THE NATIONALMEDICAL JOURNAL OF INDIA VOL. 10, NO. 4, 1997

Everyday Practice183

Otalgia in children

N.N.MATHUR, A.MATHUR

INTRODUCTIONOtalgia (earache) in children is a very common problem encoun-tered by physicians. It can be caused by pathological conditionsin the middle ear cleft, external auditory meatus, parotid area andneck or may be referred from areas such as the oral cavity,pharynx, paranasal sinuses, temporomandibular joint and teeth.In infants and young children who are unable to complain ofotalgia, it should be suspected if the following symptoms arepresent:

I. Pulling of the ear2. Hand on affected ear3. Fever4. General irritability5. Excessive crying6. Disturbed nights; rolling in bed7. Banging of head against side of cot8. Disturbed feeding habit9. Nausea and vomiting10. Mucopurulent discharge from ear canal

The various parts of the ear are richly innervated and this is thereason for the common occurrence of referred pain. The pinna issupplied by the C2 and C3 nerves, the auditory meatus by the V,VII and X cranial nerves, the eardrum by the VII and X, and themiddle ear by the V, VII and IX cranial nerves. The eustachiantube is supplied by the pharyngeal branch of the pterygopalatineganglion while its ostium is supplied by the meningeal branch ofthe V cranial nerve, which also supplies the mastoid air cells. Theauriculotemporal nerve (C2,C3) supplies the temporomandibularskin and fascia around the gland. The temporomandibular joint isalso supplied by the masseteric nerve, a branch of the mandibularnerve. The conditions causing otalgia in children are listed inTable I.

EXAMINATION OF A CHILD WITH OTALGIASmall infants, uncooperative older infants and children requiringparacentesis are usually evaluated on an examining table. Othersmay be examined in an adult's lap in a sitting position with thechild's wrist held over the abdomen by one hand and the head heldagainst the adult's chest with the other. Older children can beexamined while they are sitting on a chair. The use of an otoscopeis necessary. It is held in one hand like a pen with the wrist restingagainstthe cheek ofthe patient, so thatthe examiner's hand moves

Lady Hardinge Medical College, New Delhi, IndiaN. N. MATHUR Department of OtorhinolaryngologyEscorts Heart Institute, New Delhi, IndiaA. MATHUR Department of Paediatrics

Correspondence to N. N. MATHUR

© The National Medical Journal of India 1997

TABLEI. Conditions causing otalgia in children

Middle earAcute otitis media-most common causeOtitis media with effusion or glue ear (dull ache)Myringitis haemorrhagica bullosaTumours (rare)- eosinophilic granuloma, rhabdomyosarcoma,

non-Hodgkin's lymphoma and leukaemiaBarotrauma

MastoidAcute mastoiditis as a complication of acute otitis media or chronicsuppurative otitis media

Complications of cholesteatomaEosinophilic granuloma

IntracranialExtradural abscess as a complication of chronic suppurative otitis media

Eustachian tubeEustachian catarrhMeatusForeign body-vegetative, impacted, maggotsImpacted waxFuruncleTrauma to external meatusAcute diffuse otitis extema-swimmer's earsOtomycosisPinnaTraumaInfected pre-auricular sinusErysipelasHerpes zoster oticus (Ramsay-Hunt syndrome)Herpes simplex

Referred otalgiaTonsillitisPost adenoidectomy or tonsillectomyNasal polyps-antrochoanalMumpsParotitis-recurrent, caused by Epstein-Barr virusPeritonsillar, parapharyngeal and retropharyngeal abscessMolar teeth-mainly lower molars (eruption. caries, periodontal anddental abscess)

Oral Ulceration-primary herpetic stomatitis, aphthous ulcersTemporomandibular joint-rheumatoid arthritis. arthrosisBezold abscess resulting in torticollisAcute thyroiditis

School avoidance

with the movement of the patient preventing any trauma to the earcanal. Pulling the pinna upwards and backwards or only back-wards to straighten the canal is necessary in infants and children,respectively.Before examining the ear, the pre-auricular area is examined

for any swelling (as in mumps) or an infected pre-auricular sinus.The post-auricular area is examined for any tenderness over themastoid, obliteration of the post-auricular sulcus resulting frommastoiditis, mastoid abscess or an enlarged lymph node second-ary to otitis externa. The position of the pinna is then noted andcompared with that of the opposite side by examining frombehind. It may be pushed out in patients with acute mastoiditis.Any swelling or change in the shape of the pinna is noted to ruleout any perichondritis. The conchal skin is examined for any

184

vesicles resulting from the Ramsay-Hunt syndrome or excoria-tion of the skin caused by pooling of secretions in the externalauditory canal. The ear canal is examined for the presence of anydischarge which may result from otitis externaorotitis media. Themastoid reservoir sign, i.e. the ear canal getting filled up withdischarge soon after cleaning may result from acute mastoiditis oran extradural abscess, both of which cause otalgia or pain in thetemporal region. The presence of inflammation, impacted wax,furuncle, otomycosis (which has a wet newspaper appearance),foreign body, polyp, granulations or tumour in the externalauditory canal is noted. Sagging of the postero-superior canal walland pulsatile discharge through a perforation may be seen in acutemastoiditis.Careful examination of the tympanic membrane is important

as it reveals the pathology inside the middle ear to the clinician.Its examination in neonates may be difficult as it is small andcollapsible, it angulates acutely in an inferior direction away fromthe observer, and because of the presence of vernix caseosa in thecanal (which may need to be removed). The tympanic membraneis examined for any congestion, bulge, perforation or bullae. Abulging membrane is more predictive of acute inflammation thanerythema, as erythema may be secondary to crying or fever. I Acrying child must be allowed to settle down and the examinationshould then be repeated. It is extremely uncommon to find waxobscuring an acutely inflammed drum. Pneumatic otoscopy iscarried out to determine the mobility of the tympanic membraneexcept when the membrane is bulging or severely inflammed asthis procedure would result in increased pain. Mobility of thetympanic membrane is restricted in the presence of a blockedeustachian tube, otitis media with effusion and acute otitis media.The presence of a cholesteatoma or any granulation should benoted. Pus, if any, should be sent for culture and sensitivity.Tuning fork tests and pure tone audiometry can be performed

to evaluate hearing loss in patients above 4 years of age. Imped-ance audiometry is carried out in those children where retractionof the membrane or effusion in the middle ear is suspected. Adecreased compliance and wider or absent peak are associatedwith a higher probablity of effusion.Evaluation of the throat, nose and neck should also be done to

locate any of the referred causes of otalgia.As in any other disease, treatment is given for the disease and

not for the symptom though analgesics should be given to allevi-ate pain. Therefore, it is important in the management of otalgiato diagnose the condition producing the symptom.

ACUTE OTITIS MEDIAAcute otitis media (AOM) is the most common cause of otalgia inchildren. However, in 20% of children with AOM, pain may notbe a presenting symptom.' AOM is particularly common ininfants and young children. Approximately two-thirds of infantshave had at least one ear infection by their second birthday,' andnearly 85% of children suffer from at least one episode of otitismedia by the age of 3. The incidence of AOM peaks at 6-13months of age.4The predisposing factors in children are a horizon-tal eustachian tube, poor immunity to upper respiratory tractinfections of viral origin and its bacterial sequelae, active growthoflymphoid tissue of the pharynx particularly the adenoids, teeth-ing, horizontal position of a baby, poor hygiene, parental igno-rance and a higher incidence of infections such as measles.The presenting symptoms include pain, pyrexia, irritability,

anorexia, vomiting and diarrhoea.' Accumulation of pus in themiddle ear causes hearing loss.

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 10, No.4, 1997

The four stages of the disease, which are ;apidly progressive,are:

1. Eustachian tubal obstruction. Stuffy feeling, local discomfort,mild retraction of the tympanic membrane, horizontal positionof the handle of the malleus, and prominence of the lateralprocess.

2. Redness. Increased otalgia and hearing loss, constitutionalsymptoms, erythema and bulging of the pars flaccida, a smallcollection behind the lower portion of the tympanic membrane,dilatation of manubrial and circumferential vessels and laterredness of the entire surface.

3. Suppuration. An increase in pain and constitutional symptomsoccurs as the tympanic membrane is now the outer wall of theabscess cavity. It ulcerates at the inner surface and then per-forates.

4. Resolution. Following perforation there is transient purulentotorrhoea and the pain disappears dramatically. The perforationheals spontaneously in 4-5 weeks.

AOM is a bacterial infection of the mucoperiosteum of themiddle ear cleft commonly caused by Pneumococcus, Haemophilusinfluenzae, M. catarrhalis and haemolytic Streptococcus. How-ever, viruses do playa role in many cases by paving the way forbacterial invasion. Therefore, amoxycillin which is effectiveagainst all the common bacterial organisms incriminated in AOMshould be started. 6However, in the last decade 30% ofHaemophilusinfluenzae and 50%-80% of M. catarrhalis which may be res-ponsible for 10% of all AOMs have developed the ~-lactamaseenzyme rendering them resistant to amoxycillin. Therefore, someclinicians prefer to start amoxyciIlin-clavulanate, trimethoprim-sulphamethoxazole or cefaclor.'AOM in neonates can be caused by organisms such as

Escherichia coli, Klebsiella, Enterobacter spp., Pseudomonasaeruginosa and Staphylococcus aureus" Infants tend to localizethe infection poorly and are at risk of developing sepsis andmeningitis. In such cases tympanocentesis and culture of the fluidshould be done prior to starting antibiotics. To do tympanocentesis,the ear canal is first cultured to identify possible contaminatingorganisms. After sterilizing the canal with alcohol for I minute,the canal is suctioned. Tympanocentesis is then performed in theinferior portion of the tympanic membrane using an Alden-Senturia trap with an I8-gauge spinal needle.A broad treatment plan for children with acute otitits media is

shown in Fig. 1.

OTITIS MEDIA WITH EFFUSIONOtitis media with effusion (OME) is a common chronic conditionin childhood which presents with hearing loss causing educa-tional or behavioural problems. Though this condition by itselfmay cause no or minimal dull earache, it predisposes to frequentepisodes of acute suppurative otitis media and severe otalgia.The mild form of the disease may resolve by itself. Medical

managment in the form oftopical and systemic vasoconstrictors,antihistamines, antibiotics and systemic steroids have been tried,but are not very effective. Surgical treatment in the form ofmyringotomy and aspiration with or without insertion of grommetin the anterosuperior or anteroinferior quadrants of the tympanicmembrane is performed in many cases. This mayor may not beaccompanied with adenoidectomy.

MYRINGITIS HAEMORRHAGICA BULLOSAThis occurs frequently during epidemics of respiratory viral

MATHUR, MATHUR: OTALGIA IN CHILDREN 185

,--------- Acute otitis media

Severe pain L Antibiotics for 10-14 days (amoxycillinlerythromycin)-!. and analgesics, antipyretics and local fomentation

Tympanocentesis/myringotomy j Iin the posteroinferior quadrant

1 Symptomatic improvement

TympanocenteSiS/myringot0:jyin the posteroinferior quadrant

Re-examine after 10-14 days-It

Otitis media with effusion (OME) ) Yes~

f-----~:------------------------ Re-examine at 3 months(monitor progress every 2-4 weeks)

~OME present

~Re-treat with antibioticsand re-examine at 4 months

J,<E(------------------ OME present

Symptomatic failure in 48 hoursI

Change antibiotic(amoxycillin-clavulanate/cefaclor)

I ~')

No ~(---------

Myringotomy with grommet

FIG I. Treatment plan in acute otitis media

infections such as influenza. It causes excruciating earache andpresents with haemorrhagic blebs or outlines of ruptured blebs onthe tympanic membrane.

ACUTE MASTOIDITISIt usually develops a few days to 4 weeks after an attack of acutesuppurative otitis media which has either remained untreated orhas failed to respond to treatment. These patients are treated withparenteral antibiotics and most of them recover completely. How-ever, if it does not resolve within 48 hours a cortical mastoidectomyis required. Simple incision and drainage of a post-auricularabscess is indicated in the following situations:

1. Infants in whom the mastoid is not pneumatized2. Those who are too sick to undergo cortical mastoidectomy3. Those in whom rapid evacuation of some pus may be helpful

Patients with otalgia caused by the tympanomastoid type ofchronic suppurative otitis media with acute mastoiditis or anycomplication of cholesteatoma require a modified radicalmastoidectomy. Those with an extradural abscess require, inaddition, the removal of enough bone to expose the healthy duraaround the diseased portion and for evacuation of pus.

IMPACTED WAX, OTOMYCOSIS AND FOREIGN BODYWax can be removed either with a Jobson Home probe or can besyringed out using sterile water at body temperature with thesyringe directed posteriorly on the canal. Soda-glycerine drops orcommercially available cerumen loosening preparations can beused to make the wax soft, thereby making its removal easier.Otomycosis and non-vegetative foreign bodies can be syringedout. It is better to remove the vegetative foreign bodies with an earprobe or suction, as they tend to swell on coming in contact withwater. The main symptom in otomycosis is itching but sometimessevere pain may occur. After clearing the canal, antifungal dropssuch as 2% salicylic acid or c1otrimazole can be used.

FURUNCULOSISEarache aggravated by jaw movements or by lying on that side,post-auricular oedema, protuberance of the pinna, purulentotorrhoea not containing any mucus, and most characteristicallysevere pain on pushing the tragus or pulling the pinna are featuresof furunculosis. Local heat application is helpful in reducing painin early cases. When a furuncle starts discharging, the canal ismopped and a wick soaked in icthammol glycerine is inserted intothe canal. This is changed daily. Penicillin or cloxacillin isadministered systemically when there ismarked oedema or adenitis.

CONCLUSIONCareful inspection of the tympanic membrane with an otoscope isessential for the management of otalgia. Acute otitis media withits characteristic otoscopic features is the commonest cause ofotalgia in children and must be treated promptly with antibiotics.In referred otalgia, the tympanic membrane looks normal and aneffort should be made to identify and treat the primary causewhich may lie in the pharynx, teeth, paranasal sinuses or neck.

REFERENCESI Karma PH. Pemtila MA. Sipila MM. Karaja Ml. Otoscopic diagnosis of middle eareffusion in acute and non-acute otitis media. I. The value of different otoscopicfindings. Int J Paediatr Otorhinolaryngol 1989;17:37-9.

2 Hayden GF. Schwartz RH. Characteristics of earache among children with AOM. AmJ tn« Child 1985;139:721-3.

3 Howie VM. Ploussard lH. Sloyer 1. The 'otitis prone' condition. Am J Dis Child1975;129:676-7.

4 Teele OW. Klein 10. Rosner B. Epidemiology of otitis media during the first sevenyears of life in children in greater Boston: A prospective. cohort study. J Infect Dis1989;160:83-94.

5 Bluestone CD. Kleim 10. Otitis media in infants and children. Philadelphia. WBSaunders. 1988.

6 GiebinkGS. Canafax OM. Controversies in the management of acute otitis media. AdvPediatr Infect ots 1988;3:47-63.

7 Kempthorne J. Giebink as. Pediatric approach to the diagnosis and management ofotitis media. Oto/aryn~o( Clin North Am 1991 ;24:905-29.

8 Burton OM. Seid AB. Kearns DB. Pransky SM. Neonatal otitis media: An update.Arch Otoluryngol Head Neck Surg 1993;119:672-5.