Episode Transcript
Hi and welcome to Clerkship Ready – Pediatrics – A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
I am Dr. Chris Stadnick, and I am a pediatric resident at the University of Virginia.
Listen up, because today we’re going to be talking about ear pain in children (get it?). 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.
First, let’s talk about ear anatomy. The ear is divided into three parts, the inner, middle, and outer ear. The outer ear involves the pinna (or the part that we see) and the external ear canal that leads to the tympanic membrane or TM. The TM is also known as the ear drum. Manipulation of or moving the pinna when looking at ears is important but more on that later. The middle ear involves the tympanic membrane and three small bones behind it. These small bones are the malleus, the incus, and the stapes. These bones help with soundwave conduction. Lastly, the inner ear includes the cochlea, utricle, saccule, and semicircular canals which also help with sound transmission as well as balance.
One key anatomical structure that plays a role in draining the middle ear is the eustachian tube. The eustachian tube connects the middle ear to the nasal cavity. In children, the eustachian tube is smaller in diameter and angled more horizontally than in adults. As you might expect, 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. Around the time that children enter kindergarten and elementary school, the eustachian tube becomes a little larger and starts to angle down more vertically, so it starts to drain more effectively. The adenoids also are thought to play a role in fluid collection and buildup. The adenoids sit next to the opening of the eustachian tubes in the nasal cavity, so large adenoids or inflamed adenoids (like when you’re sick) could hinder fluid drainage from the middle ear too!
Now that we know the anatomy, let’s dive into the approach of a patient with a chief complaint of ear pain. As with any presenting symptom or problem in a child, nothing surpasses a good history and physical. For ear pain there are a few questions you want to make sure to ask the caregiver as well as yourself. How old is this child? Thinking about what their eustachian tubes look like. Have they had a fever? Are there any other viral symptoms such as cough, runny nose, or sore throat? If they have a virus, there’s a good chance they will have some fluid behind their ears and depending on the age/eustachian tube of the child, this predisposes them to acute otitis media, which we’ll talk about later. Has the child been swimming recently? This should make you think about otitis externa, or swimmer’s ear. Has the child put anything in their ears? A foreign body or damage from a foreign body can cause pain and if it’s still there can be a nidus for infection. Has there been any ear drainage or changes in hearing? Ear drainage makes you concerned about a perforated tympanic membrane. Changes in hearing are common when there is a middle ear effusion. All of these questions help point you closer to the correct diagnosis.
Probably the most useful piece of information for you will be what the ear and the tympanic membrane, or TM, look like on otoscopy. Some kids will cooperate beautifully during the exam and let you look without any fuss while others will require an extra set of hands to help you see what’s going on in that ear! Don’t be afraid to get a parent or other caregiver or even a nurse involved to help you out. Keeping the child as still as possible is important, not only so that you can get the best look, but also so that the child does not end up getting injured. To look in a child’s ear, you’ll be using the otoscope with a speculum. I typically like to use the speculum with the widest diameter to help me see as much of the TM as possible and get my bearings. When working with the otoscope, you want to use one hand to manipulate the pinna, typically by pulling it posteriorly and up to help align the ear canal with the otoscope. With the hand that is holding the otoscope, you want to have some anchor point against the child’s head. This way you can move when they move to avoid any accidental ear injury. One way to hold the otoscope is like a pencil, with the otoscope head between the 2nd and 3rd fingers and the end of the otoscope sticking upwards between the thumb and index finger. This way, the rest of your hand can act as that anchor point against the child’s head.
When looking at the ear and TM, there are a few things you want to note: the color, presence of fluid, overall appearance, light reflex, and what the ear canal looks like. Let’s talk about what’s normal and not normal for each of these features.
First, the color of the TM. It can range from a translucent, pearly-gray color to opaque to a bright red. A normal TM will be clear-gray, and you should be able to see the malleus which almost looks like a clock-hand going to the center of the TM. Now TMs can also be red and angry but that depends on what the patient is doing when you’re looking. If they are screaming and crying, it wouldn’t be surprising to see a red TM. This is why you should try to do your ear exam when the child is calm. However if the patient is calm and the TM appears red, there could be an infection going on. Other colors the TM can appear are a dull yellow and even a white/opaque color which brings us to the next feature…fluid.
Fluid behind the TM is not normal, but it does not necessarily mean there is a bacterial ear infection. It depends on what kind of fluid you see behind the ear. If it’s a serous fluid (this will make the TM look a dull, yellow color) then this means the child has a middle ear effusion which can be common, especially if the child has upper respiratory symptoms. These serous effusions can be present for some time in children as they get frequent upper respiratory infections or colds. If the fluid looks like a white, yellow, cottage cheese-appearance then that would be pus and is a sign of acute otitis media. Pus behind the TM is not normal.
Looking at the overall TM, there is one feature you should try to note: bulging or non-bulging. A bulging TM will appear almost like a doughnut, and this can mean there is fluid or pus behind the ear drum. You can use the insufflator to see if the TM can be pushed back or if it is rigid. An insufflator is sometimes attached to otoscopes and provides a puff of air into the ear canal. If you can see the ear drum flicker with this puff of air, then there is likely no fluid behind it causing it to bulge out. Normally, a TM should not be bulging out. Another feature that should be noted on a normal TM is the light reflex, which is a small cone of light, typically around the middle portion of the TM. It is difficult to see the light reflex if the TM is bulging.
Lastly you should take note of what the ear canal looks like. Is there a lot of wax? Is the wax moist appearing or dry? Is the ear canal red and inflamed? Is there drainage in the ear canal? A normal ear canal should have a little bit of wax, no drainage, and not appear red or irritated.
Now that we’ve talked a little bit about what to ask and look for on exam, let’s talk about the differential diagnoses and their presentations.
The first one we’ll talk about is the one we’ll spend the most time on, acute otitis media. This is an infection of the middle ear. The main bacterial causes of acute otitis media are Strep pneumonia, H influenzae, and Moraxella catarrhalis, but many cases are caused by respiratory viruses. The criteria/presentation of acute otitis media per the American Academy of Pediatrics is: moderate to severe bulging of the TM or otorrhea – which means ear drainage - that is not from otitis externa (more on that later) or mild bulging of the TM with ear pain or erythema of the TM in a child who cannot yet talk. Basically, the TM should be bulging, and you should have either a red TM, cloudy TM, or drainage. Something that happens frequently is a young child presents with ear pain and fever and the TM is red, but not bulging. If the child has a runny nose and cough, then it is more likely a virus causing an upper respiratory infection creating ear pain from swelling and blockage of the eustachian tube rather than a bacterial otitis media.
Now that we’ve talked about how to make the diagnosis of an acute otitis media, let’s talk about treatment. Treatment for acute otitis media depends on the age of the child, if the infection is bilateral, and how severe the symptoms are. The AAP published clinical guidelines on this, and I’ve put that reference in the show notes. The vast majority of otitis media, even bacterial otitis media, resolves without antibiotics, so the AAP has provided guidelines so that you know when antibiotics are needed and when you can use the “watch and wait approach”, which we’ll talk about in a minute. This is part of antibiotic stewardship – which are principles to improve antibiotic prescribing so that we don’t use antibiotics unnecessarily and can try to prevent antibiotic resistance. Check out our episode Before You Choose Antibiotics For a Child or Adolescent for more info on antibiotics and antibiotic stewardship!
You should definitely treat with antibiotics if the child is younger than 6 months. If the child is older than 6 months, you should treat them if there are severe symptoms, which the AAP defines as fevers greater than 102.2 F, which is 39 C, or ear pain for at least 48 hours. You should also treat children who are younger than 2 years old who have bilateral otitis media. What about when the child is 6 months or older with unilateral AOM without severe features? This is where shared decision making plays a role. Talking with parents about the role of antibiotics and their potential side effects (such as upset stomach, diarrhea, or allergic reactions) is important. The antibiotics should help the ear infection, but if the child is not experiencing severe features, the ear infection will likely resolve on its own. Having an open conversation about what the parents want and their concerns is important. What’s even more important, if you elect to go without antibiotics, which is called the “watch and wait approach”, is to make sure the child and their ear infection has improved, and to have a contingencyplan in place if not. One simple way is to go ahead and prescribe an antibiotic, but tell the parent to only pick it up and use it if the child’s ear pain continues after 2 days. Once they start the course of antibiotics, they need to finish it. Another option is to see them back in the clinic and check on how things are going or have them call the office or give an update through a patient messaging portal to see if a prescription is needed. Check with your resident or attending to see how your practice site handles these situations. Regardless of whether you start antibiotics or not, make sure that you recommend good pain control, for instance by providing the parents with the appropriate dose of acetaminophen or ibuprofen.
Now, if you’re going to prescribe an antibiotic, what antibiotic are you going to prescribe? The recommendation is to start with amoxicillin unless the patient has history of a penicillin allergy, ongoing purulent conjunctivitis, has had amoxicillin in the past 30 days, or has history of amoxicillin-resistant acute otitis media. The amoxicillin should be prescribed for 5-7 days in children over the age of 2 without severe symptoms. In children <2 or with severe symptoms, then a 10 day course is more appropriate. In the case of amoxicillin resistance or previous amoxicillin use, a Beta-lactam inhibitor should be prescribed as well, like amoxicillin-clavulanate, or augmentin. In the case of penicillin allergy, cephalosporins such as cefdinir or cefuroxime are recommended. Once on antibiotic therapy, the patient’s symptoms should improve within the next 48-72 hours. If the patient does not improve then you should try the next line of antibiotics recommended by the AAP, so check the AAP’s full acute otitis media guidelines in the show notes if you need to go to the next line.
For the children who are frequent flyers with ear infections, ear tubes are an option as well. An ear tube or more formally, tympanostomy tube – or pressure equalizing or PE tube, is a small tube that is inserted into the tympanic membrane by an ENT doctor to help drain fluid from the middle ear. In general, tubes are not inserted unless the child has had at least 3 ear infections within 6 months or 4 ear infections over the course of a year. Some ENT doctors will also insert tubes if there is persistent effusion causing significant hearing loss at the time when the child is learning how to speak.
Another common ear problem is acute otitis externa, also known as “Swimmer’s ear”. This is an infection of the pinna and external ear canal. It occurs after water stays in the ear for a long time, which breaks down the ear’s natural defenses, allowing bacteria to grow. It presents with a painful pinna and sometimes purulent drainage from the ear. The main bacterial culprits of acute otitis externa are Pseudomonas or Staph aureus. The treatment is ear drops that are put into the external ear canal for a period of 7-10 days. The drops can include either acetic acid drops, a neomycin ear drop mixed with polymyxin B and hydrocortisone, or a fluoroquinolone topical antibiotic. Acetic acid drops should be used for mild otitis externa by a fungus or bacteria. For mild disease think about redness and a slightly swollen ear canal. More severe bacterial disease, which can present with more significant swelling of the ear canal as well as purulent drainage, can be treated with a topical fluoroquinolone or the neomycin ear drop. One thing to note is that fluoroquinolone drops are the only antibiotic that should be used if the tympanic membrane is perforated, so it is important to visualize the TM in otitis externa.
Foreign objects in ears are also something you might see while looking through the otoscope. The clinical presentation will depend on how long the object has been in the ear and what kind of object it is. Symptoms can involve ear pain, drainage, swelling, and hearing loss. To treat, depending on how comfortable you are and where the object is, you may be able to remove it. Otherwise, the patient will need referral to ENT or a trip to the emergency department for removal.
One diagnosis to make sure to rule out is mastoiditis. This is an emergent condition where the mastoid process behind the ear becomes infected. Presentation is swelling and erythema in this area and the ear itself can be propped forward out of position due to the swelling – this is called proptosis. These patients should be referred to the emergency department for further management and potential surgery.
Alright, let’s recap what we talked about today. Ear pain is a pretty common problem and can be caused by infection (bacterial or viral), foreign objects, or even some water left over from swimming. Getting a glimpse of the TM is important and don’t be afraid to get some help. The most important things to note are the color of the TM and whether it is bulging or not. Acute otitis media and externa are both infections of the ear. With AOM, shared decision making with the parents is super important when discussing antibiotics and the watch and wait method for kids who don’t meet antibiotic criteria. As for otitis externa, a topical ear drop is needed and can vary from antibiotic to acetic acid. Lastly, always make sure to look out for mastoiditis when a patient comes in for ear pain.
Thanks for listening to Clerkship Ready – Pediatrics. I hope you found today’s podcast helpful. Don’t forget to subscribe below and rate the podcast.
