitis
- - Herpes zoster oticus
- - Allergic angioedema
- - Environmental injuries to the ear
- Ear canal
- - Otitis externa
- - Malignant otitis externa
- - Contact dermatitis
- - Furuncle
- - Foreign body
- - Cerumen impaction
- - Tumor
- Middle and inner ear
- - Acute otitis media (AOM)
- - Complications of AOM
- - Otitis media with effusion (OME)
- - Cholesteatoma
- - Traumatic tympanic membrane (TM) perforation
- - Traumatic disruption of the ossicles or inner ear
- - Hemotympanum
- - Basilar skull fracture
- Secondary otalgia
- - Auricular lymphadenopathy or lymphadenitis
- - Parotitis
- - Temporal mandibular joint (TMJ) dysfunction syndrome
- - Facial nerve (Bells) palsy
- - Oropharyngeal infections
- - Sinusitis
- - Cervical spine injury
- PHYSICAL EXAMINATION
- External ear
- Auditory canal and middle ear
- Sources of secondary otalgia
- ANCILLARY STUDIES
- The critically ill patient
- Ear pain in the trauma patient
- Nontraumatic ear pain
- - External ear disease
- - Tragal motion tenderness
- - Auditory canal mass
- - Middle ear disease
- Secondary causes of otalgia
- INFORMATION FOR PATIENTS