Ear pain in children
Synonyms and keywords: Ear pain in kids, earache, ear infection, otitis, ear discomfort, ear sore, otalgia, otodynia.

# Historical Perspective
- In the 1840s , the first otoscope was invented by Anton von Troeltsh in Germany to diagnose ear pain.

# Classification
- Ear pain in children may be classified according to the anatomic site of er pain :
- Primary
- Secondary
- Traumatic
Other variants of ear pain in children include:
- Diseases of the auricle
- Diseases of the ear canal
- Secondary otalgia
- Diseases of the middle and inner ear
- Traumatic injuries to the ear

# Pathophysiology
- The pathogenesis of ear pain in children  is characterized by pain from the ear itself which is called primary ear pain and referred pain which is called Secondary ear pain .

# Causes
The most common causes of ear pain in children are: is primary otalgia include otitis media and otitis externa include:
1.Diseases of the auricle like: Cellulitis of the auricle, perichondritis,Herpes zoster oticus, local allergic reaction (bug bite), Contact dermatitis, Sunburn, Frostbite.
2.Diseases of the ear canal like: Otitis externa( Bacterial, Fungal, Malignant otitis externa), Furunculosis, Cerumen impaction, foreign bodies, Granuloma,Malignant tumor, Contact dermatitis, Eczema.
3.Diseases of the middle and inner ear like: acute otitis media, eustachian tube dysfunction, Otitis media with effusion, Otitis media with perforation, Otitis media with tympanostomy tubes, myringitis, cholesteatoma, malignant tumor, Complications of otitis media( Mastoiditis, Meningitis, Brain abscess, Venous sinus thrombosis, inner ear infection, Facial nerve palsy).
Less common causes of ear pain in children is secondary otalgia which include: : temporomandibular joint syndrome, pharyngitis, stomatitis, auricular lymphadenopathy or lymphadenitis, sinusitis (maxillary),Parotitis, facial nerve palsy, psychogenic, cervical spine arthritis, and dental infections but it's more common in adults than children. Or traumatic injuries to the ear abrasions or lacerations, auricular hematoma, traumatic perforation of the TM, disruption of the ossicles, hemotympanum (blunt or barotrauma), Basilar skull fracture, associated intracranial injury, Inner ear injury (blunt or barotrauma).

# Differentiating  ear pain in children from other diseases
Ear pain in children must be differentiated from:
Auricle:
- Contusion (auricular hematoma).
- Infection: Cellulitis, Perichondritis, Herpes zoster oticus (Ramsay Hunt syndrome).
- Allergic angioedema
- Juvenile spring eruption (polymorphous light eruption)
- Environmental injury
Ear canal:
- Otitis externa 
- Malignant otitis externa 
- Contact dermatitis
- Furuncle
- Foreign body
- Cerumen impaction
- Tumor
Middle and inner ear:
- Acute otitis media
- Complications of acute otitis media are: spontaneous rupture of the tympanic membrane , Mastoiditis, Facial palsy, Inner ear infection, involvement of contiguous structures,
- Otitis media with effusion
- Eustachian tube dysfunction
- Cholesteatoma
- Blunt or penetrating trauma: traumatic tympanic membrane perforation, traumatic disruption of the ossicles or inner ear, Basilar skull fracture.
Secondary otalgia: 
- Auricular lymphadenopathy or lymphadenitis.
- Parotitis,
- Temporomandibular joint dysfunction syndrome,
- Facial nerve (Bell's) palsy,
- Oropharyngeal infections,
- Sinusitis,
- Cervical spine injury

# Epidemiology and Demographics
- The prevalence of ear pain in children of::
- Acute otitis media is approximately 83% of children by 3 years of age.
- Cerumen impaction occurs in 1 out of every 10 children

## Age
- Ear pain in children especially  primary otalgia of  infection (acute otitis media) is more commonly observed among ages 624 months .
- Ear pain of otitis externae is more commonly observed among patients aged 7-12 years old.

## Gender
- There is no gender predisposition for ear pain in children.

## Race
- There is no racial predisposition for ear pain in children.

# Risk Factors
- Common risk factors in the development of ear pain in children are :
- Allergies or asthma, ear infections, and family history of ear infections.
- Coronary artery disease.
- Diabetes or immunocompromise.
- Smoker or negative smoker(tobacco smoke exposure).
- Unilateral hearing loss.
- Superior tympanic membrane retraction pocket.
- Otorrhea .

# Natural History, Complications and Prognosis
Common complications of ear pain (infection) include: 
- Hearing loss
- Problems learning to talk and to understand speech with recurrent infections
- Rupture of the eardrum
- Inflammation of the middle ear
- Cholesteatoma
- Damage to the tiny bones in the middle ear
- Mastoiditis(rare)
- Meningitis(rare)
Prognosis is generally good which is resolved symptoms within several days.

# Diagnosis

## Diagnostic Criteria
- The diagnosis of acute otitis media in children may made when at least one of the following criteria are met:
- Pain (rubbing, tugging, or holding the ear may be a sign of pain)
- Fever
- Irritability
- Otorrhea
- Anorexia
- Sometimes vomiting or lethargy

## Symptoms
- Ear pain in children is sometimes asymptomatic.
- Symptoms of ear pain in children may include the following:
- Ear pain, especially when lying down.
- Tugging or pulling at an ear.
- Difficulty sleeping.
- Crying more than usual.
- Acting more irritable than usual.
- Difficulty hearing or responding to sounds.
- Loss of balance
- Fever of 100 F (38 C) or higher.
- Drainage of fluid from the ear.
- Headache
- Loss of appetite.

## Physical Examination
- Patients that are a child  with ear pain  usually appear either stable with discomfort and holding their ear and crying, younger infants or toddlers may be fussy and difficult to console. Or with abnormal vital signs like ear pain, epidural hematoma, and  abnormal mental status due to brain infection or traumatic injury.
- Physical examination may be remarkable for::
- Abnormal vital signs due to serious infection, like meningitis, sepsis, or serious traumatic injury, like epidural hematoma.
- Holding their ear and crying in sever otitis media or externa.
- Moderate to severe hearing loss.
- Traumatic injury like lacerations, ecchymoses, fluctuant hematomas, or swelling.
- Periorbital ecchymoses signs of basilar skull fracture.
- Battle's sign (ecchymosis overlying the mastoid bone)
- Diffuse redness and swelling of the external ear due to  indicate infection or local allergic reaction
- Protrusion of the ear from the side of the head due to either  allergic or infectious inflammation of the pinna or mastoiditis.
- Pre- or postauricular lymphadenopathy presence of any fluctuance and overlying redness or swelling.

## Laboratory Findings
Imaging studies; and consultation with an otolaryngologist
- There are no specific laboratory findings associated with ear pain in children.
- An elevated concentration of CBC, ESR, and CRP is diagnostic of serious or deep-seated infections, such as mastoiditis, malignant otitis externa, or bacterial meningitis .
- Other laboratory findings consistent with the diagnosis of ear pain in children  include bacterial or fungal culture of ear drainage, blood culture, lumbar puncture,and  Audiometry.

## Electrocardiogram
An ECG may be helpful in the diagnosis of carcinoma of the middle ear in children. Findings on an ECG suggestive of  carcinoma of the middle ear include atrial dissociation.

## X-ray
An x-ray may be helpful in the diagnosis of the inner ear. Findings on an x-ray suggestive of microstructure defects or tumors include otoconia masses, most of the morphology studies of the inner ear.

## Echocardiography or Ultrasound
Echocardiography may be helpful in the diagnosis of carcinoma of the middle ear in children. Findings on an echocardiography suggestive  of carcinoma of the middle ear include atrial dissociation.

## CT scan
There are no CT scan findings associated with ear pain in children. However, a CT scan may be helpful in the diagnosis of complications of otitis media in ear pain in children, which include altered mental status in conjunction with cardiovascular instability, fever, focal neurologic findings, meningismus, and severe headache, complications, such as venous sinus thrombosis, meningitis, or brain abscess should be suspected.

## MRI
Ear MRI( Magnetic resonance imaging) and referral for nasolaryngoscopymay be helpful in the diagnosis of ear pain in children in the setting of otalgia with normal ear examination findings and symptoms of or risk factors for a tumor . Findings on MRI diagnostic of ear tumor include equal T1 and T2 signals with intensifying in tympanum, and long T1 or equal T1 and long T2 signal in mastoid showed obstructive inflammation.

## Other Imaging Findings
There are no other imaging findings associated with ear pain in children.

## Other Diagnostic Studies
- Ear pain in children is usually diagnosed using an otoscope  , or tympanometry can be helpful if there is suspicion of middle ear disease:
- Findingson otoscopic examination include  redness, flaking, swelling, or thick discharge of ear canal, presence of masses, foreign bodies, bullae, or eczematous changes, and  the TM appears thickened or cloudy, or if air bubbles are evident behind the TM, a middle ear effusion should be suspected, tense, pus-filled bullae may be seen in AOM(Auditory canal and middle ear), redness or bullae of the TM without evident fluid in the middle ear suggests isolated myringitis, perforations of the TM, inserted tympanostomy tube can see location and patency should be assessed, in cases of trauma, hemotympanum may be noted. Hemotympanum is characterized by a red or purple effusion, which may occupy the entire middle ear space or may appear as an air-fluid level.

# Treatment

## Medical Therapy
- The mainstay of therapy for ear pain in children are over-the-counter drugs like Tylenol(acetaminophen) or ibuprofen (Advil, Motrin) and anesthetic drops, warm compresses for some kinds of bacterial ear infections, DIY remedies , antibiotics for ear infections even its not effective treatment:
- Acute bacterial otitis externa (AOE),  necrotizing external otitis.
- Acute otitis media (AOM).
- Acute folliculitis.
- Auricular cellulitis.
- Tympanic membrane rupture
- Perichondritis
- Sinusitis 
- Necrotizing external otitis
- Acute mastoiditis
- Chondritis

## Surgery
- Surgery is the mainstay of therapy for cholesteatoma (Abnormal squamous epithelium) polypoid disease, and infected bone that must be removed in order to create a dry, safe ear that is free of infection.
- Surgical procedures like:
- Debridement can only be performed for patients with chronic perichondritis and chondritis.
- Keratosis obturans is treated with removal of impacted desquamated keratin debris in the ear canal.
- Foreign body in the ear canal can cause pain and be treated with careful removal.
- Infected sebaceous cyst is treated with incision and drainage of the cysts, oral antibiotics and otorhinolaryngology assessment.

## Prevention
- Effective measures for the primary prevention of ear pain in children include not smoking, and avoiding secondhand smoke,Keep all foreign objects out of your ears  always take time to carefully dry your ears after swimming, showering, or bathing, and You can also wear a bathing cap, earplugs, or use custom-fitted swim molds when swimming. Hold a hair drier on a low heat setting at least 12 inches from the ear