Pediatric emergency medicine trisk 1123 1123
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CHAPTER 58 ■ PAIN: EARACHE
MARK D. JOFFE
INTRODUCTION
Ear pain or otalgia is a very common chief complaint in children seeking
emergent or urgent care. In younger, preverbal children, ear pain is usually
inferred by parents from various child behaviors. Ear tugging in younger infants,
however, is often not associated with ear disease. While acute otitis media
(AOM) may be the main parental concern, astute clinicians must consider a
broader range of potential causes. Otalgia may result from diseases in all parts of
the ear, and also from a variety of nonotogenic conditions. When ear pain is
accompanied by neurologic signs and symptoms such as cranial nerve palsies,
vertigo, or altered mental status, a more extensive evaluation is required.
DIFFERENTIAL DIAGNOSIS
Ear pain may be the presenting symptom of problems in external, middle, or inner
ear ( Fig. 58.1 ), as well as referred pain from other anatomic structures. Causes
of auricular pain are often readily apparent from the history. Trauma to the auricle
results in contusions, abrasions, hematomas, and lacerations that are easily noted
on physical examination. In younger children, and in particular in cases of
inflicted injury, a history of ear trauma may be lacking. Swelling and/or bruising
of the external ear, especially the medial aspect of the auricle, from forcible
traction is a well-recognized manifestation of child abuse. Hematomas of the
auricle are of particular concern because, interposed between the perichondrium
and underlying avascular cartilage, the accumulation of blood disrupts the
diffusion of nutrients to the cartilage. Necrosis of auricular cartilage leads to
deformity and results in the characteristic “cauliflower ear.” Pressure dressings on
injured external ears may prevent the accumulation of significant auricular
hematomas. Larger auricular hematomas may need to be drained.
The popularity of body piercing, and in particular multiple piercings of the ear,
has increased the number of patients requiring treatment for complications.
Infections of the ear lobe or of the cartilaginous portions of the auricle after
piercing should be treated with topical and sometimes systemic antibiotics. While
Staphylococcus aureus is the most frequent pathogen, cartilaginous infection with
Pseudomonas aeruginosa is well described. Drainage, debridement, and
treatment with fluoroquinolone antibiotics may be necessary. Preauricular cysts or
