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Otalgia inChildren
20
YeşimYüksel, ErdemAtalayÇetinkaya,
andCodrutSarafoleanu
20.1 Introduction
Otalgia, a prevalent symptom in pediatric age groups, is one of the most common
causes of hospital admissions. It is a highly distressing condition for both the child
and the family, especially in kids below two who cannot articulate their pain. Otalgia
may occur due to otologic or non-otologic causes. Otalgia due to otologic causes is
termed primary while non-otologic otalgia is called secondary [1–3]. Primary otalgia with otologic causes is the most common in children. Otologic causes may originate from the auricle, external auditory canal, and middle ear. However, non-otologic
conditions with oral, oropharyngeal, laryngeal, dentoalveolar, sinonasal, and musculoskeletal origins may also cause referred otalgia in childhood [3]. Therefore,
when it comes to ear pain in children, otologic examination is not enough, other
structures in the ear that may cause secondary otalgia should also be examined.
In this chapter, primary and secondary causes, clinical diagnosis, and evaluation
of otalgia will be covered.
Y. Yüksel · E. A. Çetinkaya (*)
Department of Otorhinolaryngology, University of Health Sciences, Antalya Training and
Research Hospital, Antalya, Turkey
C. Sarafoleanu
Department of Otorhinolaryngology, Head and Neck Surgery, Carol Davila University of
Medicine and Pharmacy, Santa Maria Hospital, Bucharest, Romania
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
H. Yüksel et al. (eds.), Pediatric Airway Diseases, Comprehensive ENT,
https://doi.org/10.1007/978-3-031-74853-0_20
263
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Y. Yüksel et al.
20.2 Primary Otalgia Causes
20.2.1 Auricle
20.2.1.1 Infections
Infections such as cellulitis, perichondritis, and herpes zoster oticus (Ramsay Hunt
syndrome) may affect the auricle, causing otalgia.
While cellulitis often occurs following trauma, insect bites, and piercings, perichondritis develops primarily due to blunt trauma. Both conditions entail pain,
hyperemia, swelling, and tenderness; however, the ear lobe, which is noncartilaginous, is not affected in perichondritis [4].
Herpes zoster oticus, on the other hand, is a unilateral infection resulting from
varicella. In this condition, vesicular lesions may involve the auricle and external
auditory canal and cause pain, burning sensation, itching, and hyperesthesia [5, 6].
20.2.1.2 Trauma
Trauma to the auricle and external auditory canal may result in ecchymosis, abrasion, contusion, laceration, or hematoma depending on the severity of the trauma.
Early recognition and treatment of these post-traumatic pathologies, especially
hematomas, is highly crucial for an optimal cosmetic outcome [4, 6].
20.2.1.3 Allergic Angioedema
Allergic reactions following exposure to the relevant allergen in patients suffering
from insect bites or contact dermatitis may lead to itching, swelling, mild pain,
induration, or tenderness in the auricle [4].
20.2.1.4 Thermal Damage
Exposure to extreme cold can cause frostbite of the auricle. Initially, numb and pale
in color, the auricle later becomes painful, edematous, and erythematous. If the
damage progresses, arterial circulation is compromised, and thus necrotic changes
may ensue [6].
In auricular burns, although there are different additional ndings depending on
the degree of burn, pain, which is initially persistent and severe and later becomes
intermittent, is a highly unpleasant symptom [6].
The causes of otalgia originating from the auricle are as mentioned above; the
patient’s medical history is often enough to make a clinical diagnosis. Following the
diagnosis, treatment should be planned in accordance with and aimed at the etiology.
20.2.2 External Auditory Canal
20.2.2.1 Otitis Externa
Otitis externa is an inammation of the external auditory canal and is caused by
swimming, excessive humidity, and localized trauma [6]. P. aeruginosa, S. aureus,
and other gram-negative bacilli are the most common pathogens. The main
20 Otalgia inChildren
265
symptoms in acute cases are pain and localized tenderness in the ear canal [7].
There may also be a feeling of fullness inside the ear, itching, and discharge. Fever
is rarely concomitant. Physical examination ndings include tenderness in the tragus and pain during otoscopy in most patients. The external auditory canal may be
edematous, hyperemic, or macerated.
In particular, prolonged bacterial otitis externa or extended use of topical antibiotics may cause disturbance of the external auditory canal ora. This often leads to
fungal otitis externa, or otomycosis, caused by pathogens such as Aspergillus and
Candida. While these patients may have a feeling of fullness inside the ear, intense
itching, and sometimes pain, they may also be asymptomatic [4].
20.2.2.2 Malignant Otitis Externa
Malignant otitis externa, which is extremely rare in pediatric patients, is a potentially fatal infection resulting from the spread of infection in the external auditory
canal to adjacent structures through the bone. It is more common in immunocompromised, diabetic, and HIV-positive patients. Patients typically have a persistent
earache that is quite deep and intense and lasts longer than 1week. Depending on
the spread of infection, complications such as chondritis, temporal bone and skull
base osteomyelitis, meningitis, brain abscess, and facial paralysis may develop.
Computed tomography and magnetic resonance imaging are critical in the diagnosis [8].
20.2.2.3 Eczematous Dermatitis
Especially in atopic children, some chemicals may have an irritant effect on the
external auditory canal after the skin barrier is impaired due to different reasons
such as excessive cleaning of this area. This leads to recurrent erythematous, edematous, painful, and itchy lesions. If the disease becomes chronic, the skin in and
around the external auditory canal becomes atrophic and dry. Itching then occurs as
the main symptom. In eczematous dermatitis, avoiding contact with water and
chemicals is as important as medical treatment [4].
20.2.2.4 Furunculosis
Mainly caused by S. aureus, furunculosis is a local skin infection originating in the
hair follicles and sebaceous and ceruminous glands located in the cartilaginous part
of the external auditory canal. Increased ear pain with chewing is typical, and there
is a tender, hyperemic swelling at the canal entrance. The main treatment is incisional drainage of the lesion together with antibiotherapy if needed [4, 6].
20.2.2.5 Foreign Body
One of the causes that should be considered in cases of children presenting with
otalgia is the foreign body in the ear. Foreign bodies in the external ear canal are
quite common in children because of children’s tendency to insert small objects into
their ears. Ear pain, aural fullness, and mild hearing loss are the main symptoms [4,
6]. If detected by otoscopic examination, the foreign body should be removed as
soon as possible by an ENT physician using special instruments. It should be kept
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Y. Yüksel et al.
in mind that attempts to remove the foreign body by non-specialists or family members may lead to undesirable consequences such as external auditory canal injury
and tympanic membrane perforation.
20.2.2.6 Cerumen Impaction
Cerumen, a mixture of the special secretion produced by the ceruminous glands in
the external auditory canal, exfoliated epithelial cells, and the secretion of the pilosebaceous glands, is the most common cause of congestion and discomfort in the
ear. It is so common that it occurs in one in ten children. Symptoms include itching,
mild hearing loss, and pain due to movement of the cerumen, especially in case of
contact with the tympanic membrane. Sometimes pain occurs when cerumen is
attempted to be removed. Removal of the cerumen by curette or aspiration under the
microscope relieves the symptoms [6, 8].
20.2.2.7 Tumors
Tumors of the external auditory canal are very rare in pediatric patients. Pain in and
discharge from the ear is the most common reason for presentation.
Rhabdomyosarcoma, lymphoma, and eosinophilic granuloma are the reported
tumors of the external auditory canal in children. These patients have a granulomatous mass and bloody or serohemorrhagic discharge in the external auditory canal.
It is of utmost importance that patients with otitis externa or perforated otitis media
with frequent recurrences and persistent symptoms and signs be evaluated for possible tumors of the external auditory canal [4].
20.2.3 Middle Ear
20.2.3.1 Acute Otitis Media
Acute otitis media is the most common cause of primary otalgia in children and one
of the most common diseases diagnosed by clinicians. Approximately 70% of children have at least one episode of acute otitis before the age of two. It peaks at
6–15months of age and usually occurs following upper respiratory tract infections
[3, 9, 10]. In infants and young children, the development of otitis media is facilitated by reasons such as shorter and wider Eustachian tube, higher occurrence of
upper respiratory tract infections, immature immune system, and frequent adenoid
hypertrophy, which has an obstructive effect and acts as a reservoir for pathogenic
agents. The most common infectious agents are viruses (adenovirus, respiratory
syncytial virus, inuenza virus) and bacteria (Streptococcus pneumoniae,
Haemophilus inuenzae, Moraxella catarrhalis). However, approximately 60% of
patients recover spontaneously within 24h and 80% within 3 days without any
treatment [10]. In acute otitis media, ear pain is initially milder but then turns into a
pulsatile pain that is felt directly inside the ear and increases especially in the supine
position. The pain decreases dramatically when the tympanic membrane is perforated [8]. Fever accompanies in some patients. Infants may show nonspecic symptoms such as restlessness, loss of appetite, and sleep disturbance. Following
20 Otalgia inChildren
267
perforation of the tympanic membrane, some patients may experience otorrhea, and
at times vomiting and lethargy may be observed [3, 4]. In patients with acute otitis
media, a bulging tympanic membrane with decreased mobility is the most specic
nding on otoscopic examination [11]. Depending on the opacity of the membrane
and the color of the uid behind the membrane, a yellow, white, or green reex may
be observed. In children with acute otitis media, appropriate analgesics should be
given to reduce pain, especially in the rst 24h. In those whose symptoms do not
resolve within 48–72h, antibiotherapy is deemed appropriate.
In children, acute otitis media may progress with complications. Complications such
as hearing loss and suppurative tympanic membrane perforation are more common
while severe complications such as facial paralysis, mastoiditis, labyrinthitis, meningitis, intracranial abscess, and lateral sinus thrombosis are much rarer [3, 4]. In cases with
symptoms such as fever, severe otalgia, headache, irritability, loss of appetite, otorrhea,
vomiting, and lethargy that do not diminish despite medical treatment, more caution
should be exercised and the patient should be evaluated for complications.
Bullous myringitis usually involves focal bullae on the tympanic membrane
without uid accumulation in the middle ear. Bacterial pathogens are frequently
implicated, however, the condition may also develop due to trauma. Ear pain is the
most distinctive symptom [4].
20.2.3.2 Otitis Media withEffusion
It is an inammatory condition characterized by the accumulation of serous or
mucoid uid behind an intact tympanic membrane without signs of acute infection.
It usually occurs as a result of the impairment of ventilation, drainage, or protective
functions of the Eustachian tube due to nasal infection or allergy. Patients are usually asymptomatic. In symptomatic patients, however, the main complaint is hearing loss while some may have mild ear pain. On otoscopic examination, the tympanic
membrane is opaque, retracted, and usually amber in color, its vascularity is elevated, and there is an air-uid level behind the membrane [3, 4]. First, follow-up and
medical treatment are recommended. In patients whose symptoms do not subside,
surgical myringotomy with a ventilation tube should be performed.
20.2.3.3 Eustachian Tube Dysfunction
The Eustachian tube in children is anatomically different than in adults and reaches
its adult form around the age of 7. Anatomical or physiologic dysfunction of the
Eustachian tube may develop due to inammatory causes such as upper respiratory
tract infection or allergic rhinitis, or obstructive lesions of the nasopharynx and
middle ear. Patients may experience ear pain, tinnitus, subjective sensation of ear
fullness, or hearing loss. These complaints are especially pronounced while chewing, swallowing, and yawning. On otoscopic examination, everything may be normal, or tympanic membrane retraction may also be observed [4, 6, 9].
Current ENT guidelines consider otoscopy or otomicroscopy, tympanometry,
Weber and Rinne tests or pure tone audiometry, nasopharyngoscopy to assess the
pharyngeal opening of Eustachian tube to be the most essential assessment tools.
Still, they have to be adapted to the patient age and compliance [12].
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Y. Yüksel et al.
20.2.3.4 Cholesteatoma
Cholesteatomas are benign masses that develop from keratinized epithelium that
should not normally be present in the middle ear cavity. It is locally invasive and its
osteolytic effect worsens with infection. It is divided into three categories: congenital, acquired, and unclassiable cholesteatoma. Acquired cholesteatomas are most
common and result from retraction pockets of the tympanic membrane caused by
permanent eustachian dysfunction. They may also result from perforation of the
tympanic membrane, trauma, or iatrogenic causes. They can lead to bone erosion
where they are located (Fig.20.1).
Congenital cholesteatomas that develop behind the intact tympanic membrane
without any history of infection or otitis are more common in boys. Most of them
are recognized incidentally at the age of 4–5. There may be complaints such as ear
pain or a sensation of fullness in the ear. Otoscopy reveals a whitish mass behind the
intact tympanic membrane, often at the anterosuperior or around the manubrium.
The CT scan of the ear completes the disease assessment.
The literature describes the Potsic staging system for congenital cholesteatoma:
stage I—one single quadrant of the tympanic cavity affected; stage II—multiple
quadrants are affected, but with no ossicular involvement or mastoid extension;
stage III—presence of ossicular involvement; stage IV—mastoid extension. This
classication system reects a strong association between staging and recurrence of
disease, ranging from a 13% recurrence rate in stage I to a 67% rate in stage IV [13].
Congenital cholesteatoma usually grows slowly and has no symptoms until the
presence of secondary ossicular erosion, local infection, damage of the tympanic
membrane, and otorrhea. Thus, in advanced stages of the disease, differentiating
between acquired and congenital cholesteatoma may be impossible.
Given the high morbidity risk and complications, surgical treatment is ideal for
cholesteatoma [13].
Fig. 20.1 Mastoid abscess
due to cholesteatoma.
(Picture taken from the
archive of Prof Dr. Erdem
Atalay Cetinkaya)
20 Otalgia inChildren
269
20.2.3.5 Trauma
Ear pain can be a symptom of severe trauma or skull base fractures affecting the
middle ear. In addition to blunt and penetrating trauma, we may encounter cases of
barotrauma.
Traumatic tympanic membrane perforation is the most common trauma-induced
condition. It may be caused by penetrating objects or barotrauma. Patients experience
severe ear pain during trauma, which may be accompanied by hearing loss and tinnitus.
After blunt trauma or barotrauma, blood accumulation may occur in the middle
ear cavity called hemotympanum. Rarely, blood may accumulate in the middle ear
through the Eustachian tube in children with profuse epistaxis [14]. On examination, the tympanic membrane is red or purple and may be bulging.
Another condition that may develop due to trauma is the ossicular chain anatomy
disruption. In addition to ear pain, severe hearing loss may also be observed as a
symptom. These patients should be evaluated with computed tomography.
Inner ear injuries are rare but severe in children. It should be suspected in the
presence of tinnitus, hearing loss, and vertigo after trauma. Urgent surgical intervention may be required in some patients.
Ear pain is a signicant symptom in fractures of the skull base that may result
from blunt trauma to the ear region. Altered mental status, headache, and vomiting
may be observed, or focal neurologic ndings may be noted. Physical examination
ndings may include ecchymosis, swelling, tenderness, hemotympanum, tympanic
membrane perforation, facial palsy, bloody or cerebrospinal uid otorrhea, periorbital ecchymosis, cerebrospinal uid rhinorrhea on the mastoid bone, and other
parts of the temporal bone [4].
20.3 Secondary Otalgia Causes
In pediatric patients, while primary otalgia is frequently seen due to ear-related
causes, sometimes referred to as ear pain, i.e., secondary otalgia, due to pathologies
of the structures around the ear can be observed [15]. The ear has a rich sensory
innervation. Sensory bers from the V (trigeminal), VII (facial), IX (glossopharyngeal), X (vagus), and C2–C3 cervical nerves innervate the outer ear and middle ear.
Due to the long course of these nerves, ear pain may also be a symptom in diseases
of other structures they innervate. The inner ear structures, on the other hand, are
innervated by the VIIIth cranial nerve (vestibulocochlear), which has no pain bers;
therefore, most inner ear pathologies do not present pain [2].
20.3.1 Oropharyngeal Infections
In pediatric patients, referred ear pain may occur after oral cavity conditions such as
gingivitis, aphthous stomatitis, and glossitis, oropharyngeal infections such as pharyngitis and tonsillitis, and adenoidectomy and tonsillectomy operations.
Acute pharyngotonsillitis is the most common cause of secondary otalgia in children.
Acute pharyngotonsillitis is quite common between the ages of 5–15. The most
270
common causative agents are viruses; however, bacteria account for 15–30% of cases.
Group A beta-hemolytic streptococci are mainly the most common bacterial agent. The
disease has an acute onset. It may present a clinical picture ranging from mild sore throat
to exudative tonsillitis with high fever. Patients have complaints such as fever over
38°C, shivering, malaise, dysphagia, arthralgia, and ear pain. The pharynx and tonsils
have a hyperemic and edematous appearance on physical examination. Exudation
occurs on the tonsils as the condition progresses. There is tender lymphadenopathy in
the neck. Patients usually respond well to medical treatment. Correct diagnosis and
treatment of acute pharyngotonsillitis brings positive outcomes, including preventing
complications such as acute rheumatic fever, acute glomerulonephritis, and peritonsillar
abscesses, and reduction of acute morbidity associated with the disease [16].
Y. Yüksel et al.
20.3.2 Dental Causes
In children, referred ear pain is joint especially during the teething period. It usually
occurs due to problems affecting mandibular molar teeth. The pain is mostly localized on the side of the problematic teeth. In children presenting with ear pain and
normal otoscopy ndings, a history of teething, infection, dental caries, trauma, and
bruxism should be inquired [17]. During the oral cavity examination, swelling of
the gingiva or face may be detected if there are dental pathologies, gingivitis, or
dental abscesses. Patients with dental pathology should be referred to a dentist [3].
20.3.3 Auricular Lymphadenitis
Preauricular lymph nodes may be enlarged, often in response to ocular infections such
as conjunctivitis or parotid diseases, and postauricular lymph nodes may be enlarged
in response to external ear and mastoid skin pathologies, or infectious mononucleosis.
If acute infection develops in these lymph nodes, redness and uctuation may be
observed in addition to pain. The pain may also be felt inside the ear [4].
20.3.4 Neck Abscess
Deep neck infections, which are rare in children, start as cellulitis-phlegmon in the
soft tissues in the potential cavities of the neck and usually result in abscess development. Late diagnosis or inadequate treatment may lead to severe complications.
Peritonsillar abscesses are more common in adolescents and older children, whereas
retropharyngeal abscesses are observed more commonly in children under 5years
of age. Parapharyngeal abscesses, on the other hand, can be seen in all ages.
Although studies differ, peritonsillar and parapharyngeal abscesses are encountered
more frequently in clinical presentations, and these cause referred ear pain.
Treatment of neck abscesses in children includes appropriate intravenous antibiotherapy, follow-up, and surgical drainage if necessary [18].
20 Otalgia inChildren
271
20.3.5 Parotitis
Parotid gland diseases involve localized pain in the inferior part of the ear. On examination, swelling, tenderness, and redness can be seen in this area. Most parotid
gland infections in children are viral (such as mumps, parainuenza, inuenza A)
[19, 20]. Parotid involvement is typically bilateral in these infections. Bacterial parotitis caused by S. aureus is rare and presents with high fever. Unilateral and erythematous parotid swelling, tenderness, and pus from Stensen’s duct with parotid
massage may be observed [21].
Sialolithiasis leading to obstruction of the parotid gland duct may cause swelling
and pain in the glands and referred ear pain. However, this pathology is rarely found
in pediatric population, which accounts for only 3% of cases [22].
Recurrent parotitis is a noninfectious inammatory disease of the parotid gland
characterized by repeated parotitis attacks. It can affect both glands. It requires no
treatment other than analgesia and regular monitoring [3, 4].
20.3.6 Temporomandibular Joint Dysfunction
Temporomandibular joint dysfunction is more common in children over 10years of
age but is rare in younger age groups. The temporomandibular joint may be affected
by rheumatoid arthritis, bruxism (teeth grinding), trauma, and infections. Patients
may complain of ear pain, a sensation of fullness in the ear, and a clicking sound.
The pain is exacerbated by opening the mouth or clenching the teeth. While no
pathology is observed in the ear on examination, clicking, crepitation, preauricular
tenderness, and malocclusion may be detected on joint examination. Appropriate
analgesics should be used in treatment, soft food diet and heat application should be
recommended, and joint pathologies should be investigated in patients [3, 17].
20.3.7 Sinusitis
Sinus infections, especially of the maxillary and ethmoid sinuses, may cause
referred pain in the ear via the second branch of the trigeminal nerve [8]. In these
patients, nasal obstruction is the most common symptom, and ndings such as anterior or posterior nasal discharge and cough are present. The medical treatment given
to patients with sinusitis ndings determined by history and physical examination
relieves the symptoms.
20.4 Differential Diagnosis
To make a clinical diagnosis in pediatric patients presenting with otalgia complaints,
rst, a thorough anamnesis should be taken, and the causes that may lead to otalgia
should be inquired. In the anamnesis taken considering the child’s age, the
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localization and spread of pain, factors that exacerbate pain (such as chewing), risk
factors, and otologic and systemic concomitant factors should be questioned.
In terms of the diagnostic approach, it is essential to evaluate the information
from the family regarding the etiology as part of the anamnesis by considering the
age groups of the children. For example, acute otitis media is most frequently
encountered in children up to 3years of age, while tonsillitis is more common in the
5–15 age group. In a 10-month-old child presenting with ear pain and normal otoscopic ndings, otalgia due to teething should be considered. In contrast, dental
infection or temporomandibular joint dysfunction should be considered in a 10-yearold child. Having information about the history of foreign body, onset of complaints
after swimming, environmental factors such as insect bites or exposure to heat or
cold that may have caused thermal damage, presence of recurrent ENT-related
chronic infections, history of surgical operations with the use of ventilation tube,
presence of concomitant diabetes, immunodeciency or atopic nature is highly signicant in the differential diagnosis of otalgia in children. In addition to fever, otorrhea, and hearing loss, which are the cardinal symptoms usually accompanying the
otalgia complaint, symptoms related to the causative pathology, such as itching,
increased sensitivity, and pain with pressure on the tragus, a sensation of fullness in
the ear, tinnitus, vertigo, rhinorrhea, headache, chewing and swallowing difculties
should also be evaluated. In younger children, nonspecic symptoms such as restlessness, loss of appetite, sleep disturbance, and excessive crying may accompany
otalgia (Table20.1).
Physical examination can quickly reveal signs of infection such as perichondritis, cellulitis, and herpes zoster related to the auricle; thermal damage and angioedema; auricle pushed forwards, which may be a sign of mastoiditis; abrasion,
contusion, laceration, and ecchymosis in the ear due to ear and head trauma; ecchymosis in the periorbital area and on the mastoid bone skin; localized lymphadenopathy and lymphadenitis in the periauricular region; signs related to parotid diseases.
In physical examination, the otoscopic examination should follow the inspection. In
patients presenting normal ndings in the ear examination, temporomandibular
joint test, nasal examination, oral cavity, oropharynx, and neck examination are
required to diagnose the pathologies causing secondary otalgia. Moreover, facial
nerve examination is also crucial in children with suspected facial palsy. When it is
deemed necessary about the etiology of otalgia in relevant patients, laboratory tests
and radiological imaging should be requested, and audiometric and tympanometric
examinations should be performed (Table20.2). These examinations are needed for
early diagnosis of complications, especially in patients with prolonged symptoms
who do not respond to medical treatment for the etiology.
Ear pain in children is a complaint that should be heeded. Ear pain may have a
simple cause, such as teething or a plug or foreign body in the ear, or it may as well
be a symptom of a severe condition such as mastoiditis, meningitis, facial palsy, and
brain abscess. Therefore, in pediatric presentations due to otalgia, a detailed history
should be taken along with the physical examination and, if necessary, appropriate
tests to make an accurate diagnosis. Then proper treatment and follow-up should be
applied.