Basics
Description
- Otalgia, classified as primary or secondary, means ear pain or an earache.
- Primary (or otogenic) otalgia is ear pain that originates inside the ear, either from the external auditory canal or from the middle ear structures.
- Secondary (or referred) otalgia is ear pain that originates from outside of the ear. Any anatomic area that shares innervation with the ear can be the primary source of perceived ear pain.
Diagnosis
Differential Diagnosis
Primary otalgia
- Infectious
- Acute otitis media (AOM)-most common cause of otalgia in children
- Otitis externa-inflammation of external auditory canal, usually associated with swimming and/or localized trauma; second most common cause of otalgia in children
- Cellulitis of the auricle-usually caused by Streptococcus pyogenes; typically involves the earlobe
- Perichondritis-inflammation of the auricle without earlobe involvement
- Furunculosis-infection of the cartilaginous portion of the external auditory canal. Most commonly caused by Staphylococcus aureus. Pain is usually made worse by chewing.
- Mastoiditis-now a rare complication of AOM, characterized by the auricle being pushed out and forward, away from the head
- Myringitis (bullous myringitis)-inflammation of the tympanic membrane, usually with painful blisters on the eardrum
- Varicella and herpes zoster infection within the ear
- Herpes simplex virus infection within the ear
- Trauma
- Blunt trauma
- Laceration or abrasion-if inside the ear canal, usually due to cleaning with cotton swabs
- Thermal injury-frostbite of the ear or burn from a heat source
- Barotrauma-associated with pressure changes on airplanes and scuba diving
- Traumatic perforation of the tympanic membrane-frequently presents with tinnitus
- Tumors-rare; usually associated with weight loss, voice changes, dysphagia, and persistent cervical lymphadenopathy
- Allergic/inflammatory
- Otitis media with effusion
- Eczema
- Psoriasis
- Allergic reaction to topical antibiotics and cerumenolytic agents
- Functional
- Eustachian tube dysfunction-symptoms are due to pressure differences between the middle ear and the Eustachian tube.
- Miscellaneous
- Foreign body-can lead to pain, fullness, and minor hearing loss
- Impacted cerumen-may cause pain if the cerumen presses against the tympanic membrane
Note: Serous otitis media or otitis media with effusion (OME) is common in pediatrics but is usually painless. Children usually complain of fullness or hearing loss.
Secondary otalgia
- Infectious
- Dental infections-cavities, abscesses, gingivitis
- Pharyngitis
- Parotitis
- Tonsillitis
- Peritonsillar abscess
- Retropharyngeal abscess
- Sinusitis
- Cervical lymphadenitis
- Neck abscess
- Stomatitis
- Sialadenitis
- Ramsay Hunt syndrome-viral neuritis of the facial nerve secondary to herpes zoster infection
- Trauma
- Dental trauma
- Postsurgical-tonsillectomy, adenoidectomy
- Oropharyngeal trauma-penetrating injuries, burns
- Neck and cervical spine injuries
- Allergic/inflammatory
- Allergic rhinitis
- Cervical spine arthritis
- Subacute thyroiditis
- Esophagitis-secondary to gastroesophageal reflux
- Bell palsy
- Functional
- Temporomandibular joint (TMJ) dysfunction-less common in children. Pain is usually unilateral and aggravated by chewing and biting.
- Miscellaneous
- Foreign body-in oropharynx or esophagus
- Aphthous ulcers
- Esophagitis
- TMJ disease
- Migraine
- Aural neuralgia
- Pillow otalgia (otalgia from sleep position)
- Psychogenic pain
Approach to the Patient
The first decision that must be made is whether the patient's symptoms require emergent, urgent, or nonurgent intervention. Emergency treatment is rarely required for pediatric patients with otalgia.
- Phase 1: Thorough history-must include a full assessment of ear symptoms, followed by questions to determine possible involvement of other head and neck structures
- Phase 2: Physical exam-thorough examination of external and internal ear, followed by inspection of the head, neck, and inside of the mouth
- Phase 3: Treatment of identifiable conditions
- Phase 4: Referral to otolaryngologist (ENT physician), dentist, or other specialist as needed
History
- Question: Duration of symptoms?
- Significance: acute (more likely infection or trauma) versus chronic
- Question: Quality of the pain?
- Significance:
- Constant (more likely otogenic) versus intermittent (more likely referred)
- Dull (more likely due to inflammation) versus sharp (more likely due to trauma or neuralgia)
- Question: Severity of pain?
- Significance:
- Severe-usually otogenic
- Mild to moderate-more likely to be referred
Worsening factors
- Question: Movement of auricle or pressure on tragus?
- Significance: Characteristic of otitis externa; can also be associated with furunculosis.
- Question: Movement of the jaw (biting, chewing)?
- Significance: TMJ dysfunction; furunculosis
Associated symptoms
- Question: Fever?
- Significance: Infection
- Question: Upper respiratory infection (URI) symptoms?
- Significance: AOM or OME
- Question: Sore throat?
- Significance: Referred otalgia
- Question: Ear discharge, tinnitus, or vertigo?
- Significance: Otogenic causes
- Question: Mouth pain?
- Significance: Dental issues or stomatitis
- Question: Hoarseness?
- Significance: Gastroesophageal reflux
- Question: Multiple somatic complaints?
- Significance: Psychogenic
- Question: Recent swimming?
- Significance: Otitis externa
- Question: Recent travel? Hobbies?
- Significance:
- Barotrauma from scuba diving or air travel
- Wrestling-auricular trauma
- Question: History of recurrent AOM or OME?
- Significance: Cholesteatoma
Physical Exam
- Finding: Erythematous, dull, bulging tympanic membrane, with decreased mobility?
- Significance: Suggestive of AOM
- Finding: Retracted, immobile tympanic membrane?
- Significance: Suggestive of OME or eustachian tube dysfunction
- Finding: Pain with pressure on the tragus or traction on the pinna?
- Significance: Suggestive of otitis externa or furunculosis
- Finding: Erythema and edema of the external auditory canal?
- Significance: Suggestive of otitis externa
- Finding: Purulent discharge in external auditory canal?
- Significance: Suggestive of otitis externa or AOM with a ruptured tympanic membrane
- Finding: Redness, swelling, and/or tenderness of the auricle?
- Significance:
- With earlobe involvement-cellulitis
- Without earlobe involvement-perichondritis
- Finding: Swelling behind the pinna with its lateral displacement?
- Significance: Suggestive of mastoiditis
- Finding: Normal ear exam?
- Significance: Suggestive of secondary otalgia, thus other possible sources must be carefully examined
- Finding: Multiple dental caries?
- Significance: May be the source of pain; can indicate the presence of a dental abscess
- Finding: Foreign body within the ear or in the oropharynx?
- Significance: May be the source of pain from direct pressure or secondary to inflammation
- Finding: Enlarged, asymmetric tonsils or uvular deviation from midline?
- Significance: Suggestive of tonsillitis or peritonsillar abscess
Look for signs of trauma inside or outside of the ear.
Diagnostic Tests & Interpretation
Labs, imaging studies, and other diagnostic tests are usually unnecessary as a thorough history and physical exam can lead to a diagnosis in the majority of cases.
- Test: Culture of ear discharge
- Significance: Indicated when otitis externa or AOM with perforation of the tympanic membrane does not resolve as expected with routine antibiotic treatment
- Test: Audiometry
- Significance: Evaluate for hearing loss, which would suggest primary otalgia
- Test: Tympanometry
- Significance: Evaluate for OME, eustachian tube dysfunction, or tympanostomy tube obstruction
Imaging
- CT scan: rarely needed
- CT of neck-evaluate for retropharyngeal abscess, mass, or hematoma
- CT of sinuses-evaluate for sinusitis
- CT of temporal bone-evaluate for AOM, mastoiditis, and other bony pathology
- MRI: rarely needed unless intracranial lesion is suspected
Treatment
Additional Treatment
General Measures
- Therapy is directed at the identified underlying cause.
- Pain medications such as acetaminophen, ibuprofen, or topical benzocaine are important because many of the infectious causes are exquisitely painful.
- Observation without antibiotic therapy ("watchful waiting") is indicated in certain groups of children with AOM.
Emergency Care
- Rarely needed with most causes of otalgia but may be required if
- Potential airway compromise from foreign body, mass, or abscess
- Significant trauma-possible basilar skull fracture
- Infection with a toxic-appearing child
- For all of the above situations, first establish "ABCs" as needed, hospitalize, and consult ENT promptly.
Issues for Referral
Referral to ENT when otalgia is primary in origin and any of the following:
- Pain with unexplained hearing loss, vertigo, or tinnitus
- Unexplained or persistent otorrhea
- Suspected neoplasm
- History suggestive of severe barotrauma
- AOM with complications
- Foreign bodies that cannot be removed easily from the ear
- Potential for auricle destruction (e.g., perichondritis may lead to permanent deformation, cauliflower ear)
- Persistent ear pain without an identifiable source should prompt a referral.
Additional Reading
- American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113(5):1451-1465. [View Abstract]
- Conover K. Earache. Emerg Med Clin North Am. 2013;31(2):413-442. [View Abstract]
- Leung AK, Fong JH, Leong AG. Otalgia in children. J Natl Med Assoc. 2000;92(5):254-260. [View Abstract]
- Licameli GR. Diagnosis and management of otalgia in the pediatric patient. Pediatr Ann. 1999;28(6):364-368. [View Abstract]
- Majumdar S, Wu K, Bateman N, et al. Diagnosis and management of otalgia in children. Arch Dis Child Educ Pract Ed. 2009;94(2):33-36. [View Abstract]
- Shah RK, Blevins NH. Otalgia. Otolaryngol Clin North Am. 2003;36(6):1137-1151. [View Abstract]
Codes
ICD09
- 388.7 Otalgia, unspecified
- 388.71 Otogenic pain
- 382.9 Unspecified otitis media
- 388.72 Referred otogenic pain
- 380.1 Infective otitis externa, unspecified
ICD10
- H92.09 Otalgia, unspecified ear
- H66.90 Otitis media, unspecified, unspecified ear
- H60.90 Unspecified otitis externa, unspecified ear
- H66.93 Otitis media, unspecified, bilateral
- H60.91 Unspecified otitis externa, right ear
- H60.92 Unspecified otitis externa, left ear
- H60.93 Unspecified otitis externa, bilateral
- H92.03 Otalgia, bilateral
- H66.91 Otitis media, unspecified, right ear
- H66.92 Otitis media, unspecified, left ear
- H92.01 Otalgia, right ear
- H92.02 Otalgia, left ear
SNOMED
- 16001004 Otalgia (disorder)
- 74123003 Otogenic otalgia (finding)
- 3110003 Acute otitis media (disorder)
- 12336008 Referred otalgia (finding)
- 3135009 Otitis externa (disorder)
FAQ
- Q: What are the most common organisms that cause AOM?
- A:
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
- Viruses
- Q: What are the most common organisms that cause otitis externa?
- A:
- Pseudomonas aeruginosa
- Staphylococcus aureus
- Staphylococcus epidermidis
- Gram-negative rods
- Fungal (Aspergillus) or yeast (Candida)-rare
- Q: What is the most common cause of referred ear pain?
- A: Dental disease