Clerkship Ready: Pediatrics

Ear pain is one of the most common chief complaints pediatricians encounter in the outpatient setting and there are quite a few things you need to consider to make a thoughtful diagnosis, assessment, and plan. In this episode, we will discuss the differential diagnosis of ear pain in children, physical exam findings that will help you make a diagnosis, and treatment for the most common causes of ear pain.

1. Ear anatomy
   
   
   1. Outer ear, tympanic membrane (TM), middle ear, inner ear
   
   
   2. Eustacian tube in children is smaller in diameter and angled more horizontally than in adults. This makes it more difficult to drain fluid behind the middle ear and why kids are more prone to get ear infections when they get a cold than adults are.
   
   
   3. The adenoids also are thought to play a role in fluid collection and buildup.
   
   



2. Taking a history for patient with chief complaint of ear pain
   
   
   1. How old is this child?
   
   
   2. Have they had a fever?
   
   
   3. Are there any other viral symptoms such as cough, runny nose, or sore throat?
   
   
   4. Has the child been swimming recently?
   
   
   5. Has the child put anything in their ears?
   
   
   6. Has there been any ear drainage or changes in hearing?
   
   



3. Ear examination
   
   
   1. Make sure that the child’s head is as still as possible
   
   
   2. How to use the otoscope
   
   
   3. What to look for:
      
      
      1. Color of the TM.
      
      
      2. Fluid behind the TM
      
      
      3. Is the TM bulging or not bulging
      
      
      4. Light reflex of the TM
      
      
      5. Ear canal
      
      
   
   
   



4. Acute otitis media
   
   
   1. Infectious causes - bacteria (especially Strep pneumonia, H influenzae, and Moraxella catarrhalis), viruses
   
   
   2. Treatment
      
      
      1. Antibiotics vs. “watch and wait approach”
      
      
      2. Criteria for using antibiotics
      
      
      3. Antibiotic options
      
      
      4. Indications for tympanostomy tubes
      
      
   
   
   
   3. Acute otitis externa (“Swimmer’s ear”)
      
      
      1. Causes
      
      
      2. Clinical presentation
      
      
      3. Treatment
      
      
   
   
   
   4. Foreign body in ear
   
   
   5. Mastoiditis
   
   

Resources and Links:

Anatomy and Ear Tubes/Adenoidectomy

https://www.texaschildrens.org/departments/ear-nose-and-throat-otolaryngology/conditions-we-treat/dysfunction-eustachian-tube#:~:text=Eustachian%20tubes%20in%20children%20are,cause%20pain%20for%20the%20child.

https://www.childrensmn.org/educationmaterials/childrensmn/article/18784/adenoidectomy-and-ear-tubes/#:~:text=The%20adenoid%20is%20located%20next,is%20for%20recurrent%20nasal%20infections

https://www.ncbi.nlm.nih.gov/books/NBK570549/#:~:text=The%20middle%20ear%20consists%20of,the%20transmission%20of%20sound%20waves.

https://www.ncbi.nlm.nih.gov/books/NBK551658/#:~:text=The%20inner%20ear%20is%20located,labyrinth%2C%20separated%20only%20by%20perilymph.

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/ear-tube-insertion

https://www.chop.edu/news/health-tip/3-signs-your-child-may-need-ear-tubes

Otitis Externa

https://publications.aap.org/pediatricsinreview/article/34/3/143/34784/Otitis-Externa

https://www.aafp.org/pubs/afp/issues/2001/0301/p927.html

https://www.aafp.org/pubs/afp/issues/2006/1101/p1510.html

AAP Otitis Media Guidelines:

https://publications.aap.org/pediatrics/article/131/3/e964/30912/The-Diagnosis-and-Management-of-Acute-Otitis-Media