Ear Pain
Ear pain is a common symptom in emergency medicine, particularly in the pediatric age group. A meticulous evaluation of the ear, pharynx, and general periauricular area is essential for an accurate diagnosis.
COMMON CAUSES OF EAR PAIN
Acute suppurative otitis media*
Acute otitis externa (“swimmer’s ear”)*
Acute serous otitis media*
Preauricular lymphadenopathy*
Temporomandibular joint dysfunction*
Cellulitis of the external ear*
LESS COMMON CAUSES OF EAR PAIN NOT TO BE MISSED
Malignant otitis externa*
Bullous myringitis*
Acute mastoiditis*
Foreign body in the external auditory canal
OTHER CAUSES OF EAR PAIN
HISTORY
Pain followed by its disappearance in association with a bloody or purulent discharge from the auditory canal suggests acute suppurative otitis media with tympanic membrane perforation. Serous otitis media is often a cause of acute ear pain in patients with a history of a recent upper respiratory tract infection or allergies. Ear discomfort related to mastication may be caused by temporomandibular joint dysfunction or acute otitis externa. Postauricular pain developing in the setting of chronic or recurrent otitis media suggests acute mastoiditis. Recent swimming or high-altitude travel may also be noted in patients with external otitis or barotrauma, respectively. Vague pain involving the ear, often with radiation to the jaw or teeth, is sometimes reported early in patients with herpes zoster; this often occurs before the development of rash.
PHYSICAL EXAMINATION
The disappearance of the normal light reflex is noted in patients with a middle ear effusion. The tympanic membrane in patients with serous otitis media is usually amber, with or without an air-fluid level. Pain with traction on the auricle or tragus suggests an external otitic process, whereas reproduction of pain with palpation of the temporomandibular joint in the external auditory meatus suggests temporomandibular joint dysfunction. Tenderness to percussion or palpation postauricularly suggests acute mastoiditis, which requires radiologic evaluation, otolaryngologic consultation, and most often intravenous antibiotics. Erythema or vesicles involving the surrounding scalp, the pinna, or the periauricular area suggest herpes zoster, although in some patients pain may precede the development of rash.
SPECIFIC DISORDERS
Acute Suppurative Otitis Media
Acute bacterial infection involving the middle ear occurs most often in children in who high fever, pain, irritability, crying, lack of interest in nursing or eating, and pulling or brushing the affected ear are common symptoms. In some children, vomiting, usually not associated with abdominal discomfort, is prominent. Older children and adults may report varying degrees of hearing loss. Pain is intense and often described as excruciating and throbbing. After the onset of pain, a small number of patients report the sudden disappearance of pain followed by a bloody or purulent discharge from the ear canal; such a scenario suggests tympanic membrane perforation.
Findings in patients without perforation include bulging and erythema of the tympanic membrane and a disappearance of the normally present light reflex and bony landmarks of the middle ear. If perforation has occurred, blood or pus may be seen in the canal, and the site of perforation may be noted.
The organisms that commonly cause acute suppurative otitis media include pneumococci, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, group A streptococci, and (in infants and neonates) Enterobacteriaceae and group B streptococci.
Children
Children who are significantly ill with high fever, persistent vomiting, severe discomfort, or extreme bulging of the tympanic membrane should be considered candidates for hospitalization and intravenous antibiotics. Myringotomy or tympanocentesis is rarely needed.
Outpatient Therapy
Outpatient therapy should include fluids, antipyretics as needed, and analgesics for 3 to 5 days. Because of the intensity of discomfort, patients may require a narcotic for 2 or 3 days; we prefer acetaminophen and codeine elixir in children and codeine or an equivalent in adults. In addition, when perforation is not present, a topical analgesic, such as benzocaine (Americaine) drops, may be prescribed. A specific antibiotic should be prescribed for 10 to 14 days, the therapeutic options for which are discussed in section “Antibiotics.” It is important to recommend reevaluation in 3 or 4 days if symptoms do not improve. All adults with recurrent or refractory otitis should be referred to an otolaryngologist for appropriate follow-up because a small percentage of these patients have otitis secondary to an obstructing nasopharyngeal process. Decongestants are generally not recommended and have been shown not to accelerate resolution of otitis in children.
Treatment of Perforation
The treatment of perforation secondary to acute bacterial otitis media is similar to that of suppurative otitis media; it is important to advise the patient that the ear canal should remain unobstructed. The use of ear drops is contraindicated. Perforations generally heal quite well within 3 weeks without loss of hearing; otolaryngologic follow-up should be recommended at 10 days after the initiation of therapy.
Antibiotics
The initial choice of an antibiotic in patients with suppurative otitis media remains controversial; important factors include changing bacterial resistance, complications of therapy, the convenience/practicality of the various dosing schedules, patient palatability, and cost. Based on these factors, many authorities continue to recommend initial treatment with amoxicillin; this reflects a long history of success with this agent, very low cost, reasonable palatability in children, and relatively few complications. The dose is 500 mg three times daily in adults and 80 to 90 mg/kg/day in three divided doses for 10 days in children. Because of emerging patterns of resistance in some strains of Streptococcus pneumoniae, some authorities have recently recommended higher doses of amoxicillin (up to 80 mg/kg/day in three divided doses). In patients with treatment failures or in communities with a high prevalence of b-lactamase-producing organisms (H. influenzae, M. catarrhalis species, and S. pneumoniae), other agents are preferred. These include azithromycin (Zithromax 10 mg/kg/day as a single dose on day 1, followed by 5 mg/kg/day given as a single dose on days 2 to 5), amoxicillin-clavulanate (Augmentin, administered as 80 to 90 mg/kg/day in three divided doses for 10 days), cefpodoxime (Vantin, administered as 10 mg/day given as a single dose for 10 days), cefuroxime axetil (Ceftin, 30 mg/kg/day divided twice daily for ten days), or ceftriaxone (Rocephin, 50 mg/kg intravenous or intramuscular daily for 3 days). In patients with penicillin allergy, we generally recommend treatment with azithromycin. In patients with vomiting, or when prescription or medication compliance is an issue, an acceptable treatment option is to give a single intramuscular dose of ceftriaxone, 50 mg/kg, which need not be followed with oral antibiotics.
Mastoiditis
Mastoiditis is suggested by tenderness behind the ear with percussion or palpation. Such patients should have imaging of the mastoid and should be considered candidates for hospital admission. Intravenous antibiotics and otolaryngologic consultation at the time of presentation are appropriate.
