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Arterial blood gases (ABGs) should be determined
in an acutely ill patient with dyspnea or tachypnea.
l
If sputum is present, a sputum culture should be ob-
tained to determine the presence of an infectious
agent.
DIFFERENTIAL DIAGNOSIS
When a patient reports severe dyspnea and manifests
signicant oxygen deprivation, emergent assessment
and referral are indicated. The following health prob-
lems can be the cause of the emergent situation.
Emergent Conditions Manifested by Dyspnea
Pulmonary Embolus
A patient reporting severe dyspnea, cough, fever, he-
moptysis, chest pain, history of deep vein thrombosis,
and/or history of recent immobilization should be
evaluated for possible PE (see Chapter 8). The Wells
risk score can be used to assess the probability of PE.
Foreign Body Aspiration
Foreign body aspiration occurs most frequently in chil-
dren and the elderly. If the event was witnessed, history
of aspiration is usually clear. If the person is found after
the event, the history cannot be as revealing. Generally,
the onset of cough is sudden and unexpected. If the
foreign body is obstructing the airway, the patient is in
acute respiratory distress, and immediate intubation or
bronchoscopy is indicated to remove the foreign body
and open the airway. Partial obstruction of the airway
can cause stridor, cyanosis, labored respirations, and/or
wheezing. Lateral neck and chest radiographs can re-
veal the location and size of the obstructing object (see
Chapter 11).
Anaphylaxis
Anaphylaxis is an emergent situation. History can in-
clude insect bite, drug ingestion, or recent meal con-
taining exposure to known allergens. Early symptoms
include pruritic rash, feeling of warmth, wheezing,
fatigue, light-headedness, and dyspnea. On examina-
tion, patients in anaphylaxis manifest angioedema,
tachypnea, clammy skin, hypotension, wheezes, and
tachycardia. Immediate treatment and support of ven-
tilation is necessary.
Chapter 14 • Dyspnea
169
can cause a spontaneous pneumothorax from rupture of
subpleural blebs located at the apex of the upper lobe or
in the superior segment of the lower lobe. Spontaneous
pneumothorax can also occur, with the highest incidence in tall, thin males between the ages of 15 and
30 years. There is sudden severe chest pain and dyspnea
aggravated by normal respiratory movement. Absent or
decreased breath sounds are found on the side of the
pneumothorax. Chest radiography can be diagnostic.
Croup
Croup, or laryngotracheobronchitis, is a parainuenza
infection that is usually preceded by symptoms of an
upper respiratory tract infection. The illness is usually
gradual in onset and includes a hoarse, seal-bark cough
and fever. The degree of respiratory distress is variable.
Acute Epiglottitis
Acute epiglottitis is a serious, life-threatening bacterial
infection caused primarily by H. inuenzae. It typically has a rapid onset with stridor, high fever, drooling, mufed voice, and sore throat. A child will appear
anxious and may be sitting forward. Parents should be
asked if the child has received an H. inuenzae B or
Hib immunization. This condition is rare in children
who have been immunized.
Bacterial Tracheitis
Bacterial tracheitis is usually a secondary infection
caused by Staphylococcus aureus or H. inuenzae that
inames the trachea after a viral infection. It is a subglottic lesion and mimics croup; however, a high fever
and toxic appearance are present. Frequently there is a
copious amount of purulent sputum present.
Status Asthmaticus
Acute bronchoconstriction in a patient with asthma can
develop as a result of a respiratory tract infection, exposure to allergens, inhalation of fumes or other airway
irritants, or environmental factors. Airway obstruction
is caused not only by bronchial smooth muscle constriction but also by mucosal edema and excessive
mucus production. Predominant symptoms include
breathlessness, wheezing, and coughing. Absence of
wheezing in a child with asthma can indicate severe
airway obstruction with poor air exchange.
Pneumothorax
History of blunt chest trauma, often seen after a motor
vehicle accident or a fall, can cause pneumothorax,
hemothorax, or pulmonary contusion. Cystic brosis
Botulism
Botulism poisoning can occur after ingestion of the
toxin in inadequately cooked or improperly canned
food. Infant botulism is caused by ingestion of the
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Chapter 14 • Dyspnea
spores of C. botulinum rather than the exotoxin. It occurs
before the rst year of life, and honey has been implicated in 20% of patients. Symptoms occur within hours
after ingestion of contaminated food. Weakness and respiratory dyspnea and failure often accompany visual
problems. Infant botulism begins with constipation, and
the infant becomes weaker and listless. Respiratory arrest
can be sudden.
Nonemergent Conditions Manifested by Dyspnea
Chronic progressive dyspnea is most often caused by
COPD, heart failure, and obesity. It is seen less often
in severe anemia and carcinoma of the pulmonary system. These patients report gradual onset of SOB over
days or weeks.
Chronic Obstructive Pulmonary Disease
COPD is associated with frequent cough that is worse in
the morning, sputum production that is clear to yellow
in color, decreasing exercise tolerance, and mild to moderate fatigue. History of smoking is present in most
instances. Exposure to asbestos, coal dust, and other
signicant environmental pollutants may also be reported. Objective manifestations of COPD include rapid,
shallow respirations, reddish complexion, increased AP
diameter, use of accessory muscles to breathe, pursed-lip
breathing, decreased tactile fremitus, decreased respiratory excursion bilaterally, hyperresonant lungs, distant
breath sounds, prolonged expiration, occasional wheezes,
and mufed heart sounds. Chest radiography, pulmonary
function tests, and possible exercise tests are indicated
to conrm the diagnosis of COPD.
Heart Failure
Individuals reporting a history of heart disease or heart
valve disease, dyspnea, orthopnea, PND, peripheral
edema, weight gain, cough with frothy sputum, fatigue,
and palpitations must be further assessed for acute heart
failure. Physical examination ndings can include altered level of consciousness, anxiety, jugular venous
distention, tachypnea, rales, rhonchi, tachycardia, displaced point of maximum impulse, S3, S4, and possible
ascites. Symptoms in children also include sweating on
the forehead or upper lip. An ECG and chest radiograph
will show increased heart size, oximetry will reveal a
decreased arterial PO2, and an echocardiogram will
display a signicantly reduced ejection fraction.
Anemia
Patients reporting dyspnea (especially on exertion),
fatigue, light-headedness, palpitations, and possible
history of chronic disease should have blood tests to
measure the oxygen-carrying capacity of their blood
(hemoglobin and hematocrit levels). Hematological
diseases affect the oxygen-carrying capacity of the
blood, with resulting tissue hypoxia. Hypoxia from
anemia leads the patient to hyperventilate to try and get
more oxygen which leads to respiratory alkalosis, or
an increasing pH. Objective signs of anemia include
tachycardia and pallor.
Poor Physical Conditioning
Poor physical conditioning can cause the patient to
experience shortness of breath with exertion. Associated symptoms may include cardiac palpitations, history of excessive weight, and sedentary lifestyle. The
physical examination is often normal except for tachycardia and possible obesity. Exercise stress tests can be
done for an adult with cardiovascular risk factors or a
history of cardiovascular disease.
Asthma
Asthma is the most frequent cause of recurrent dyspnea. People usually report a history of asthma and
possibly allergies and can be taking prescribed inhaled
bronchodilators and/or inhaled steroids. Paroxysmal
cough and audible wheeze often accompany dyspnea.
They can report recent respiratory tract infection, exposure to known allergens, or strenuous exercise. Objective manifestation on physical examination includes
restlessness, tachypnea, use of accessory muscles to
breathe, intercostal retraction, decreased tactile fremitus, decreased breath sounds, and inspiratory and possible expiratory wheezes. Pulse oximetry and spirometry testing will assist in the diagnosis of asthma.
ABGs are indicated in the patient manifesting acute
oxygen (O2) deprivation or carbon dioxide (CO2) retention, and chest radiographs are indicated if a lower
respiratory tract infection is suspected. If the patient
does not have a history of asthma and the spirometry
test result has normal ndings, a methacholine challenge test can be diagnostic.
The lessening or absence of wheezes in a person
with asthma can indicate mucus plugging and an impending episode of status asthmaticus.
Pneumonia
Pneumonia is usually associated with dyspnea, pleuritic
chest pain, cough with greenish or rust-colored sputum,
fever, and chills. In children, irritability, feeding problems, and lack of playfulness can also be seen. Objective
manifestations of pneumonia include fever, tachycardia,
Chapter 14 • Dyspnea
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171
tachypnea, inspiratory crackles, asynchronous breathing, tactile fremitus, dull percussion sound over area of
consolidation, and bronchophony. Pneumonia can be
conrmed by chest radiography and sputum cultures.
always within the rst 4 weeks of life, commonly in
the rst week (with preterm neonates who were on
ventilation at high risk). Occasionally parents be-
come aware of the condition when a respiratory tract
infection is present. Stridor is predominantly inspira-
Hyperventilation Syndrome
Hyperventilation syndrome is a common cause of recurrent faintness without actual loss of consciousness.
Dyspnea, light-headedness, palpitations, and paresthe-
tory, and the sound can be altered with change in
position of the infant. The cry and cough are normal.
Direct visualization of the larynx is performed for
diagnosis.
sias (perioral and extremities) occur. Restlessness,
anxiety, and a normal cardiovascular examination are
present. Recumbency does not relieve the symptoms.
Chest radiographs show normal ndings.
Vascular Ring
Tracheal compression from vascular anomalies can
cause stridor and dyspnea in infants. The main symp-
tom is soft inspiratory stridor with expiratory wheeze.
Bronchomalacia
Bronchomalacia is the most common cause of persistent stridor in infancy. Onset of the stridor is almost
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Pulmonary
embolus
Foreign body
aspiration
Anaphylaxis
Pneumothorax Acute-onset dyspnea; sharp, tearing
Croup History of upper respiratory tract
Acute
epiglottitis
Bacterial
tracheitis
Status
asthmaticus
Botulism Honey ingestion in infant, contami-
ABG, Arterial blood gas; DVT, deep vein thrombosis; ECG, electrocardiogram.
Acute-onset dyspnea, cough, mild to
severe chest pain, sense of impending doom; hemoptysis; history of DVT,
recent surgery, oral contraceptive,
smoker, hypercoagulability states
Acute-onset dyspnea; history of drink-
ing large amounts of alcohol; in
children, history of putting small
objects in mouth; possible cough
Acute-onset dyspnea; history of insect
sting, ingestion of drug, or allergen
chest pain; pain can radiate to
ipsilateral shoulder
infection
Positional sitting forward; sore throat,
anxious, toxic child
Recent viral infection Fever, stridor, purulent sputum Radiography of airway,
Recent URI, exposure to allergens,
breathlessness
nated food ingestion
Emergent Conditions Manifested by Dyspnea
Frequently a brassy cough and difculty swallowing
may be present. Barium swallow followed by echocar-
diography is done to establish the diagnosis.
Restlessness, fever, tachycardia,
tachypnea, diminished breath
sounds, crackles, wheezing,
pleural friction rub
Apnea or tachypnea, restlessness,
suprasternal retractions, intoxication, inspiratory stridor,
localized wheeze
Angioedema, tachypnea, clammy
skin, hypotension, bilateral
wheezes, tachycardia
Tachycardia, diminished breath
sounds, decreased tactile
fremitus, hyperresonance of
lung area affected; possible
hypertension and tracheal shift
Hoarse, seal-bark cough, fever
(variable)
High fever, drooling, stridor,
muffled voice
Wheezing, coughing, tachycardia,
tachypnea
Hypoventilation, drooling, weak
cry, ptosis, ophthalmoplegia,
loss of head control
CTPA, ABGs, chest radio-
graph, ECG, ventilation/
perfusion scans, d-dimer,
Wells score
Lateral neck radiograph,
chest radiograph,
bronchoscopy
None; emergency
measures necessary
Chest radiograph, ABGs
None initially; if respira-
tory distress increases,
pulse oximeter and
referral
None; emergency measures
for airway support
WBC increased,
tracheal culture
Peak flows, chest
radiograph, ABGs
Pulmonary function testing,
chest radiograph, fluoroscopy, stool culture
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Chapter 14 • Dyspnea
DIFFERENTIAL DIAGNOSIS OF
Nonemergent Conditions Manifested by Dyspnea
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Pneumonia Dyspnea, cough, sputum produc-
tion (green, rust, or red),
pleuritic chest pain, chills; in
infants and children: irritability and feeding problems
Hyperventilation
syndrome
Bronchomalacia
Vascular ring Infant: dyspnea, brassy cough,
Heart failure Chronic progressive dyspnea,
Anemia Dyspnea on exertion, fatigue,
Poor physical
conditioning
Asthma Dyspnea, paroxysmal cough,
COPD Chronic progressive dyspnea,
ABGs, Arterial blood gases; AP, anteroposterior; COPD, chronic obstructive pulmonary disease; CPTA, computer tomography pulmonary angiography;
CV, cerebrovascular; ECG, electrocardiogram; PMI, point of maximal impulse; PND, paroxysmal nocturnal dyspnea; TSH, thyroid stimulating hormone;
URI, upper respiratory tract infection; WBC, white blood cell count.
Dyspnea, light-headedness,
palpitations, paresthesias
(perioral and extremities)
Neonate, infant: history of
stridor, history of URI
difficulty swallowing
cough, frothy sputum, fatigue,
lightheadedness, syncope,
weight gain, ankle swelling,
palpitations, PND, orthopnea,
history of heart disease; in
children: chronic progressive
dyspnea, sweating above lip
and forehead, especially while
eating
palpitations, light-headedness,
history of chronic disease
Dyspnea on exertion, weight
gain, palpitation on exertion,
sedentary lifestyle, cigarette
smoker
audible wheeze, history of
asthma or allergies
dyspnea on exertion, persistent cough, minimal sputum,
easy fatigue, history of
smoking
Fever, tachycardia, tachypnea, in-
spiratory crackles, asynchronous
breathing, vocal fremitus, percussion dull or flat over area of
consolidation, bronchophony,
egophony
Restlessness, anxiety, normal
CV examination
Inspiratory stridor; normal
cough, cry
Inspiratory stridor with expiratory
wheeze
Altered level of consciousness,
restlessness, jugular venous
distention, tachypnea, use of
accessory muscles to breathe,
rales, rhonchi, wheezes, tachycardia, decreased peripheral
pulses, cool extremities, displaced PMI, S3, S4, ascites,
liver enlargement
Pallor, tachypnea, cool dry skin of
extremities, possible orthostatic
hypotension
Overweight, tachycardia Cardiac stress test
Restlessness, tachypnea, use of
accessory muscles to breathe,
intercostal retractions, decreased
vocal fremitus, decreased breath
sounds, inspiratory and possibly
expiratory wheezes
Rapid shallow respirations, reddish
complexion, increased AP diameter of thorax, use of accessory
muscles to breathe, pursed-lip
breathing, decreased tactile
fremitus, decreased respiratory
excursion bilaterally, lungs
hyperresonant, distant breath
sounds, prolonged expiration,
occasional wheezes, possible
tachycardia, muffled heart
sounds
Chest radiograph,
sputum cultures,
ABGs, WBC
Chest radiograph,
TSH
Refer for visualization
of larynx
Barium swallow,
echocardiography
ECG, chest
radiograph, ABGs,
echocardiogram
CBC, iron studies
Spirometry followed
by a methacholine
challenge, chest
radiograph, ABGs
Chest radiograph,
spirometry,
exercise tests,
ABGs
Chapter 14 • Dyspnea
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173
References and Readings
Bettmann MA, Baginski SG, White RD, et al, Expert Panel on Car-
diac Imaging: ACR Appropriateness Criteria® acute chest pain:
Suspected pulmonary embolism. [online publication]. Reston,
Va., 2011, American College of Radiology.
Carroll C, Sala K: Pediatric status asthmatics, Crit Care Clin 29:2,
2013.
Divo M, Pinto-Plata V: Role of exercise in testing and in therapy of
COPD, Med Clin N Am 96:753–766, 2012.
Dobbie A, White D: Laryngomalacia, Ped Clin of North Amer
60:893–902, 2013.
Evans SE, Scanlon PD: Current practice in pulmonary function test-
ing, Mayo Clin Proc 78:758, 2003.
Fedullo PF, Tapson VF: The evaluation of suspected pulmonary
embolism, N Engl J Med 349:1247, 2003.
Karnani NG, Reiseld GM, Wilson GR: Evaluation of chronic dys-
pnea, Am Fam Phys 71:8, 2005.
Leung AKC, Kellner JD, Johnson DW: Viral croup: A current per-
spective, J Pediatr Health Care 18:297, 2004.
Meek PM: Measurement of dyspnea in chronic obstructive pulmonary
disease: What is the tool telling you? Chron Respir Dis 1:1, 2004.
Owens S: Exercise intolerance, Pediatr Rev 21:6, 2000.
Schwartzstein RM: Evaluation of the patient with chronic dyspnea:
Clinical application of pathophysiologic principles, Prim Care
Case Rev 3:201, 2000.
Sveum R, Bergstrom J, Brottman G, et al: Diagnosis and manage-
ment of asthma, Bloomington, Minn., 2012, Institute for Clinical
Systems Improvement.
Weinberger M, Abu-Hasan M: Perceptions and pathophysiology of
dyspnea and exercise intolerance, Pediatr Clin N Am 56:33, 2009.
Wells P, Anderson D, Rodger M, et al: Derivation of a simple clinical
model to categorize patients probability of pulmonary embolism:
Increasing the models utility with the SimpliRED D-dimer,
Thromb Haemost 83:416, 2000.
Zoorob R, Campbell J: Acute dyspnea in the ofce, Am Fam Physician
68:1803, 2003.
Zoorob R, Sidani M, Murray J: Croup: An overview, Am Fam Physician
83:9, 2011.
CHAPTER
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15
talgia, or ear pain, is a common problem in both
O
children and adults and is generally caused by an
inammatory process. In children, inammation most
commonly occurs in the middle ear. Adults more often
have an earache from external ear conditions or from
referred pain from other head and neck structures.
Acute otitis media (AOM) refers to any inammation
of the middle ear and encompasses a variety of clinical
conditions. Otitis media with effusion is a collection of
uid in the middle ear. This condition is also known as
serous otitis media, secretory otitis, or nonsuppurative
otitis. External or middle ear disorders can often be
distinguished after a brief history and physical examination. If the physical ndings are normal, referred
pain is a likely cause. About 50% of referred pain is
caused by dental problems, although other causes may
include temporomandibular joint (TMJ) disorder, parotitis, pharyngitis, and cervical, mouth, or facial disorders. The most serious, although least common, cause
of referred pain is nasopharyngeal cancer, a condition
more common in people of Asian descent. Figure 15-1
illustrates the structures of the ear.
Earache
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Is this an acute infection?
Key Questions
l
How old are you?
l
Have you had a fever?
l
Have you had an upper respiratory infection?
l
Have you had ear infections before?
l
Is there a family history of ear infections?
Fever
Fever is present in 60% of all children with AOM. In
infants younger than 2 months, fever with AOM is
uncommon. A high fever accompanying otitis is more
likely to indicate a systemic illness such as pneumonia
or meningitis.
Upper Respiratory Infection
An upper respiratory infection (URI) occurs when the
mucous membranes of the nasopharynx and/or sinuses
become infected and organisms are forced up the lumen
of the eustachian tube. Inammation of the mucosa or
enlarged adenoids obstruct the eustachian opening so
that the air in the middle ear is absorbed and replaced
by mucus. This mucus creates a mechanical obstruction
and can serve as a medium for bacterial growth.
Previous Infections
Infants younger than 3 months who have their rst
AOM run a high risk of recurrence. Up to 71% of children younger than age 3 years have had at least one
episode, and one third have had an average of three
episodes. Chronic otitis media can result in anatomical
changes to the tympanic membrane (TM) and middle
ear ossicles, which may predispose the patient to
additional ear infections.
Family History
Having a sibling or parent with chronic otitis media
makes it twice as likely for the illness to develop in the
child. The presence of chronic otitis media may also be
related to child-care practices such as bottle propping
or environmental exposures such as second-hand cigarette smoke.
Age
The occurrence of AOM declines signicantly after
age 6 years. Increased age raises the likelihood of secondary otalgia caused by disorders of the head, face,
and neck; by sinus or periodontal disease; by chronic
reux; and by malignancy.
174
What environmental conditions might suggest increased
risk?
Key Questions
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Does anyone around you smoke? Do you smoke?
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If a child: Does the child attend day care?
Chapter 15 • Earache
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175
Malleus
Auricle
External
auditory
canal
Tympanic membrane
FIGURE 15-1 External auditory canal, middle ear, inner ear. (From Barkauskas VH, Baumann L, Darling-Fisher C:
Health and physical assessment, ed. 3, St. Louis, 2002, Mosby.)
l
If a child: Does the infant take a bottle lying down?
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Have you been swimming recently?
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Have you recently been in an airplane or been scuba
diving?
Incus
Stapes and footplate
Semicircular
canals
Facial nerve
(cranial nerve VII)
Cochlear and
vestibular
branch
(cranial
nerve VIII)
Cochlea
Oval window
Round window
Eustachian
tube
Attending Day Care
Attending a day care with other children is associated
with an increased incidence rate of otitis media because of exposure to organisms.
Smoke Exposure
Second-hand cigarette smoke exposure has been associated with a twofold to threefold increased risk of otitis
media. Cigarette smoking leads to functional eustachian
tube obstruction and decreases the protective ciliary
action in the tube.
EVIDENCE-BASED PRACTICE
for Otitis Media?
Bottle Propping
In very young children, lying supine while drinking
from a bottle has been associated with AOM. It is postulated that swallowing while lying down allows nasopharyngeal uid to enter the middle ear, with subsequent infection.
What is the Risk of Secondary Smoke Exposure
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Chapter 15 • Earache
Swimming
Repeated or prolonged immersion in water results in
loss of protective cerumen and chronic irritation, with
maceration from excessive moisture in the canal. This
leads to an increased occurrence of otitis externa, also
called swimmer’s ear.
Airplane Travelers, Divers
Barotrauma is a cause of acute serous otitis related to
pressure changes from ying or scuba diving. This is
often aggravated by recent upper respiratory tract infection or nasal congestion. Failure of the eustachian
tube to open and equilibrate during descent results in a
collection of serosanguineous uid in the middle ear.
This may be felt as ear pressure that can lead to pain,
tinnitus, and temporary deafness. Swallowing, chewing, or blowing out the nose with the mouth and nose
occluded can relieve symptoms.
Could this be related to another organ system?
Key Questions
l
Do you have diabetes?
l
Do you have any other health conditions you are be-
ing treated for?
l
Have you ever had dermatitis, eczema, or psoriasis?
l
If a child: Does the child have a cleft palate that is
not repaired?
Diabetes Mellitus
Diabetes mellitus predisposes adults to malignant otitis
externa, which is cellulitis involving the ear and surrounding tissue. People with diabetes are also at increased risk for otitis media, mastoiditis, and osteomyelitis of the skull base.
Immunosuppression
Patients being treated for cancer or HIV/AIDS may
be on immunosuppressive medications and are at increased risk for malignant otitis externa.
History of Seborrheic Dermatitis or Psoriasis
The etiology of debris in the external canal in
seborrheic dermatitis and psoriasis is the result of
the increased desquamation associated with these
two disorders, and in the case of psoriasis hyperkeratosis, thickening of the epidermis with desquamation. Chronic inflammatory dermatitis can result
as a reaction to wearing a hearing aid. Overproduction of sebum in the external canal can cause otitis
externa.
Cleft Palate
Anomalies that are not repaired anatomically predispose a child to otitis media because of functional obstruction of the eustachian tubes.
What does the presence of pain tell me?
Key Questions
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Where specically is the pain felt?
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Is it in one or both ears?
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How severe is the pain?
l
Does it interfere with sleeping, eating, or other ac-
tivities?
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How long have you had this pain?
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Is the pain constant or intermittent? If intermittent,
how long does it last?
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Does the pain travel (radiate) to other areas?
Location of the Pain
Pain of otitis externa is described as tenderness around
the outer ear or the opening to the ear canal that worsens
with manipulation of the pinna. Mastoiditis is often associated with severe pain or tenderness over the mastoid
bone. If pain is bilateral suspect otitis externa. Referred
pain or pain of AOM is usually unilateral. Ramsay Hunt
syndrome is more common in older adults and produces
a painful rash with vesicles in, on, or around one ear;
facial weakness may appear on the same side. Infants
cannot assist in location of the ear pain; instead, they
exhibit behavioral changes that may indicate pain, such
as irritability, malaise, poor appetite, vomiting, and diarrhea. Young children may pull or tug at their ears.
Quality of the Pain
The pain of AOM is often described as a deep pain or
a blockage of the ear. Serous otitis is often painless or
may be described as a bubbling, popping, or stuffy
sensation in the ear. Otitis externa involves a tenderness of the outer ear or ear canal that can be accompanied by itching. A cerumen impaction creates a milder
pain or vague discomfort of stuffed ears.
Quantity and Severity of the Pain
The pain of AOM is severe enough to interfere with
sleep and may be suddenly relieved if the eardrum
perforates. Chronic ear pain that is unresponsive to
treatment may indicate a tumor.
Onset, Timing, and Duration of the Pain
TMJ pain is often described as severe pain lasting a
few minutes and recurring three or four times per
Chapter 15 • Earache
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177
day, sometimes associated with headache. It is worse
in the morning because nighttime teeth grinding
is associated with this condition. The pain is intermittent but can be acute and is related to trauma
or overextension of the mouth. Chronic pain may
be related to dental malocclusion or rheumatoid
arthritis.
Crying when sucking is often an infant’s only indication of pain with compression and increased pressure
in the ears. Nocturnal onset of otalgia from a developing infection is caused by increased vascular pressure
in the reclined position, which causes the TM to bulge
and to stimulate pain sensation.
What does the presence of discharge or itching tell me?
Key Questions
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Do you have any itching in the ear?
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Do you have any discharge from the ear?
Itching or Drainage
Itching or drainage from the ear usually indicates an
infection or inammation of the external canal. Itching
can also be a precursor to herpes zoster of the trigeminal nerve (cranial nerve V), which can cause paroxysmal pain of the face and jaw, and hyperalgesia to
minimal stimulation such as tooth brushing, cold air, or
grimacing. The prodrome for herpes zoster consists of
itching, burning, or tingling before vesicular eruption.
The facial nerve (cranial nerve VII) is also involved in
ear pain. Itching may be related to allergic rhinitis,
especially when patients describe a deep itching in
the ears.
Drainage may also be present after the TM ruptures
from increased middle ear pressure, as exudate from
otitis externa or malignant otitis externa, or it may be
from exudate secondary to mastoiditis. Cholesteatoma
is an epidermal inclusion cyst of the middle ear or
mastoid. A perforation of the TM and associated foulsmelling discharge may occur.
What does a history of trauma or injury tell me?
Key Questions
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Have you had any recent trauma to the ear?
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Have you had any head trauma?
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How do you clean your ears? Do you use cotton-
tipped swabs?
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Do you have a history of excessive earwax?
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If a child: Does the child have a history of putting
objects in the ears?
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Have you had any recent insect bites around the ear?
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Have you been exposed to any loud noise?
Ear Trauma
Perforation of the eardrum can be caused by blunt or
penetrating trauma. Blunt trauma might include a slap
to the ear or barotrauma. Penetrating trauma to the canal or TM may be self-induced with cotton-tipped
swabs or other sharp objects used to remove cerumen
or to scratch the canal.
Head Trauma
Direct injury to the inner ear by fracture of the petrous
temporal bone, located at the base of the skull, also
destroys the inner ear.
Cerumen Impaction
Cerumen is a naturally wet, sticky, honey-colored wax
that lubricates and protects the external ear canal. In
some individuals it occurs in a dark, scaly form and
accumulates in the ear canal. This accumulation may
cause hearing loss, tinnitus, pressure sensation, vertigo, and infection. Self-cleaning practices can produce
trauma to the canal, and cerumen-softening solutions
can cause chemical irritation to the canal tissue.
Foreign Bodies
Foreign bodies such as feathers, beads, and insects
(especially cockroaches) can produce ear pain and inammation. Children often self-insert objects into the
ear canal.
Insect Bites
Insect bites can lead to acute pain and tenderness of
the external canal and may develop into a secondary
infection.
Loud Noise
Exposure to high-pitched and loud noise for a prolonged period of time destroys the cochlear hair cells.
Exposure to noisy work environments, to the operation
of heavy machinery, and to loud music increases the
risk of injury and eventual hearing loss.
Is hearing loss a clue?
Key Questions
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Do you have any difculty in hearing?
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Do you have any dizziness?
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Do you have any ringing in the ear?
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If a child: Do you think the child can hear normally?
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If a child: Does the child turn his or her head to
Chapter 15 • Earache
listen?
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If a child: Does the child seem to focus on your
mouth when listening to you?
the TM, however, otitis media cannot be ruled out. Lavage solution helps to soften the cerumen and can be
purchased commercially in kits, or a solution can be
made of hydrogen peroxide and water (1:1).
Difficulty in Hearing
Reports of hearing loss or “difculty hearing” can indicate blockage of the ear canal by cerumen or a foreign body, inammation of the middle or inner ear, or
a neoplasm. The most frequent cause is conductive
hearing loss caused by blockage of the external canal,
usually by cerumen. Chronic otitis media is usually a
condition of adults who have a chronic infection that
may destroy the ossicles and spread to the mastoid,
labyrinth, and intracranial structures, causing hearing
loss. Chronic ear pain is often associated with hearing
loss and ear discharge secondary to a perforated nonhealing TM.
Hearing Loss in Children
Chronic otitis media with effusion causes a conductive
hearing loss in children. This loss may be caused by
negative middle ear pressure, the presence of an effusion in the middle ear, or structural damage to the TM
or ossicles.
Dizziness, Ringing in Ear
Hearing loss associated with dizziness, vertigo, or tinnitus may indicate a serious inner ear condition such
as acoustic neuroma or Meniere disease. Abnormal
middle ear ventilation and middle ear effusion are the
most common causes of balance disturbance in children. These symptoms are caused by reestablishment
of aeration in the middle ear cavity as the effusion
clears.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
A correct diagnosis of ear pain requires a good view
of the TM and external ear canal. Cerumen obstruction should be removed through lavage or by separating an impaction with an ear curette so that irrigation
uid can penetrate behind the impaction. The curette
must be manipulated cautiously because trauma to or
inammation of the sensitive perichondrium, which
lies immediately below a thin layer of epithelium in
the ear canal, elicits excruciating pain and bleeds
easily.
Lavage should not be performed if the medical history
suggests perforation of the TM. Without visualization of
Note Behaviors in Children
Otitis media is the most common childhood disorder.
Young infants may exhibit nonspecic signs of irritability, poor feeding, congestion, and fever. Older infants
and young toddlers are irritable, may pull on the painful
ear, or bang their head on the affected side. Older children will report an earache.
Inspect External Ears
General inspection should begin with the pinna and
condition of the skin around the ear, face, and scalp.
Hemorrhage over the mastoid bone (Battle sign) may
occur with a basal skull fracture. Eczema, seborrheic
dermatitis, or psoriasis manifests as redness and scaling of the skin that can extend into the external ear
canal. Pain in the opening of the ear canal and inamed
skin may be suggestive of a bacterial infection. Fungal
and yeast infections appear as white or dark patches.
Furuncles or lesions secondary to trauma or irritation
appear as localized areas of tenderness or swelling.
A hot, swollen, and erythematous ear and surrounding
skin indicate cellulitis. Redness and painful swelling
over the mastoid process is a sign of infection in the
mastoid air cells.
Palpate External Ears
Palpate the pinna and tragus for tenderness. In mastoiditis, the pinna is displaced forward and swelling
may be present behind the ear. Palpation of the mastoid
process elicits severe tenderness. Otitis externa is associated with pain on manipulation of the pinna and
tragus. With referred pain, the structures will appear
normal, although palpation over the TMJ may elicit
tenderness, and movement of the jaw may create a
clicking sound.
Palpate the preauricular and postauricular areas on
the right and left simultaneously to elicit pain. Palpate
the anterior and posterior cervical lymph nodes and the
area over the mastoid process. Preauricular nodes may
be enlarged in AOM and otitis externa. Postauricular
swelling may indicate extension of infection into the
mastoid cavity.
Inspect Ear Canals
With the otoscope, observe for the patency of the
canal, the condition of the skin of the ear canal, and
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