CHAPTER 14 Earache

Otalgia, or ear pain, 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, or cervical, mouth, or facial disorders. The most serious, although least common, cause of referred pain is nasopharyngeal cancer, a condition more common in Asians. Figure 14-1 illustrates the structures of the ear.

FIGURE 14-1 External auditory canal, middle ear, inner ear.

(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?

Have you had an upper respiratory infection?

Have you had ear infections before?

Is there a family history of ear infections?

Age

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

A URI occurs when the mucous membranes of the nasopharynx and/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. Seventy-one percent of children younger than age 3 years have had at least one episode, and one third 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 second-hand 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

Second-hand 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

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.

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, 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 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 a systemic disease?

Key questions

Do you have diabetes?

Have you ever had dermatitis, eczema, or psoriasis?

If a child: Does the child have a nonrepaired cleft palate?

Diabetes mellitus

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

History of seborrheic dermatitis or psoriasis

Chronic inflammatory dermatitis from overproduction of sebum can occur in the external canal and cause otitis externa.

Cleft palate

Nonrepaired anomalies 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 it in one ear or both?

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?

Location of the pain

Pain of otitis externa is described as tenderness around the outer ear or 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. If the pain is bilateral, suspect otitis externa. Referred pain or pain of AOM is usually unilateral. Infants cannot assist in location of the ear pain; instead, they exhibit behavioral changes that may indicate pain, such as irritability, lethargy, 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

TMJ 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, causing 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 (CN V). Drainage may also be present after the TM ruptures from increased middle ear pressure, 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 foul-smelling 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 cotton-tipped swabs?

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?

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