Case: Ear Pain

Posted on Aug 24, 2010 in Case Studies | 2 comments

Case Study: Ear Pain, Worse With Eating and Direct Pressure

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“My son has been crying all night long because his ear hurts. The pain is bad enough to wake him up from sleep. Do you think he has another ear infection?”

Case: Mark is a 6-year-old boy accompanied to the office by his mom. He is indeed in some distress, holding his ear and crying intermittently. Mom states that he has been complaining of pain in his ear for 3 days and yesterday complained that the pain was worse with movement of his ear or when he is eating. She has noted no discharge from the ear and he has not been running a fever.

Patient has been spending the summer at an urban day camp, swimming in the pool every day and playing T-ball. Mom recalls no exposure to ticks or poison ivy/oak. There is a cat at home, which has been present since Mark was an infant. His appetite is good and he is normally “very energetic.” Both parents are smokers.

Past medical history: Normal childhood development. History of frequent middle ear infections as well as exertional asthma. History of mild seasonal allergies.

Medications: Occasional oral antibiotic for otitis media in the past year and intermittent use of an asthma inhaler. Mom has been giving him baby aspirin for the past few days for pain relief.  

Physical Examination: Afebrile fit young boy in obvious distress.
Ears: Canal is red and swollen. There is reproduceable pain and traction of the pinna and tragus. No fluid or discharge noted. On visual exam, no pus or debris is present in the canal. Eardrum appears intact.  

How would you proceed?

Published on August 24, 2010
Updated on August 31, 2010

Discussion 

Given his past history of frequent otitis media it is tempting to attribute Mark’s symptoms to another ear infection. However, his symptoms are more likely due to otitis externa, a bacterial infection of the ear canal. Often called swimmer’s ear, otitis externa is usually the result of excessive moisture in the ear canal from showering or swimming that has altered the acidic environment of the ear canal, allowing for bacterial or fungal infection. The earliest symptoms are usually itching and pain, especially with direct pressure on the pinna or tragus. Subsequent symptoms may include a liquid or cheesy discharge from the ear and decreased hearing.

Visualization of the ear canal is the best way to distinguish between otitis media and otitis externa. In children with otitis media, the ear canal looks normal, but the eardrum looks dull, red, or inflamed. In children with swimmer’s ear, the canal is usually inflamed but the eardrum appears normal. If it’s not possible to visualize the ear canal, wiggle the earlobe gently; patients with swimmer’s ear will generally report an increase in pain. The critical point of diagnosis is not to over look the external ear canal when conducting an otoscopic examination.

An accurate diagnosis is important, as the treatment for swimmer’s ear is different than the treatment for otitis media. Topical antimicrobials are beneficial for swimmer’s ear, but oral antibiotics have limited utility.[1] The choice of topical antimicrobial for initial therapy of otitis externa should be based upon efficacy, low incidence of adverse events, likelihood of adherence to therapy, and cost.[2] When the status of the ear drum is unclear, ciprofloxacin or tobramycin drops are a good choice. If the eardrum is intact, cortisporin otic suspension is inexpensive and generally effective.[3]

Mark and his mom should be encouraged to use antibacterial eardrops for 7 days; if symptoms persist, continue the treatment for a maximum of 7 more days. Mark and his mom should be instructed to stay out of the water for at least 5 days and to dry his ears carefully after swimming. Mark should also be instructed not to put anything in his ear—including fingers and cotton swabs—that might scratch the wax layer or ear canal and cause reinfection.

References

1. Hajioff D, Mackeith S. Otitis externa. Clin Evid. 2008;pii:0510.
2. Rosenfeld RM, Brown L, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngolog Head Neck Surg. 2006;134(4 Supppl):S4-S23.
3. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database Syst Rev. 2010; (1):CD004740.