Society for Pediatric Urgent Care

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Society for Pediatric Urgent Care

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Ear Pain

ALERTS

  • Mastoiditis
  • Perforated TM
  • Persistent or recurrent OM

AGE CONSIDERATIONS

  • Otitis Media: infant, toddler >school age, adolescent

DIFFERENTIAL DIAGNOSIS

  • Ear foreign body
  • Otitis Externa
  • Otitis Media
  • Parotitis
  • Referred pain from oropharynx or teeth
  • Temporomandibular joint pain

EVALUATION

HISTORY

  • Onset and quality of pain, associated fever, URI, ear drainage, ear trauma, recent activities (i.e. swimming)

PHYSICAL EXAM

  • HEENT: otoscopic findings, oropharynx, dentition

DIAGNOSTIC FINDINGS

  • Ear: Tympanic membrane findings: Position, erythema, effusion, mobility, light reflex, perforation
  • Pinna: assess for pain with traction, foreign body, laceration

CONCERNING FINDINGS

  • Mastoiditis: proptosis of the ear, swelling or erythema over the mastoid
  • Parotitis: swelling anterior and/or inferior to the ear

DIAGNOSTIC TESTS

Diagnostic Procedures

  • Pneumatic otoscopy

MANAGEMENT

TRANSFER/ADMISSION CONSIDERATIONS

  • Mastoiditis
  • Suppurative parotitis
  • Ear foreign body of organic material
  • Deeper ear canal foreign body
  • Laceration to the auricle involving cartilage

OTITIS MEDIA

Treatment

First Line

  • Otitis media with intact TM: Amoxicillin (80-90 mg/kg divided BID for 10 days)
  • Otitis media with tympanostomy tubes: Ofloxacin or Ciprodex
  • Otitis media with perforation should be treated with oral and topical antibiotics

Second Line

  • Augmentin (80-90 mg/kg of amoxicillin component divided BID for 10 days). Use high dose formulation only
  • Azithromycin

Supportive

  • Fever and pain reliever

Complementary & Alternative Therapies

  • Xylitol may play a role in prevention
  • Antihistamine or over the counter cold remedies are not recommended

Surgery / Other Procedures

  • Persistent effusion may require tympanostomy

Follow Up

Outpatient Referral

  • Follow up in 10-14 days for reevaluation, sooner with persistent symptoms
  • Consider specialist for persistent effusion, recurrent infections

Anticipatory Guidance

  • May take 24-48 hours for symptoms relief after starting antibiotics

Signs and Symptoms to return

  • Persistent fever, ear drainage
  • Ear swelling, proptosis, mastoid tenderness or erythema

PROGNOSIS, COMPLICATIONS

  • Mastoiditis
  • Otitis Media with perforation

Otitis Externa

Treatment

First Line

  • Topical antibiotic drops: Cortosporin
  • Consider wick placement for significant debris to improve delivery of drops

Second Line

  • Ciprodex or Ofloxacin

Supportive

  • Pain reliever
  • Avoid swimming or use ear plugs until treatment is completed

FOLLOW UP

Outpatient Referral

  • Resistant/Persistent infections may be mycotic, refer to Ear, Nose and Throat specialist

Anticipatory Guidance

  • Pain reliever
  • Pain may persist for 1-2 days affter treatment is started
  • Preventative measures with OTC swimmers ear drops have unknown benefit

Activity, Diet

  • Refrain from swimming or use ear plugs until therapy is complete

Signs and Symptoms to return

  • Worsening or persistent ear pain

PROGNOSIS, COMPLICATIONS

  • Fever is rare and should prompt concern for complications
  • Cellulitis of the Pinna can develop if untreated

EAR FOREIGN BODY (CANAL)

see Procedures

 

EAR FOREIGN BODY (SOFT TISSUE)

see Procedures

REFERENCES

1
2

ADDITIONAL RESOURCES

  • AAP Otitis Media