Ear pain resident survival guide (pediatrics): Difference between revisions
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==Causes== | ==Causes== | ||
===Life Threatening Causes | ===Life Threatening Causes=== | ||
Ear pain is not life threatening | Ear pain is not life threatening | ||
Common Causes | Common Causes | ||
primary otalgia | primary otalgia | ||
====== Otitis externa | ====== Otitis externa (swimmer's ear)====== | ||
*Pseudomonas. | *Pseudomonas. | ||
*Staph aureus. | *Staph aureus. | ||
==== Mechanical obstruction ==== | ==== Mechanical obstruction ==== | ||
*Earwax | *Earwax | ||
*Foreign body | *Foreign body | ||
Otitis media | Otitis media<ref name="pmid24453496" /> | ||
*common cold or upper respiratory tract infection | *common cold or upper respiratory tract infection | ||
*Streptococcus pneumoniae | *Streptococcus pneumoniae | ||
*nontypable Haemophilus influenzae | *nontypable Haemophilus influenzae | ||
*Moraxella catarrhalis | *Moraxella catarrhalis | ||
Otitis media with effusion | Otitis media with effusion | ||
*Enter into group child care(Amounts of time spent) | *Enter into group child care(Amounts of time spent) | ||
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=== Truma === | === Truma === | ||
* Air travel | * Air travel | ||
=== secondary otalgia<ref name="pmid20736106" /><ref name="pmid29365233" />=== | === secondary otalgia<ref name="pmid20736106" /><ref name="pmid29365233" />=== | ||
==== Refered ear pain==== | ==== Refered ear pain==== | ||
* Tonsillitis and Tonsillectomy | * Tonsillitis and Tonsillectomy | ||
* Toothaches. | * Toothaches. | ||
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* Mumps | * Mumps | ||
* dental infections | * dental infections | ||
* Temporomandibular joint disorder (TMJ) | * Temporomandibular joint disorder (TMJ) | ||
==FIRE: Focused Initial Rapid Evaluation== | ==FIRE: Focused Initial Rapid Evaluation== | ||
'''Ear pain''' | '''Ear pain''' | ||
* Abnormal ear examination(otoscopy). | * Abnormal ear examination(otoscopy). | ||
** primary otalgia. | ** primary otalgia. | ||
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{{familytree | | | | |!| | | | }} | {{familytree | | | | |!| | | | }} | ||
{{familytree | | | | B01 | | | B01= }} | {{familytree | | | | B01 | | | B01= }} | ||
{{familytree | | |,|-|^|-|.| | }} | {{familytree | | |,|-|^|-|.| | }}Key differences in the 2004 and 2013 American Academy of Pediatrics guidelines for the diagnosis and management of acute otitis media (AOM) | ||
{{familytree | | C01 | | C02 | C01= | C02= }} | {| class="wikitable" | ||
! colspan="1" rowspan="1" |Subject | |||
! colspan="1" rowspan="1" |2004 | |||
! colspan="1" rowspan="1" |2013 | |||
! colspan="1" rowspan="1" |Rationale for 2013 Changes | |||
|- | |||
| colspan="1" rowspan="1" |Children <6 mo | |||
| colspan="1" rowspan="1" |Treat with antibiotic therapy | |||
| colspan="1" rowspan="1" |No recommendations | |||
| colspan="1" rowspan="1" | | |||
|- | |||
| colspan="4" rowspan="1" | | |||
---- | |||
|- | |||
| colspan="1" rowspan="3" |Diagnosis of AOM | |||
| colspan="1" rowspan="1" |Acute onset of signs and symptoms | |||
| colspan="1" rowspan="1" |Moderate to severe bulging of TM, or new-onset otorrhea not owing to acute otitis externa | |||
| colspan="1" rowspan="3" |2004 criteria allowed less precise diagnosis, provided treatment recommendation when diagnosis was uncertain. | |||
|- | |||
| colspan="1" rowspan="1" |Presence of MEE | |||
| colspan="1" rowspan="1" |Mild bulging of TM and recentb onset ear painc or intense TM erythema | |||
|- | |||
| colspan="1" rowspan="1" |Signs and symptoms of middle ear inflammationa | |||
| colspan="1" rowspan="1" |Must have MEE | |||
|- | |||
| colspan="4" rowspan="1" | | |||
---- | |||
|- | |||
| colspan="1" rowspan="1" |Uncertain diagnosis | |||
| colspan="1" rowspan="1" |Expected and included in treatment guidelines | |||
| colspan="1" rowspan="1" |Excluded | |||
| colspan="1" rowspan="1" |Emphasized need for diagnosis of AOM for best management. | |||
|- | |||
| colspan="4" rowspan="1" | | |||
---- | |||
|- | |||
| colspan="1" rowspan="2" |Initial observation option instead of initial antibiotic therapy | |||
| colspan="1" rowspan="1" |Option for observation: | |||
* 6 mo–2 y: Option if uncertain diagnosis and nonsevere illnessd | |||
* ≥2 y: Option if nonsevered and certain diagnosis | |||
| colspan="1" rowspan="1" |Option for observation: | |||
* 6 mo–2 y: Unilateral OM without otorrhea | |||
* ≥2 y: Unilateral or bilateral AOM without otorrhea | |||
| colspan="1" rowspan="1" |Favorable natural history overall. | |||
|- | |||
| colspan="1" rowspan="1" |Observation recommended: | |||
* ≥2 y and uncertain diagnosis | |||
| colspan="1" rowspan="1" |Observation recommended: | |||
* None | |||
| colspan="1" rowspan="1" |Evidence of small benefit of antibiotics in recent trials that used stringent diagnostic criteria. | |||
|- | |||
| colspan="4" rowspan="1" | | |||
---- | |||
|- | |||
| colspan="1" rowspan="3" |Initial antibiotic therapy recommended | |||
| colspan="1" rowspan="1" |Antibiotics recommended: | |||
* <6 mo: All cases | |||
* 6 mo–2 y: Certain diagnosis, or uncertain diagnosis if severee illness | |||
* ≥2 y: Certain diagnosis and severee illness | |||
| colspan="1" rowspan="1" |Antibiotics recommended: | |||
* 6 mo–2 y: Otorrhea or severee illness or bilateral without otorrhea | |||
* ≥2 y: Otorrhea or severee illness | |||
| colspan="1" rowspan="1" |More stringent diagnostic guidelines in 2013 should lead to greater antibiotic benefit. | |||
|- | |||
| colspan="1" rowspan="1" |Antibiotics an option: | |||
* 6 mo–2 y: Uncertain diagnosis and nonsevered illness | |||
* ≥2 y: Certain diagnosis and nonsevered illness | |||
| colspan="1" rowspan="1" |Antibiotics an option: | |||
* 6 mo–2 y: Unilateral without otorrhea | |||
* ≥2 y: Bilateral without otorrhea or unilateral without otorrhea | |||
| colspan="1" rowspan="1" |Greater antibiotic benefit for bilateral disease, AOM with otorrhea. | |||
|- | |||
| colspan="1" rowspan="1" | | |||
| colspan="1" rowspan="1" | | |||
| colspan="1" rowspan="1" |Two recent studies show small benefit of antibiotics for age 6–24 mo. | |||
|- | |||
| colspan="4" rowspan="1" | | |||
---- | |||
|- | |||
| colspan="1" rowspan="2" |Recurrent AOM | |||
| colspan="1" rowspan="2" |No recommendations | |||
| colspan="1" rowspan="1" |Do not prescribe prophylactic antibiotics | |||
| colspan="1" rowspan="1" |Minimal benefit for prophylaxis and antibiotics come with risks (antibiotic resistance and adverse effects). | |||
|- | |||
| colspan="1" rowspan="2" |May offer tympanostomy tubes | |||
| colspan="1" rowspan="1" |Modest reduction in AOM with tubes. | |||
|} | |||
''Abbreviations:'' MEE, middle ear effusion; TM, tympanic membrane. | |||
aSigns and symptoms of middle ear inflammation include distinct erythema of TM or distinct otalgia (‘discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep’). | |||
bRecent: <48 hours. | |||
cEar pain may be indicated by holding, tugging, or rubbing of the ear in a nonverbal child. | |||
dNonsevere illness defined as mild otalgia and fever <39°C in the past 24 hours in the 2004 guideline; the 2013 guideline modifies this to “mild otalgia for less than 48 hours and temperature less than 39°C.” | |||
eSevere signs or symptoms include moderate or severe otalgia or temperature ≥39°C in 2004 guideline; the 2013 guideline also includes otalgia for ≥48 hours. | |||
''Adapted from'' Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964–99; and American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113(5):1451–65.{{familytree | | C01 | | C02 | C01= | C02= }} | |||
{{familytree/end}} | {{familytree/end}} |
Revision as of 19:14, 17 August 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:
Ear pain resident survival guide (pediatrics) Microchapters |
---|
Overview |
Causes |
FIRE |
Diagnosis |
Treatment |
Do's |
Don'ts |
Overview
This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.
Causes
Life Threatening Causes
Ear pain is not life threatening
Common Causes
primary otalgia
Otitis externa (swimmer's ear)
- Pseudomonas.
- Staph aureus.
Mechanical obstruction
- Earwax
- Foreign body
Otitis media[1]
- common cold or upper respiratory tract infection
- Streptococcus pneumoniae
- nontypable Haemophilus influenzae
- Moraxella catarrhalis
Otitis media with effusion
- Enter into group child care(Amounts of time spent)
- Exposure of smoking
- Peroid of breastfeeding
Truma
- Air travel
secondary otalgia[2][3]
Refered ear pain
- Tonsillitis and Tonsillectomy
- Toothaches.
- Sorethroat.
- Mumps
- dental infections
- Temporomandibular joint disorder (TMJ)
FIRE: Focused Initial Rapid Evaluation
Ear pain
- Abnormal ear examination(otoscopy).
- primary otalgia.
- Normal ear examination(otoscopy).
- secondary otalgia.
- imaging studies.
IF Diagnosis is not clear from the history and physical examination.
Complete Diagnostic Approach
Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the [...] guidelines.
Key differences in the 2004 and 2013 American Academy of Pediatrics guidelines for the diagnosis and management of acute otitis media (AOM)Subject | 2004 | 2013 | Rationale for 2013 Changes |
---|---|---|---|
Children <6 mo | Treat with antibiotic therapy | No recommendations | |
| |||
Diagnosis of AOM | Acute onset of signs and symptoms | Moderate to severe bulging of TM, or new-onset otorrhea not owing to acute otitis externa | 2004 criteria allowed less precise diagnosis, provided treatment recommendation when diagnosis was uncertain. |
Presence of MEE | Mild bulging of TM and recentb onset ear painc or intense TM erythema | ||
Signs and symptoms of middle ear inflammationa | Must have MEE | ||
| |||
Uncertain diagnosis | Expected and included in treatment guidelines | Excluded | Emphasized need for diagnosis of AOM for best management. |
| |||
Initial observation option instead of initial antibiotic therapy | Option for observation:
|
Option for observation:
|
Favorable natural history overall. |
Observation recommended:
|
Observation recommended:
|
Evidence of small benefit of antibiotics in recent trials that used stringent diagnostic criteria. | |
| |||
Initial antibiotic therapy recommended | Antibiotics recommended:
|
Antibiotics recommended:
|
More stringent diagnostic guidelines in 2013 should lead to greater antibiotic benefit. |
Antibiotics an option:
|
Antibiotics an option:
|
Greater antibiotic benefit for bilateral disease, AOM with otorrhea. | |
Two recent studies show small benefit of antibiotics for age 6–24 mo. | |||
| |||
Recurrent AOM | No recommendations | Do not prescribe prophylactic antibiotics | Minimal benefit for prophylaxis and antibiotics come with risks (antibiotic resistance and adverse effects). |
May offer tympanostomy tubes | Modest reduction in AOM with tubes. |
Abbreviations: MEE, middle ear effusion; TM, tympanic membrane.
aSigns and symptoms of middle ear inflammation include distinct erythema of TM or distinct otalgia (‘discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep’).
bRecent: <48 hours.
cEar pain may be indicated by holding, tugging, or rubbing of the ear in a nonverbal child.
dNonsevere illness defined as mild otalgia and fever <39°C in the past 24 hours in the 2004 guideline; the 2013 guideline modifies this to “mild otalgia for less than 48 hours and temperature less than 39°C.”
eSevere signs or symptoms include moderate or severe otalgia or temperature ≥39°C in 2004 guideline; the 2013 guideline also includes otalgia for ≥48 hours.
Adapted from Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964–99; and American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113(5):1451–65.
Treatment
Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.
Do's
- The content in this section is in bullet points.
Don'ts
- The content in this section is in bullet points.
DO NOT block any drainage coming from the ear. DO NOT try to clean or wash the inside of the ear canal. DO NOT put any liquid into the ear. DO NOT attempt to remove the object by probing with a cotton swab, a pin, or any other tool. To do so will risk pushing the object farther into the ear and damaging the middle ear. DO NOT reach inside the ear canal with tweezers.