• Otitis media—most common cause of pediatric otalgia, acute onset
• Otitis externa—more common in summer months; pain increases with traction on pinna
• Serous otitis media—child may complain of pain, fullness, hearing loss, or “hearing things”
• Varicella—chickenpox may involve the auricle and ear canal, as may herpes zoster
• Herpes simplex—appears as grouped vesicles
• Cellulitis
• Furunculosis—localized abscess
• Mastoiditis—complication of otitis media; ear protrudes anteriorly

• Foreign body—child may have an intense inflammatory reaction
• Lacerations, abrasions—usually from putting objects in ear or cleaning
• Blunt trauma—may be associated with tympanic membrane perforation, inner ear injury, or basilar skull fractures
• Barotrauma—arising from abrupt changes in middle ear pressure (airplanes, scuba diving)

• Rare in pediatric patients, but may involve any of the ear structures including skin, bone, vascular, and neural components

• Dermatologic conditions such as eczema and psoriasis
• Allergy to topical antibiotic and cerumenolytic agents

• Eustachian tube dysfunction

• Impacted cerumen

• Dental infections including abscess and gingivitis
• Stomatitis—herpes simplex and coxsackieviruses are common causes
• Tonsillitis
• Peritonsillar abscess
• Post-tonsillectomy/post-adenoidectomy— pain worsens with swallowing
• Retropharyngeal abscess—drooling, stridor, child usually appears ill
• Mumps
• Sinusitis
• Cervical adenitis
• Laryngitis

• Dental trauma
• Penetrating injuries to the oropharynx
• Lacerations
• Burns—caustic, thermal, or electrical
• Injuries to the neck and C-spine including fractures and muscle tension

• Oropharyngeal/laryngeal tumors—may be cystic, benign, or malignant
• Rarely intracranial tumors will present with ear pain

• Allergic rhinitis
• Cervical spine arthritis

• Foreign body may be lodged in piriform sinus or esophagus
• Esophagitis—usually secondary to severe gastroesophageal reflex (GER)
• Bell palsy—may present as a complication of otitis media
• Temporomandibular joint (TMJ) disease

Question: Duration of symptoms?
Significance: Acute onset more likely suggests recent trauma or infection.

Question: Location?
Significance: If referred pain, will likely have symptoms at primary site as well.

Question: Fever?
Significance: Suggestive of infectious etiology.

Question: Trauma?
Significance: Ask about recent ear cleaning, falls, accidents, etc.

Question: History of recurrent otitis media?
Significance: Consider serous otitis media, cholesteatoma.

Question: Tinnitus?
Significance: May represent otitis media with effusion, inner ear abnormalities, vascular lesions or tumors.

Question: Ear drainage?
Significance: Look for primary source such as otitis media with perforation, cholesteatoma, otitis externa, and trauma.

Question: Vertigo?
Significance: Again a primary source from the external, middle, or inner ear is the likely cause, although CNS pathology must be a consideration.

Question: Hearing loss?
Significance: Suggestive of primary problem; however, can be associated with intracranial lesion and multiple other syndromes and diseases.

Question: Hoarseness?
Significance: Suggestive of oropharyngeal or laryngeal pathology including infections, foreign body, and GER.

Question: Drooling?
Significance: Suggestive of oropharyngeal or laryngeal pathology particularly infections, foreign bodies, and caustic ingestion.

Question: Stridor?
Significance: Suggestive of oropharyngeal or laryngeal pathology, which causes airway narrowing. Consider infections, foreign body, mass.

Question: Choking/coughing?
Significance: Consider foreign body, mass, or GER.

Finding: Intense pain elicited by traction on pinna.
Significance: Suggestive of otitis externa

Finding: Areas of trauma
Significance: There may be an isolated abrasion or laceration; however, inspect carefully for hemotympanum and associated injuries and evidence of basilar skull fracture.

Finding: Foreign bodies
Significance: May be isolated, or associated with otitis externa

Finding: Bulging, red, immobile tympanic membrane
Significance: Consistent with otitis media

Finding: Retracted, immobile tympanic membrane
Significance: Suggests otitis media with effusion

Finding: Evidence of a mass lesion
Significance: A mass lesion behind the tympanic membrane may represent a cholesteatoma, although other benign and malignant lesions must be considered.

Finding: Neck oropharynx, TMJ, lymph nodes, salivary glands, and neck
Significance: If no findings suggest a primary source, inspect each area carefully for signs of secondary pathology.

Finding: Dental caries
Significance: Multiple dental caries should raise the suspicion of a possible dental abscess.

Finding: Tonsillar asymmetry or uvular deviation from midline
Significance: May represent peritonsillar cellulitis/abscess or mass.

Finding: Trismus, drooling
Significance: May represent a mass/abscess

Finding: Assess facial-nerve function and other cranial nerves
Significance: Bell palsy may be a complication of otitis media. Other cranial nerve dysfunction suggests possible intracranial lesion.

The history and physical examination are usually enough to make a diagnosis.

Test: Audiometry
Significance: Assess for hearing loss suggestive of primary otalgia

Test: Tympanometry
Significance: Useful in assessment of otitis media with effusion, eustachian-tube dysfunction, and tympanostomy tube obstruction

Test: Lateral neck x-ray studies
Significance: Helpful for symptoms suggestive of retropharyngeal mass/abscess.

Test: Imaging of head
Significance: Rarely needed unless intracranial lesion suspected

Test: Blood screens
Significance: Not routinely useful

• Establish “ABCs” as indicated
• Consult otorhinolaryngologist (ORL)
• Hospitalize

• Establish “ABCs” as indicated
• Promptly consult ORL
• Do not attempt to remove debris from ear if suspected basilar skull fracture (can introduce bacteria)
• Hospitalize as indicated

• Establish “ABCs” as indicated
• Administer intravenous antibiotics as indicated
• Hospitalize

• Ear pain without an identifiable source
• Pain with unexplained hearing loss, vertigo, tinnitus
• Pain with unexplained or persistent otorrhea
• Suspected neoplasm
• Otitis media with complications (Otitis Media)
• Foreign bodies that cannot be removed easily from the ear

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Potsic W, Handler S, Wetmore R, Pasquariello P. Primary care pediatric otolaryngology. Andover, MA: J. Michael Ryan Publishing, Inc. 1995.

Tunnessen W. Signs and symptoms in pediatrics. Philadelphia: J.B. Lippincott Company 1988:157–163.

Yellon R. The spectrum of reflux-associated otolaryngologic problems in infants and children. Am J Med 1997;103(3S):125S–129S.