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Earache Otalgia, or ear pain, is a common problem in both children and adults and is generally caused by an inflammatory process. In children, inflammation most commonly occurs in the middle ear. Adults more often have an earache from external ear conditions or from referred pain from other head and neck structures. Acute otitis media (AOM) refers to any inflammation of the middle ear and encompasses a variety of clinical conditions. Otitis media with effusion is a collection of fluid in the middle ear. This condition is also known as serous otitis media, secretory otitis, or nonsuppurative otitis. External or middle ear disorders can often be distinguished after a brief history and physical examination. If the physical findings are normal, referred pain is a likely cause. About 50% of referred pain is caused by dental problems, although other causes may include temporomandibular joint (TMJ) disorder, parotitis, pharyngitis, and cervical, mouth, or facial disorders. The most serious, although least common, cause of referred pain is nasopharyngeal cancer, a condition more common in people of Asian descent. Figure 15.1 illustrates the structures of the ear.

FIGURE 15.1 External auditory canal, middle ear, inner ear. Source: (From Barkauskas VH, Baumann L, Darling-Fisher C: Health and physical assessment, ed. 3, St. Louis, 2002, Mosby.)

Diagnostic reasoning: Focused history Is this an acute infection? Key Questions

• How old are you? • Have you had a fever?

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• Have you had a recent upper respiratory infection? • Have you had a recent ear infection? • Is there a family history of ear infections?

Age The occurrence of AOM declines significantly after age 6 years. Increased age raises the likelihood of secondary otalgia caused by disorders of the head, face, and neck; by sinus or periodontal disease; by chronic reflux; and by malignancy.

Fever Fever is present in 60% of all children with AOM. In infants younger than 2 months, fever with AOM is uncommon. A high fever accompanying otitis is more likely to indicate a systemic illness such as pneumonia or meningitis.

Upper respiratory infection An upper respiratory infection (URI) occurs when the mucous membranes of the nasopharynx or sinuses become infected and organisms are forced up the lumen of the eustachian tube. Inflammation of the mucosa or enlarged adenoids obstruct the eustachian opening so that the air in the middle ear is absorbed and replaced by mucus. This mucus creates a mechanical obstruction and can serve as a medium for bacterial growth.

Previous infections Infants younger than 3 months who have their first AOM run a high risk of recurrence. Up to 71% of children younger than age 3 years have had at least one episode, and one­third have had an average of three episodes. Chronic otitis media can result in anatomical changes to the tympanic membrane (TM) and middle ear ossicles, which may predispose the patient to additional ear infections.

Family history Having a sibling or parent with chronic otitis media makes it twice as likely for the illness to develop in the child. The presence of chronic otitis media may also be related to child care practices such as bottle propping or environmental exposures such as secondhand cigarette smoke.

What environmental conditions might suggest increased risk? Key Questions

• Does anyone around you smoke? Do you smoke? • If a child: Does the child attend day care? • If a child: Does the infant take a bottle lying down? • Have you been swimming recently? • Have you recently been in an airplane or been scuba diving?

Smoke exposure Secondhand cigarette smoke exposure has been associated with a two­ to threefold increased risk of otitis media. Cigarette smoking leads to functional eustachian tube obstruction and decreases the protective ciliary action in the tube.

Attending day care Attending a day care with other children is associated with an increased incidence rate of otitis media because of exposure to organisms.

Bottle propping

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In very young children, lying supine while drinking from a bottle has been associated with AOM. It is postulated that swallowing while lying down allows nasopharyngeal fluid to enter the middle ear, with subsequent infection.

E V I D E N C E - B A S E D P R A C T I C E

What Is the Risk of Secondary Smoke Exposure for Otitis Media? A systematic review and meta­analysis of 61 epidemiological studies were done to examine the association between secondhand tobacco smoke (SHTS) and middle ear disease (MED) in children. Results showed that living with a smoker was associated with an increased risk of MED in children. Both maternal smoking and smoking by any household member increased risk of MED with an odds ratio (OR) of 1.62 (95% confidence interval [CI], 1.33–1.97) for maternal smoking and an OR of 1.37 (95% CI, 1.25–1.50) for any household member smoking. Maternal postnatal smoking and paternal smoking increased the risk of surgery for MED almost twofold.

Reference: Jones et al, 2012.

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Swimming Repeated or prolonged immersion in water results in loss of protective cerumen and chronic irritation, with maceration from excessive moisture in the canal. This leads to an increased occurrence of otitis externa, also called swimmer’s ear.

Airplane travelers and divers Barotrauma is a cause of acute serous otitis related to pressure changes from flying or scuba diving. This is often aggravated by recent upper respiratory tract infection (URI) or nasal congestion. Failure of the eustachian tube to open and equilibrate during descent results in a collection of serosanguineous fluid in the middle ear. This may be felt as ear pressure that can lead to pain, tinnitus, and temporary deafness. Swallowing, chewing, or blowing out the nose with the mouth and nose occluded can relieve symptoms.

Could this be related to another organ system? Key Questions

• Do you have diabetes? • Do you have any other health conditions you are being treated for? • Have you ever had dermatitis, eczema, or psoriasis? • If a child: Does the child have a cleft palate that is not repaired?

Diabetes mellitus Diabetes mellitus predisposes adults to malignant otitis externa, which is cellulitis involving the ear and surrounding tissue. People with diabetes are also at increased risk for otitis media, mastoiditis, and osteomyelitis of the skull base.

Immunosuppression Patients being treated for cancer or HIV/AIDS may be on immunosuppressive medications and are at increased risk for malignant otitis externa.

History of seborrheic dermatitis or psoriasis The etiology of debris in the external canal in seborrheic dermatitis and psoriasis is the result of the increased desquamation associated with these two disorders, and in the case of psoriasis hyperkeratosis, thickening of the epidermis with desquamation. Chronic inflammatory dermatitis can result as a reaction to wearing a hearing aid. Overproduction of sebum in the external canal can cause otitis externa.

Cleft palate Anomalies that are not repaired anatomically predispose a child to otitis media because of functional obstruction of the eustachian tubes.

What does the presence of pain tell me? Key Questions

• Where specifically is the pain felt? • Is the pain in one or both ears? • What does the pain feel like? • How severe is the pain? • Does it interfere with sleeping, eating, or other activities? • How long have you had this pain? • Is the pain constant or intermittent? If intermittent, how long does it last? • Does the pain travel (radiate) to other areas?

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Location of the pain Pain of otitis externa is described as tenderness around the outer ear or the opening to the ear canal that worsens with manipulation of the pinna. Mastoiditis is often associated with severe pain or tenderness over the mastoid bone. Bilateral pain occurs with otitis externa. Referred pain or pain of AOM is usually unilateral. Ramsay Hunt syndrome is more common in older adults and produces a painful rash with vesicles in, on, or around one ear; facial weakness may appear on the same side. Infants cannot assist in location of the ear pain; instead, they exhibit behavioral changes that may indicate pain, such as irritability, malaise, poor appetite, vomiting, and diarrhea. Young children may pull or tug at their ears.

Quality of the pain The pain of AOM is often described as a deep pain or a blockage of the ear. Serous otitis is often painless or may be described as a bubbling, popping, or stuffy sensation in the ear. Otitis externa involves a tenderness of the outer ear or ear canal that can be accompanied by itching. A cerumen impaction creates a milder pain or vague discomfort of stuffed ears.

Quantity and severity of the pain The pain of AOM is severe enough to interfere with sleep and may be suddenly relieved if the eardrum perforates. Chronic ear pain that is unresponsive to treatment may indicate a tumor.

Onset, timing, and duration of the pain Temporomandibular joint pain is often described as severe pain lasting a few minutes and recurring three or four times per day, sometimes associated with headache. It is worse in the morning because nighttime teeth grinding is associated with this condition. The pain is intermittent but can be acute and is related to trauma or overextension of the mouth. Chronic pain may be related to dental malocclusion or rheumatoid arthritis.

Crying when sucking is often an infant’s only indication of pain with compression and increased pressure in the ears. Nocturnal onset of otalgia from a developing infection is caused by increased vascular pressure in the reclined position, which causes the TM to bulge and to stimulate pain sensation.

What does the presence of discharge or itching tell me? Key Questions

• Do you have any itching in the ear? • Do you have any discharge from the ear?

Itching or drainage Itching or drainage from the ear usually indicates an infection or inflammation of the external canal. Itching can also be a precursor to herpes zoster of the trigeminal nerve (cranial nerve [CN] V), which can cause paroxysmal pain of the face and jaw, and hyperalgesia to minimal stimulation such as tooth brushing, cold air, or grimacing. The prodrome for herpes zoster consists of itching, burning, or tingling before vesicular eruption. The facial nerve (CN VII) is also involved in ear pain. Itching may be related to allergic rhinitis, especially when patients describe a deep itching in the ears.

Drainage may also be present after the TM ruptures from increased middle ear pressure, as exudate from otitis externa or malignant otitis externa, or it may be from exudate secondary to mastoiditis. Cholesteatoma is an epidermal inclusion cyst of the middle ear or mastoid. A perforation of the TM and associated foul­smelling discharge may occur.

What does a history of trauma or injury tell me? Key Questions

• Have you had any recent trauma to the ear? • Have you had any head trauma? • How do you clean your ears? Do you use cotton­tipped swabs?

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• Do you have a history of excessive earwax? • If a child: Does the child have a history of putting objects in the ears? • Have you had any recent insect bites around the ear? • Have you been exposed to any loud noise?

Ear trauma Perforation of the eardrum can be caused by blunt or penetrating trauma. Blunt trauma might include a slap to the ear or barotrauma. Penetrating trauma to the canal or TM may be self­induced with cotton­tipped swabs or other sharp objects used to remove cerumen or to scratch the canal.

Head trauma Direct injury to the inner ear by fracture of the petrous temporal bone, located at the base of the skull, also destroys the inner ear.

Cerumen impaction Cerumen is a naturally wet, sticky, honey­colored wax that lubricates and protects the external ear canal. In some individuals, it occurs in a dark, scaly form and accumulates in the ear canal. This accumulation may cause hearing loss, tinnitus, pressure sensation, vertigo, and infection. Self­cleaning practices can produce trauma to the canal, and cerumen­softening solutions can cause chemical irritation to the canal tissue.

Foreign bodies Foreign bodies such as feathers, beads, and insects (especially cockroaches) can produce

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ear pain and inflammation. Children often insert objects into the ear canal.

Insect bites Insect bites can lead to acute pain and tenderness of the external canal and may develop into a secondary infection.

Loud noise Exposure to high­pitched and loud noise for a prolonged period of time destroys the cochlear hair cells. Exposure to noisy work environments, to the operation of heavy machinery, and to loud music increases the risk of injury and eventual hearing loss.

Is hearing loss a clue? Key Questions

• Do you have any difficulty in hearing? • What is your age? • Do you have any dizziness? • Do you have any ringing in the ear? • If a child: Do you think the child can hear normally? • If a child: Does the child turn his or her head to listen? • If a child: Does the child seem to focus on your mouth when listening to you?

Difficulty in hearing Reports of hearing loss or “difficulty hearing” can indicate blockage of the ear canal by cerumen or a foreign body, inflammation of the middle or inner ear, or a neoplasm. The most frequent cause is conductive hearing loss caused by blockage of the external canal, usually by cerumen. Chronic otitis media is usually a condition of adults who have a chronic infection that may destroy the ossicles and spread to the mastoid, labyrinth, and intracranial structures, causing hearing loss. Chronic ear pain is often associated with hearing loss and ear discharge secondary to a perforated nonhealing TM.

Age-related hearing loss Age­related hearing loss (presbycusis), affects adults after 65 years. The onset is gradual and bilateral. The cause is related to changing structures in the ear and changes in neural pathways and exposures to loud noise.

Hearing loss in children Chronic otitis media with effusion causes a conductive hearing loss in children. This loss may be caused by negative middle ear pressure, the presence of an effusion in the middle ear, or structural damage to the TM or ossicles.

Dizziness and ringing in the ear Hearing loss associated with dizziness, vertigo, or tinnitus may indicate a serious inner ear condition such as acoustic neuroma or Ménière disease. Abnormal middle ear ventilation and middle ear effusion are the most common causes of balance disturbance in children. These symptoms are caused by reestablishment of aeration in the middle ear cavity as the effusion clears.

Diagnostic reasoning: Focused physical examination A correct diagnosis of ear pain requires a good view of the TM and external ear canal. Cerumen obstruction should be removed through lavage or by separating an impaction with an ear curette so that irrigation fluid can penetrate behind the impaction. The curette must be manipulated cautiously because trauma to or inflammation of the sensitive perichondrium, which lies immediately below a thin layer of epithelium in the ear canal, elicits excruciating pain and bleeds easily.

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Lavage should not be performed if the medical history suggests perforation of the TM. Without visualization of the TM, however, otitis media cannot be ruled out. Lavage solution helps to soften the cerumen and can be purchased commercially in kits, or a solution can be made of hydrogen peroxide and water (1:1 ratio).

Note behaviors in children Otitis media is the most common childhood disorder. Young infants may exhibit nonspecific signs of irritability, poor feeding, congestion, and fever. Older infants and young toddlers are irritable, may pull on the painful ear, or bang their head on the affected side. Older children will report an earache.

Inspect the external ears General inspection should begin with the pinna and condition of the skin around the ear, face, and scalp. Hemorrhage over the mastoid bone (Battle sign) may occur with a basal skull fracture. Eczema, seborrheic dermatitis, or psoriasis manifests as redness and scaling of the skin that can extend into the external ear canal. Pain in the opening of the ear canal and inflamed skin may be suggestive of a bacterial infection. Fungal and yeast infections appear as white or dark patches. Furuncles or lesions secondary to trauma or irritation appear as localized areas of tenderness or swelling. A hot, swollen, and erythematous ear and surrounding skin indicate cellulitis. Redness and painful swelling over the mastoid process is a sign of infection in the mastoid air cells.

Palpate the external ears Palpate the pinna and tragus for tenderness. In mastoiditis, the pinna is displaced forward, and swelling may be present behind the ear. Palpation of the mastoid process elicits severe tenderness. Otitis externa is associated with pain on manipulation of the pinna and tragus. With referred pain, the structures will appear normal, although palpation over the TMJ may elicit tenderness, and movement of the jaw may create a clicking sound.

Palpate the preauricular and postauricular areas on the right and left simultaneously to elicit pain. Palpate the anterior and posterior cervical lymph nodes and the area over the mastoid process. Preauricular nodes may be enlarged in AOM and otitis externa. Postauricular swelling may indicate extension of infection into the mastoid cavity.

Inspect the ear canals With the otoscope, observe for the patency of the canal, the condition of the skin of the ear canal, and the presence of cerumen. With cerumen impaction, no structures can be visualized. A foreign body is easily visualized. Vesicles on the external ear canal and auricle may indicate herpes zoster (Ramsay Hunt syndrome).

Visualize any discharge, noting color, consistency, and odor. Discharge is usually indicative of an active infection. However, cranial trauma with cerebrospinal fluid leakage must be kept in mind. Cheesy, green­blue, or gray discharge can be seen with otitis externa.

Inspect the tympanic membranes Visualize the TM, noting light reflex and anatomical structures. A normal TM is translucent and pearly gray in color. Mild diffuse redness can occur from crying or coughing. Mild vascularity is sometimes seen in the normal eardrum, especially on the handle of the malleus. Localized redness is a sign of inflammation. Scarring and effusion can cause whitening and opacification of the TM.

The contour of the normal TM is somewhat concave. Fullness or bulging indicates either increased air pressure, or more commonly, increased hydrostatic pressure within the middle ear. Fullness of the eardrum is seen first around the periphery of the TM. As pressure increases, central fullness becomes visible. Concavity or retraction of the eardrum is associated with negative middle ear pressure or postinflammatory adhesions. As the eardrum retracts, the handle of the malleus short process becomes more visible.

Myringitis is a red, inflamed eardrum without effusion. Bullous myringitis describes an extremely painful condition of small blisters on the TM caused by bacterial otitis media. Figure 15.2 illustrates the usual landmarks of a normal right TM. Chronic otitis media can lead to cholesteatoma, or a cyst­like mass behind the eardrum caused by the proliferation of squamous epithelium. The mass can grow to cause necrosis of the ossicles. Examination will reveal a collection of white granulation tissue with perforation of the TM. A series of videos

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that show the examination of the TM when otitis media with effusion is present is available at https://www.aap.org/en­us/about­the­aap/Committees­Councils­Sections/Section­on­infectious­ diseases/Pages/VideoHighlights.aspx.

FIGURE 15.2 Usual landmarks of the right tympanic membrane with a “clock” superimposed. Source: (From Barkauskas VH, Baumann L, Darling-Fisher C: Health and physical assessment, ed. 3, St Louis, 2002, Mosby.)

Perform pneumatic otoscopy (insufflation) The normal eardrum is suspended from its margins and responds to slight pressure changes. Insufflation tests the mobility of the TM. It can be an insensitive test for otitis media if poor technique fails to create a seal. Properly performed, however, it is more reliable than visualization alone.

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To perform insufflation, a large speculum is needed to create a seal. A normal finding elicits a slight motion of the TM when air is insufflated. This movement is compared with the opposite ear. A TM that has been retracted as a result of negative middle ear pressure or adhesions does not move with inflation, but rebound mobility is seen when the bulb is released. Any accumulation of liquid in the middle ear (e.g., effusion) or scarring of the TM inhibits movement when air is insufflated.

Test hearing acuity Hearing acuity is tested using the whisper test and the tuning fork for the Rinne and Weber tests. The sensory function of the acoustic nerve (CN VIII) should be tested to determine whether air or bone conduction loss is present with ear pain.

The Weber test is performed with a 512­hertz (Hz) or higher frequency tuning fork. To perform the test, firmly place the vibrating tuning fork on a midline point of the skull. If there is unilateral conductive hearing loss, sound will lateralize to the ear with the loss because the better ear will be distracted by ambient noise. Alternately, if the patient has unilateral sensorineural loss, the sound will lateralize to the better ear because the neural pathway will be interrupted on the affected side. Equal perception of vibration can indicate normal hearing or bilateral hearing loss. The Rinne test compares air conduction (AC) with bone conduction (BC); the ratio should be 2:1 AC greater than BC. A 20­ to 30­decibel (dB) conductive loss would result in better sound transmission through bone than through air. Conductive hearing loss results when sound transmission is impaired through the external or middle ear. Sensorineural hearing loss results from a defect in the inner ear. Findings of both the Weber and Rinne tests must be considered for optimal diagnosis. Sensorineural loss in the right ear lateralizes to the left with both the Weber and Rinne, and AC is greater than BC in both ears. With a conduction loss in the right ear, the Weber lateralizes to the right and BC is greater than AC on the right; if BC is greater than AC in both ears, there is a mixed defect.

Examine related body systems Examine other regional body systems of the head and neck, including inspection of the conjunctiva; examination of the mucosa and patency of the nose; percussion and palpation of the frontal and maxillary sinuses for tenderness; and inspection of the posterior pharynx for lymphedema, color, and presence of exudate. Inspection of the condition of the oral mucosa (teeth and gums) will provide information about possible causes of referred pain. A focused physical examination for head and neck symptoms should include palpation of cervicofacial lymph nodes, especially the preauricular and postauricular nodes.

Perform an intraotic manipulation If referred pain is suspected, conduct a more extensive neurologic examination and assess for TMJ disorder. TMJ pain can be replicated by instructing the patient to open the mouth wide. Face the patient, insert a single fingertip in each ear and pull the patient toward you as the patient is instructed to open and close the mouth. Pain will be elicited in 90% of patients with TMJ disorder.

Evaluate cranial nerves V, VII, and IX To evaluate the trigeminal nerve (CN V), observe jaw and facial muscle movement for symmetry and strength by palpating over the masseter muscles and ask the patient to bite and clench the teeth. Assess intactness of sensation to pain and light touch using a sharp and dull stimulus over the three branches of CN V. Both CN VII (anterior two­thirds) and CN IX (posterior one­third) innervate taste sensation to the tongue as well as sensation to the external ear. Have the patient protrude the tongue and apply sweet and salty substances separately to each half of the tongue to test CN VII and apply bitter and sour substances to test CN IX.

Laboratory and diagnostic studies

Tympanometry Tympanometry involves inserting a probe into the external ear canal while continually changing pressure against the eardrum to assess the mobility of the TM. The tympanogram provides an indirect measure of

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pressure in the middle ear. Under normal middle ear pressure, the TM absorbs the sound energy waves and produces a bell­shaped pattern that peaks when sound pressure is introduced. With positive or negative middle ear pressure, the tympanogram results in a flat pattern or an early peak pressure. Figure 15.3

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illustrates examples of various tympanogram results.

FIGURE 15.3 Middle ear evaluation with pneumatic otoscopy and impedance tympanograms. Source: (From Daeschner CW Jr: Pediatrics: An approach to independent learning, New York, 1983, John Wiley & Sons.)

Audiometry Audiometry assesses both the frequency and the intensity of sound that can be perceived. An air conduction audiometer tests each ear separately via earphones and transmits a pure tone that has variable frequency and intensity settings. The goal of audiometry is to test the lowest decibel intensity that can be heard for each frequency tested. An individual trained in the proper technique will produce reliable, reproducible, and valid test results. A threshold of up to 20 dB is considered normal. At a higher level, hearing loss is graded as mild, moderate, moderately severe, severe, or profound.

Mastoid process radiography Radiographs of the mastoid bone show clouding of the air cells when otitis media is present. Chronic mastoiditis may reveal decalcification of the bony wall between the mastoid air cells.

Computed tomography scanning A computed tomography (CT) scan of the temporal bone is helpful in diagnosing cholesteatoma and congenital syndromes.

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Differential diagnosis

External otitis External otitis is more common in adults than in children and often presents as bilateral pain that worsens with manipulation of the pinna. The patient reports a stuffed ear, and occasionally conductive hearing loss occurs. Discharge and itching that occur 1 to 2 days after swimming may be associated with otitis externa. The affected canal may be swollen shut. Palpation will often disclose enlarged preauricular or postauricular nodes. Malignant otitis externa is a rare complication and involves infection and damage of the bones of the ear canal and at the base of the skull.

Acute otitis media Acute otitis media most often occurs in children younger than 6 years and is associated with URI. It is an acute infection associated with ear pain and a bulging, red eardrum. The pain of otitis media is severe enough to interfere with sleep and may be suddenly relieved if the eardrum perforates. Swelling of the preauricular node is sometimes seen in children with AOM.

Otitis media with effusion Otitis media with effusion commonly occurs in children and is by definition painless. It is caused by a mechanical process or eustachian tube blockage that leads to inadequate ventilation of the middle ear. On examination, a collection of fluid that resembles mucus, air bubbles, or a fluid level is seen. Associated conductive hearing loss is usually present. The TM may be injected and immobile, either bulging or retracted, as noted by the shape of the cone of light reflex and pneumatic otoscopy. Associated recent URI is a common finding in adults.

Cholesteatoma Cholesteatoma is an epidermal inclusion cyst formation in the middle ear and mastoid cavity. It is often the sequelae of chronic otitis media. The formation occurs with chronic negative middle ear pressure, causing the migration of skin cells from the external ear canal through a perforation in the TM. After being established in the middle ear, the cells desquamate and form the cholesteatoma. This condition is life threatening if left untreated because it will continue to erode away medially to impinge on intracranial structures. A cholesteatoma can also occur congenitally. A cholesteatoma appears as a cyst or collection of granulation tissue on the TM, commonly located in the pars flaccida area in the superior anterior quadrant of the TM.

Mastoiditis Mastoiditis is an infection of the soft tissue surrounding the air spaces in the mastoid bone and is connected to the middle ear space. Mastoiditis usually occurs with bacterial otitis media and is associated with fever. More advanced mastoiditis is manifested by swelling, erythema, and tenderness over the mastoid bone. Swelling can displace the position of the auricle. The swelling can extend to the facial nerve, causing paralysis, or to the labyrinth or cerebrospinal fluid, causing meningitis or brain abscess. Advanced mastoiditis requires immediate referral and surgical management.

Foreign bodies Foreign bodies are easily visualized on examination of the ear canal and can produce foul­smelling ear drainage secondary to infection or abscess.

Cerumen impaction Impaction of cerumen is likely if the patient reports a stuffed­up ear or decreased hearing acuity. An impaction may also produce pain if cerumen is pressed against the TM. Examination will reveal cerumen that occludes the external canal.

Barotrauma

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Barotrauma produces an acute serous otitis that is caused by pressure changes (e.g., in divers or airplane travelers) and is often aggravated by a recent URI or nasal congestion. Serosanguineous fluid collects in the middle ear; during descent, this may be felt as ear pressure, pain, tinnitus, or temporary deafness. Swallowing, chewing, or blowing out the nose with the mouth and nose occluded can relieve symptoms.

Trauma Blunt or penetrating trauma can perforate the TM. A hole in the TM is visible on examination, or the examiner may notice an absence of normal landmarks. A perforated eardrum does not significantly impair hearing or result in vertigo, and it usually heals within 4 to 6 weeks without sequelae. Assess the extent of other damage to the ear when perforation is identified.

Cervical lymphadenitis Anterior cervical lymphadenitis is a common cause of referred ear pain in children. This may be seen with strep throat, as well as in cases of mononucleosis with extensive cervical node swelling in adolescents or young adults.

Referred pain from cervical and cranial nerves Cervical nerves II and III innervate the skin and muscles of the neck and include the great auricular nerve, which supplies the external canals and posterior auricular area. Pain is perceived in these areas. The ear examination will be normal.

Cranial nerves associated with referred ear pain include V, VII, IX, and X. The trigeminal nerve (CN V) supplies the anterior portion of the auricle and tragus, the anterior and superior auditory canal, and the anterior TM. The facial (CN VII), vagus (CN X), and glossopharyngeal (CN IX) nerves innervate the posterior portion of the TM and the external auditory canal. Inflammation of CN X is associated with lesions of the larynx, esophagus, trachea, and thyroid. With referred pain, the structures of the ear will appear normal.

Temporomandibular joint disorder Temporomandibular joint disorder is a common secondary cause of ear pain. Diagnosis of the disorder is likely if palpation over the TMJ elicits tenderness and movement of the joint creates a clicking sound. Results of examination of the ear are normal. Pain also increases with intraotic manipulation. TMJ pain is often worse in the morning. The pain can be acute (related to trauma or overextension of the mouth) or chronic (related to dental malocclusion or rheumatoid arthritis).

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DIFFERENTIAL DIAGNOSIS OF Common Causes of Ear Pain

CONDITION

External otitis

Acute otitis media

Otitis media with effusion

Cholesteatoma

Mastoiditis

Foreign body or cerumen impaction

Barotrauma

Trauma

Cervical lymphadenitis

CNs II and III (referred pain)

CNs (referred pain)

HISTORY

More common in adults, especially those with diabetes, ear pickers, or swimmers; bilateral itching; pain

More common in children younger than 6 yr; those with smoke exposure, recent URI; severe or deep pain; unilateral; sensation of fullness

More common in children but occurs in adults with recent URI; unilateral pain; sensation of crackling or decreased hearing

Hearing loss; recent perforated TM

History of recent otitis media; chronic otitis pain behind ear

Both children and adults have pain or vague sensation of discomfort; decreased hearing

History of flying, diving; severe pain; hearing loss; sensation of fullness; history of recent nasal congestion

History of blunt trauma, penetrating trauma

History of cervical node swelling; pain in ear common in children

Pain in skin and muscles of neck and in ear canal

History, depending on CN involved

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PHYSICAL FINDINGS

Discharge; inflamed, swollen external canal; pain with movement of pinna; TM normal or not visible

Red, bulging TM; fever; decreased light reflex; opaque TM; decreased TM mobility

Fluid line or air observed behind TM; conductive hearing loss; decreased TM mobility

Pearly white lesion on or behind TM

Swelling over mastoid process; fever, palpable tenderness, and erythema over mastoid process

Visualize foreign body or cerumen; may detect foul odor; conductive hearing loss

Retraction or bulging of TM; perforation of TM; fluid in canal

Perforation of TM

Enlarged, tender, cervical lymph nodes; may see early onset of AOM in children and young adults

Dermatome evaluation for cervical nerve involvement

DIAGNOSTIC STUDIES

Throat culture if indicated; in adolescents Monospot if indicated

Tympanogram

None

None initially

Pneumatic otoscopy, tympanogram

Immediate referral

Radiograph of mastoid sinuses reveals cloudiness; referral

None

Radiography or CT scan as directed by injury

None

6/7/2019

CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES

Test function of CNs V, VII, IX, and X; ear examination normal

Radiography or CT scan, directed by CN involvement

TMJ disorder More common in adults; 50% related to dental problems; discomfort to severe pain; unilateral; pain worse in morning

Malocclusion; bruxism; normal external and middle ear structures and function; jaw click; abnormal CN function; ear examination results normal

None

AOM, acute otitis media; CN, cranial nerve; CT, computed tomography; TM, tympanic membrane; TMJ, temporomandibular joint; URI, upper respiratory tract infection.

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0015-print-1559938876.xhtml 6/7/2019