Evaluation of earache in children

INTRODUCTION — This topic will discuss the evaluation of earache in children. The diagnosis and management of common causes of ear pain are discussed separately:

●(See "Acute otitis media in children: Clinical manifestations and diagnosis" and "Acute otitis media in children: Treatment".)

●(See "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis" and "Otitis media with effusion (serous otitis media) in children: Management".)

●(See "External otitis: Pathogenesis, clinical features, and diagnosis" and "External otitis: Treatment".)

BACKGROUND — Ear pain (or otalgia) ranks as one of the leading complaints among children evaluated in the primary care or emergency setting. Most patients will have one of three common diagnoses (acute otitis media [AOM], otitis media with effusion [OME]), or otitis externa, which are generally not serious. The rare cases of more serious disease associated with ear pain usually result from extension of ear infection to adjacent anatomic structures (eg, mastoiditis, meningitis, malignant otitis externa, venous sinus thrombosis). Basilar skull fracture or epidural hematoma after head trauma may also present with ear pain.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of ear pain can be categorized by the anatomic site from which the pain originates (table 1). Patients with primary otalgia have pain originating from the ear itself. Secondary otalgia is referred pain, originating in another anatomic site but causing the sensation of arising from the ear.

Auricle

Contusion (auricular hematoma) — Blunt trauma to the external ear may result in contusions of the auricle. Physical findings may include swelling, ecchymosis, and tenderness overlying the auricle. Lacerations to the ear may also occur. Care should be taken to evaluate for lacerations involving the perichondrium or cartilage itself, which will require a layered repair and present an increased risk of infection.

Auricular hematomas are localized collections of subperichondrial blood that typically result either from blunt impact or from friction, as commonly occurs during wrestling [1]. Shearing of the perichondrium away from the underlying cartilage results in rupture of the subperichondrial blood vessels. The hematomas are typically found in the anterior superior part of the auricle and present as a fluctuant, purple or red, mildly tender mass. Hematoma drainage followed by careful pressure bandaging of the auricle to prevent reaccumulation of the hematoma is essential to optimal cosmetic outcome.

Infection — Infections that involve the auricle include:

●Cellulitis – Cellulitis of the auricle frequently develops after trauma, an insect bite, or an ear piercing. Patients present with fairly rapid onset and progression of pain, redness, swelling, tenderness, and induration. In some cases, the swollen auricle will appear to protrude outward.

●Perichondritis – Perichondritis is an infection of the perichondrium, the thin fascial layer surrounding the auricular cartilage (picture 1). Perichondritis may result from blunt trauma or from piercings. Infection involving the cartilage can lead to permanent deformity of the ear, so perichondritis must be recognized and treated promptly. With perichondritis, the cartilaginous portion of the ear is red, swollen, and tender; but the ear lobe, which contains no cartilage, may be spared. Often, there is a focal area of fluctuance, indicating subperichondrial abscess that requires drainage. (See "Pseudomonas aeruginosa infections of the eye, ear, urinary tract, gastrointestinal tract, and central nervous system", section on 'Perichondritis'.)

●Herpes zoster oticus (Ramsay Hunt syndrome) – Herpes zoster oticus describes a reactivation of the varicella (chickenpox) virus after prior varicella infection that involves the skin of the external ear. Burning pain, hyperesthesia, and pruritus may precede the onset of vesicular lesions, making early diagnosis a challenge [2]. Vesicular lesions may be seen on the pinna or in the ear canal. Associated inner ear dysfunction (hearing loss or vertigo) or facial weakness (Ramsay Hunt syndrome) may occur. This syndrome is rare in young children, especially in the era of universal varicella vaccination, but it may be seen occasionally in adolescents. (See "Epidemiology, clinical manifestations, and diagnosis of herpes zoster", section on 'Ramsay Hunt syndrome (herpes zoster oticus)'.)

Allergic angioedema — Allergic swelling of the external ear may result from local allergic reactions to insect bites or from contact dermatitis (as with poison ivy). There is usually prominent pruritus and little (if any) pain, induration, or tenderness. (See "An overview of angioedema: Clinical features, diagnosis, and management".)

Juvenile spring eruption (polymorphous light eruption) — Patients with this form of sun reaction present with bullae, redness, and itch or sometimes pain on the superior aspect of the auricles, which is symmetric and bilateral (picture 2A-B). There may also be inflamed, itchy plaques on the face or dorsal hands. This condition typically presents early in the sunny season of the year. (See "Polymorphous light eruption", section on 'Juvenile spring eruption (polymorphous light eruption variant)'.)

Environmental injury — Frostbite or sunburn can also cause redness, swelling, and pain of the auricle. Typically, there will be a history of environmental exposure to suggest the diagnosis. Often, there will be bilateral ear involvement, which is atypical of most infections or local allergic reactions. (See "Frostbite: Emergency care and prevention", section on 'Clinical manifestations' and "Sunburn", section on 'Diagnosis'.)

Ear canal

Otitis externa — Otitis externa refers to diffuse infection of the external ear canal, typically caused by Pseudomonas aeruginosa, Staphylococcus aureus, or occasionally other gram-negative rods. Otitis externa usually results from the introduction of water into the ear canal as a result of swimming. (See "External otitis: Pathogenesis, clinical features, and diagnosis" and "Patient education: External otitis (including swimmer's ear) (Beyond the Basics)".)

The cardinal symptom of acute otitis externa is pain and tenderness localized to the auditory meatus [3]. There may also be pain with jaw movement, a feeling of fullness in the ear, itching of the ear canal, or discharge from the canal. Fever is uncommon. On physical examination, most patients have tenderness of the tragus and pain with otoscopy. The ear canal may appear swollen, red, or macerated. A thick and sometimes malodorous discharge may be present. The tympanic membrane (TM) may appear red, but in cases of isolated otitis externa, there should be no fluid behind the TM.

Fungal otitis externa (caused by Aspergillus or Candida) can occur, especially if the normal bacterial milieu of the ear canal has been eradicated by extensive use of topical antimicrobial agents. Fungal otitis externa is characterized by itch more than pain. White, flaky debris may be seen in the ear canal. (See "External otitis: Pathogenesis, clinical features, and diagnosis", section on 'Otomycosis'.)

Malignant otitis externa — Malignant otitis externa occurs when infection spreads from the ear canal to the surrounding bones of the skull base [4]. This condition is quite rare in pediatrics but may occur in patients with immunocompromise. Patients with malignant otitis externa typically have a more intense and deep-seated ear pain, systemic signs of toxicity or fever, and possibly tenderness of the temporal bone or facial nerve palsy. The diagnosis is suggested by elevated inflammatory markers (erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP]) and confirmed by cranial imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) indicating osteomyelitis of the skull base. P. aeruginosa is the usual pathogen. (See "Malignant (necrotizing) external otitis".)

Contact dermatitis — Use of topical antimicrobial or analgesic drops may result in contact dermatitis of the external ear. A pink-red, confluent, slightly bumpy rash may be noted in the ear canal, in the concha, or on the surrounding skin. Itch is more prominent than pain, and discharge is uncommon. Atopic dermatitis (eczema) of the ear canal may cause similar findings. (See "Allergic contact dermatitis in children" and "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis".)

Furuncle — Furunculosis is a localized skin infection involving one or more hair follicles of the outer ear canal, typically caused by S. aureus. Patients with furunculosis have focal pain and a red, swollen, tender mass in the external canal. There is typically no swelling of the pinna, ear discharge, fever, or adjacent adenopathy. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis", section on 'Skin abscess'.)

Foreign body — Foreign bodies in the ear canal usually present with a suggestive history, but sometimes, ear pain or hearing loss may be the chief complaint. Foreign bodies that have been present for some length of time may be obscured by surrounding cerumen, granulation tissue, or pus; thereby making the diagnosis more challenging. (See "Foreign bodies of the outer ear (pinna [auricle] and external auditory canal): Diagnosis and management".)

Cerumen impaction — Cerumen impaction itself is a fairly common cause of ear discomfort, though intense pain is uncommon. Often, patients complain of ear fullness or hearing impairment. (See "Cerumen".)

Tumor — Rarely, tumors of the external auditory canal can occur and may present with ear pain. Rhabdomyosarcoma, lymphoma, and eosinophilic granuloma have been reported. These cases may involve a granulomatous mass in the external auditory canal and bloody or serosanguineous discharge. Patients that appear to have a relapsing or unremitting case of otitis externa or perforated otitis media should be evaluated for the possibility of a tumor in the ear canal. (See "Rhabdomyosarcoma in childhood and adolescence: Clinical presentation, diagnostic evaluation, and staging", section on 'Head and neck' and "Clinical manifestations, pathologic features, and diagnosis of Langerhans cell histiocytosis".)

Middle and inner ear

Acute otitis media — Acute otitis media (AOM) remains the most common illness diagnosed by pediatricians. In AOM, ear pain, which at times can be quite severe, is typically felt deep within the ear. Often, the pain is worse when the patient is supine. Nasal congestion and cough typically precede the ear pain by several days. Fever occurs in some cases. In younger patients, nonspecific symptoms such as fussiness or irritability, disturbed sleep, and poor feeding may predominate. (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Clinical presentation'.)

On otoscopic examination, patients with AOM have evidence of middle ear effusion with a TM that is bulging or has decreased mobility. Bulging of the TM is the most specific sign of AOM [5]. The TM may appear cloudy or opaque, with a white, yellow, or occasionally green color reflecting pus behind the TM. An air fluid level may be seen, though this is more common with otitis media with effusion (OME). In some cases, the TM may have focal bullae. The TM usually also has focal or diffuse areas of redness, injection, or hemorrhage, which should be distinguished from the milder pink flush often seen with fever or crying. The external ear examination is typically normal, with no redness or tenderness and no adjacent lymphadenopathy. (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

Myringitis refers to inflammation of the TM with or without associated middle ear fluid. In cases of isolated myringitis, redness or bullae of the TM may be noted in the absence of apparent fluid in the middle ear. Myringitis may be caused by trauma or infection. Bacterial pathogens are most commonly implicated, but viruses may play a role. (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Bullous myringitis'.)

Complications of acute otitis media — (See "Acute otitis media in children: Epidemiology, microbiology, and complications", section on 'Complications and sequelae'.)

●Spontaneous rupture of the tympanic membrane – Suppurative TM perforation is a common complication of AOM, resulting from the accumulation of pus under pressure in the middle ear. Typically, the patient reports ear pain followed by otorrhea, which may be quite copious. After the TM has ruptured, the patient may experience a relief of pain. On physical examination, a thin, watery, and sometimes foul-smelling fluid is usually observed. In many cases, it may be impossible to visualize the TM. Purulent otorrhea may also be seen in patients who have otitis media in the setting of prior tympanostomy tube placement. In these patients, pathogens may include the typical middle ear bacteria or S. aureus or P. aeruginosa, which presumably migrate inward from the external ear.

●Mastoiditis – Mastoiditis occurs when the mastoid air cells, which connect directly to the middle ear space, become infected as a result of adjacent AOM. Diagnostic findings include ear pain, swelling, tenderness, and redness over the mastoid region; protrusion of the ear; and fever. Findings of AOM are often present. Imaging is not necessary to diagnose mastoiditis but may be warranted to confirm the diagnosis in atypical cases, to determine the stage (ie, acute mastoiditis with periostitis versus coalescent mastoiditis), or to evaluate for complications. (See "Acute mastoiditis in children: Clinical features and diagnosis".)

●Facial palsy – Dysfunction of cranial nerve VII is a rare complication of AOM probably resulting from inflammation or stretching of the nerve as it passes through the middle ear space [6]. On physical examination, limited ability to close the ipsilateral eye, limited ability to raise the eyebrows, flattening of the nasolabial fold, and asymmetric smile may be noted. (See "Facial nerve palsy in children", section on 'Otitis media'.)

●Inner ear infection – Labyrinthitis or petrositis are also rare complications of AOM resulting from contiguous spread of infection. Sensorineural hearing loss, tinnitus, or vertigo may occur. (See "Approach to the child with acute ataxia", section on 'Labyrinthitis'.)

●Involvement of contiguous structures – AOM rarely seeds contiguous structures, such as the meninges and/or the brain, causing brain, epidural, or subdural abscess or meningitis [7]. Fever, headache, meningismus, ill appearance, altered mental status or focal neurologic findings may result. Alternatively, the infection may remain confined to the middle ear, but inflammatory mediators incite a thrombosis of the adjacent sigmoid and/or lateral sinuses ("otitic hydrocephalus"). Diagnosis is confirmed by brain imaging (brain abscess, venous sinus thrombosis) or lumbar puncture (meningitis) [6,8].

Otitis media with effusion — OME refers to fluid in the middle ear space without acute inflammation. Middle ear fluid typically accumulates as a result of Eustachian tube dysfunction, which itself usually results from nasal infection or allergy. Some patients with OME are asymptomatic, but others have mild ear pain. Feelings of ear fullness or decreased hearing are common. (See "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis", section on 'Clinical features'.)

The hallmark of OME on physical examination is poor or absent mobility of the TM. Bulging of the TM is uncommon and typically indicates an alternative diagnosis of AOM. The TM may be mildly full, in neutral position, or even retracted, indicating negative pressure in the middle ear space. The TM may appear amber and translucent (indicating true serous fluid) or mildly white or yellow and cloudy. Occasionally, the TM may have a blue color. In some cases of clear, colorless effusions, the presence of bubbles (indicating air trapped within the fluid collection) may be the only sign of effusion. Redness of the TM is not expected. (See "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis", section on 'Diagnosis'.)

Eustachian tube dysfunction — Eustachian tube dysfunction, defined as a failure of the functional valve of the Eustachian tube to open and/or close properly, is a fairly common cause of ear discomfort. Eustachian tube dysfunction is a preliminary step in the pathophysiology of AOM or OME, as failure of the Eustachian tube to open leads to negative pressure and inability of the middle ear to clear accumulated fluid and bacteria. Even in the absence of AOM or OME, Eustachian tube dysfunction may lead to ear discomfort as a result of the development of negative pressure in the middle ear space. (See "Eustachian tube dysfunction", section on 'Pathophysiology of Eustachian tube dysfunction'.)

Patients with Eustachian tube dysfunction may present with ear pain; subjective sensation of ear fullness or hearing loss; a popping sensation associated with chewing, yawning, or swallowing; or tinnitus. Often, but not always, there will be an accompanying history of preceding nasal congestion, typically associated with upper respiratory infection or allergic rhinitis. Physical examination findings may be normal or may reveal focal or extensive retraction of the TM. Injection or diffuse redness of the TM may be evident as well. Abnormalities of pneumatic otoscopy will often be demonstrated. In cases of negative pressure leading to a retracted TM, there will be poor or absent mobility with application of positive pressure. (See "Eustachian tube dysfunction", section on 'Clinical evaluation'.)

Cholesteatoma — Cholesteatoma is a rare but serious complication of chronic OME in which a benign mass of epithelial tissue develops in or behind the TM and can erode into the bone of the ear canal. Permanent hearing deficits may result. The cholesteatoma may present with ear pain or a sense of ear fullness. Physical examination will reveal the presence of a red or yellow mass typically involving the posterior aspect of the TM (picture 3 and picture 4). (See "Cholesteatoma in children".)

Blunt or penetrating trauma — Earache may be a sign of serious trauma to the middle or inner ear or point to a basilar skull fracture:

●Traumatic tympanic membrane perforation — Traumatic perforation of the TM may occur because of penetrating objects (ie, a stick or cotton swab) or because of a wave of air pressure (as when the ear is slapped). In some cases, the perforation will be easily visualized, but in other cases, bleeding from the TM may obscure the diagnosis. (See "Hearing loss in children: Etiology", section on 'Tympanic membrane perforation'.)

●Traumatic disruption of the ossicles or inner ear — Penetrating or blunt trauma may also lead to traumatic disruption of the ossicles, which should be suspected in cases of trauma associated with perforation or hemotympanum and new onset of severe hearing loss. Disrupted ossicular anatomy may be visible on otoscopy but will likely require advanced imaging (CT with fine temporal cuts or MRI) for full delineation. (See "Evaluation and management of middle ear trauma", section on 'Evaluation'.)

Inner ear injury is a rare but serious consequence of barotrauma or blunt trauma. Tinnitus, hearing loss, or vertigo in the setting of trauma should lead the clinician to consider this diagnosis. In some cases, the deficits may be reversible with urgent surgical intervention. (See "Hearing loss in children: Etiology", section on 'Sensorineural hearing loss'.)

●Hemotympanum — Hemotympanum is a collection of blood in the middle ear space resulting from blunt trauma (basilar skull fracture) or from barotrauma (altered atmospheric pressure as may occur with air travel or undersea diving) to the middle ear (picture 5). Rarely, profuse epistaxis will cause hemotympanum by reflux of blood from the nares into the middle ear via the Eustachian tube [9]. On examination, the TM has a purple or red color and may be full or bulging. If blood accumulates under sufficient pressure in the middle ear, the TM may rupture. (See "Complications of SCUBA diving", section on 'Ear barotrauma' and "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fractures'.)

●Basilar skull fracture — Fractures of the skull base, which may result from blunt trauma to the ear region, can present with ear pain. Physical findings may include swelling, ecchymosis, or tenderness overlying the mastoid bone (Battle sign), tenderness and swelling in the temporal region, and facial nerve palsy. Hemotympanum or rupture of the TM, with bloody or cerebrospinal fluid otorrhea, may occur. Periorbital ecchymoses or cerebrospinal fluid rhinorrhea may also be present (picture 6). If there is associated intracranial injury, altered mental status, headache, vomiting, or focal neurologic findings may occur. (See "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fractures'.)

Secondary otalgia — Some cases of ear pain stem from inflammation of nearby structures [10]. These cases will be distinguished by the absence of findings in the ear itself and by the findings of inflammation or injury to adjacent structures. The referred pain arises from nerves that partially innervate the auricle or external auditory canal and include spinal nerves C2 and C3 and cranial nerves V, VII, IX, and X.

Auricular lymphadenopathy or lymphadenitis — Preauricular lymph nodes may become enlarged in response to ocular processes (most commonly conjunctivitis) or parotid disorders (parotitis or, rarely, malignancy). Postauricular nodes typically become enlarged in response to conditions involving the external ear, the skin overlying the mastoid region, or Epstein Barr virus infection (infectious mononucleosis). Acutely infected nodes are tender with overlying redness and occasionally fluctuance. Benign reactive nodes are typically less tender with no fluctuance and no overlying redness. Malignancy is rare but should be considered with very large or especially hard, nontender nodes. (See "Cervical lymphadenitis in children: Diagnostic approach and initial management".)

Parotitis — Parotid gland disorders cause pain just inferior to the ear. On examination, swelling and tenderness of this region will be evident, occasionally with overlying redness. Because of swelling of the isthmus of the parotid gland, the underlying bony angle of the mandible often cannot be distinctly palpated.

Most parotid infections in children result from viral infection (eg, mumps, parainfluenza, influenza A, enteroviruses) [11,12]. In these patients, parotid swelling is often bilateral. Bacterial parotitis caused by S. aureus is infrequent. This infection presents with high fever accompanied by unilateral parotid swelling with erythema, marked tenderness of the parotid gland, and pus expressed from Stensen's duct with parotid massage [13]. Parotid swelling is common in patients with HIV, but true HIV parotitis is rare.

Salivary gland stones (sialolithiasis), leading to obstruction to the parotid gland outflow, can also cause parotid swelling and pain, which may refer to the ear. (See "Salivary gland stones".)

Juvenile recurrent parotitis, a noninfectious inflammatory condition presenting with repeated episodes of nonobstructive parotid gland dilation, should be considered in children with recurrent episodes of parotitis [14].

Temporomandibular joint dysfunction syndrome — Dysfunction of the temporomandibular joint (TMJ) is fairly common in children over 10 years of age but rare in younger children. Careful examination will reveal that the pain emanates from the TMJ and not from the ear itself. Pain is often exacerbated by full opening of the mouth or by clenching of the teeth. Palpation of the TMJ region may reveal tenderness or a palpable clicking sensation with joint motion. (See "Temporomandibular disorders in adults".)

Facial nerve (Bell's) palsy — While facial nerve palsy can be a complication of otic processes, such as otitis media or malignant otitis externa, primary facial nerve palsy may itself cause otalgia. Because the facial nerve provides sensation to a region of skin adjacent to the ear, inflammation of the seventh cranial nerve may present with vaguely localized pain in this area. Typically, weakness of the ipsilateral face will be present and will lead to the correct diagnosis. (See "Facial nerve palsy in children".)

Oropharyngeal infections — Infections or inflammation of the soft palate (such as with coxsackie virus infection or aphthous stomatitis), inflammation of the posterior teeth or gingivae (ie, dental abscess or pericoronitis), or tonsillar infections may present with referred ear pain. Findings typically include an absence of tenderness or palpable abnormalities of the external ear, a normal middle ear examination, and abnormal findings in the mouth or throat. (See "Evaluation of sore throat in children" and "Soft tissue lesions of the oral cavity in children", section on 'Infections'.)

Sinusitis — Sinus infection, especially of the maxillary sinuses, may cause earache referred through the sensory pathways of the fifth cranial nerve (trigeminal nerve). The cardinal clinical features of acute sinusitis are nasal symptoms (anterior or posterior nasal discharge, obstruction, and/or congestion), cough, or both for more than 10 days but fewer than 30 days that are not improving. (See "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Acute bacterial rhinosinusitis'.)

Cervical spine injury — Cervical spine trauma with bony or soft tissue involvement may radiate or, rarely, be referred to the ear. (See "Evaluation and acute management of cervical spine injuries in children and adolescents".)

EVALUATION — A careful history and physical examination typically provide the etiology of most cases of ear pain.

History — Important questions to ask in the history of a patient with ear pain include:

●Age – In infants and toddlers, most cases of ear pain result from middle ear disease. In older children and adolescents, a larger proportion of cases stem from otitis externa, throat infections, or temporomandibular joint (TMJ) disease.

●Blunt or penetrating trauma – The timing and mechanism of injury should be elicited. Follow-up questions should determine the presence of altered mental status, headache, nausea, vomiting, focal neurologic complaints, or seizures, all of which may suggest intracranial injury. The clinician should also inquire about bloody or clear otorrhea, which may indicate traumatic disruption of the tympanic membrane (TM) and an associated basilar skull fracture.

●Fever – Fever is common in minor illnesses, such as uncomplicated otitis media and upper respiratory infection with associated otitis media with effusion (OME). However, fever may indicate complications, such as mastoiditis, meningitis, brain abscess, or malignant otitis externa. In cases with fever, the clinician should ask follow-up questions regarding the presence of headache, neck stiffness, nausea and vomiting, altered mental status, or severe toxicity, which may indicate more serious infections.

●Nasal congestion – Most cases of middle ear disease (acute otitis media [AOM] or OME) follow from preceding nasal allergy, infection, or obstruction. In cases with no history of preceding nasal symptoms, middle ear disease becomes substantially less likely [15,16]. The clinician should inquire about the duration, severity, and course of the symptoms. Other questions to distinguish the cause of the nasal symptoms may also be appropriate.

●Ear tenderness – Pain with manipulation of the ear, as when pulling a shirt over the head, strongly suggests a diagnosis of external ear disease, such as otitis externa. External ear pain is not typically present in middle ear disease.

●Hearing loss – Mild to moderate conductive hearing loss may accompany minor illnesses, such as AOM, OME, or otitis externa. However, more significant hearing loss may indicate cholesteatoma, traumatic disruption of the ossicles, or inner ear disease.

●Ear drainage – In the absence of trauma, ear drainage stems either from otitis externa or otitis media with perforation or tympanostomy tubes. Typically, the drainage in otitis externa is scant and thicker in consistency, whereas the drainage from otitis media can be quite copious and may be bloody, serosanguineous, purulent, or thin and watery.

●Swimming – A history of recent swimming makes the diagnosis of otitis externa more likely.

●Minor trauma to the ear – Bug bites or scratches to the external ear often serve as the nidus for cases of cellulitis. Bug bites also may trigger allergic angioedema of the external ear.

●Barotrauma – Recent air travel or undersea diving are potential causes of hemotympanum in the absence of external trauma.

●Environmental exposures – Exposure to sun, cold, insects, or contact allergens (like poison ivy) may be pertinent in cases of auricular inflammation.

●Past medical history – History of prior ear infections or tympanostomy tube placement increases the likelihood of AOM. Topical medication use may explain the source of external ear eruption or fungal otitis externa. Patients with immune deficiency or other significant illnesses may have earache as a sign of a serious contiguous disease, such as cerebral abscess or meningitis.

Physical examination

Initial assessment — Patients with abnormal vital signs who present initially with ear pain may be suffering from serious infection, such as meningitis or sepsis, or serious traumatic injury, such as epidural hematoma. Patients with an abnormal mental status in association with ear pain may again be suffering from brain infection or traumatic injury.

For stable patients, the level of discomfort should be assessed. Children with severe cases of otitis media or externa may be holding their ear and crying. Young infants or toddlers may be fussy and difficult to console.

If there is any possibility of hearing loss, hearing should be assessed with whispered words for older, cooperative children and with an assessment of sound localization ability in younger children. Objective hearing assessment by means of pure tone audiometry might be appropriate for patients with evidence of moderate to severe hearing loss.

External ear — The external ear should be inspected for signs of traumatic injury such as lacerations, ecchymoses, fluctuant hematomas, or swelling. If trauma is suspected, the temporal and parietal region of the skull should be assessed for deformity or tenderness indicating possible fracture. Signs of basilar skull fracture, such as periorbital ecchymoses (picture 6) or Battle sign (ecchymosis overlying the mastoid bone), should be sought. (See "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fractures'.)

In the absence of trauma, diffuse redness and swelling of the external ear may indicate infection or local allergic reaction:

●Infection will be distinguished by tenderness, more distinct redness of the skin, and induration

●Perichondritis is suggested by fluctuant abscesses of the helix with focal sparing of the ear lobe

●Allergic inflammation usually causes a paler purple hue to the skin and little (if any) tenderness

●Juvenile spring eruption causes bullae and redness to the superior aspect of the pinna (picture 2A-B)

●Ramsay Hunt syndrome causes vesicles of the external ear and/or auditory canal

●Contact dermatitis (like poison ivy) may cause a fine, bumpy, pruritic, red rash

●Frostbite, sunburn, or bug bites lead to diffuse redness with focal blisters

Protrusion of the ear from the side of the head is sometimes seen with allergic or infectious inflammation of the pinna but can also be a sign of mastoiditis. Tenderness, discoloration, and swelling over the mastoid process should be ascertained. (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Clinical features'.)

Pre- or postauricular lymphadenopathy should be noted, as should the presence of any fluctuance and overlying redness or swelling. Inflammation of these lymph nodes may be the primary cause of ear pain or may be seen in cases of external ear infection.

The tragus should be palpated, gently at first and then more vigorously, to fully exclude tragal tenderness, which is virtually always present in cases of acute otitis externa [3]. (See "External otitis: Pathogenesis, clinical features, and diagnosis".)

Auditory canal and middle ear — The physical examination of the middle ear by otoscopy is discussed in detail separately. (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Otoscopic evaluation'.)

On otoscopic examination, the examiner should first assess whether the TM can be visualized adequately. Whenever possible, cerumen should be removed to permit an unobstructed view of the entire ear canal and TM.

The ear canal should be examined for redness, flaking, swelling, or thick discharge, all of which may be signs of otitis externa. Ear discharge can also be seen with AOM with TM perforation [3]; the drainage is usually more copious and watery than with otitis externa. Additional findings may include the presence of masses, foreign bodies, bullae, or eczematous changes.

If the TM appears thickened or cloudy, or if air bubbles are evident behind the TM, a middle ear effusion should be suspected. In AOM, the TM may have diffuse redness, injection, or focal areas of hemorrhage, which should be distinguished from the generalized pink, flushed appearance of the TM frequently seen in children who have fever or who have been crying. An opaque white, yellow, or green color to the TM, without visualization of any bony landmarks, indicates a purulent effusion and is another common finding in AOM. Occasionally, tense, pus-filled bullae may be seen in AOM. Redness or bullae of the TM without evident fluid in the middle ear suggests isolated myringitis. (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Tympanic membrane findings'.)

A TM that bulges laterally towards the examiner indicates that the middle ear is under positive pressure, as with AOM, and is the most specific sign of AOM. In contrast, a retracted TM indicates negative pressure in the middle ear space, which is a sign of Eustachian tube dysfunction sometimes seen in cases of OME. Similarly, with pneumatic otoscopy, decreased movement of the TM upon application of positive pressure indicates middle ear fluid under pressure, while decreased movement with negative pressure suggests Eustachian tube dysfunction. (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Otoscopic evaluation'.)

Perforations of the TM should be noted. If a tympanostomy tube has been inserted, its location and patency should be assessed. (See "Overview of tympanostomy tube placement, postoperative care, and complications in children".)

In cases of trauma, hemotympanum may be noted. Hemotympanum is characterized by a red or purple effusion, which may occupy the entire middle ear space or may appear as an air-fluid level (picture 5).

Sources of secondary otalgia — The TMJ should be assessed for tenderness, mobility, pain with movement, clicking, or crepitus with motion. (See "Temporomandibular disorders in adults".)

The parotid gland should be evaluated for enlargement, focal masses, tenderness, and loss of the normal mandibular angle. Abnormal discharge or redness of Stensen duct in the intraoral examination may also be seen with purulent parotitis.

The oral mucosa, gingivae, teeth, tonsils, and pharynx should be evaluated for abnormalities that indicate stomatitis, dental abscess, tonsillitis, or pharyngitis, all of which may present with pain referred to the ear. (See "Evaluation of sore throat in children" and "Soft tissue lesions of the oral cavity in children", section on 'Infections'.)

Sinus tap tenderness, transillumination, and copious green nasal discharge are insensitive signs of sinusitis but are suggestive when present. (See "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Clinical features'.)

The neck examination should include an assessment for adenopathy, swelling, or masses that may indicate infection or other processes near the ear that may present with ear pain, such as neck trauma. (See "Cervical lymphadenitis in children: Diagnostic approach and initial management" and "Evaluation and acute management of cervical spine injuries in children and adolescents".)

Finally, neurologic examination should include an assessment of facial nerve function, as facial palsy may present with ear pain as one of the initial manifestations. Vestibular function and nystagmus should be assessed in patients for whom inner ear disease is a possibility. (See "Facial nerve palsy in children".)

Ancillary studies — In most routine cases of ear pain, no ancillary studies are necessary. However, ancillary testing may be appropriate in cases where more serious diagnoses are suspected. Ancillary testing may include:

●Neuroimaging – Head CT without contrast is indicated in trauma cases if intracranial injury or basilar skull fracture are suspected. In addition, patients with signs of meningitis should undergo neuroimaging before lumbar puncture if findings of increased intracranial pressure or focal neurologic deficits are present. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management" and "Lumbar puncture in children", section on 'Preprocedure evaluation'.)

CT with contrast and specialized slices and reconstructions may also be indicated for selected patients with mastoiditis or concern for complications such as sinus venous thrombosis, brain abscess, or empyema, as discussed separately. (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Imaging'.)

Either CT without contrast or MRI are indicated to evaluate for osteomyelitis of the skull base in patients with malignant otitis externa.

●Complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) – CBC, ESR, and CRP are often elevated in cases of more serious or deep-seated infections, such as mastoiditis, malignant otitis externa, or bacterial meningitis [17,18]. However, if clinical suspicion is high, normal findings on these tests should not be interpreted as definitive proof that more serious infections are not present.

●Bacterial or fungal culture of ear drainage – The spectrum of expected pathogens in external otitis is small. Thus, empiric treatment is usually sufficient and less costly than culture. Cultures are reserved for patients with severe external otitis associated with periauricular cellulitis or fever. Cultures should also be considered in patients who are immunocompromised or who have not responded to treatment within about three days. Most of these patients should be referred to an otolaryngologist. Culture of the purulent material is performed with a very small cotton swab. (See "External otitis: Pathogenesis, clinical features, and diagnosis".)

●Blood culture – If bacteremia is suspected in association with complicated otitis with invasive infection, blood cultures should be obtained.

●Lumbar puncture – Patients with signs of meningitis should undergo lumbar puncture as long as findings of increased intracranial pressure or focal neurologic deficits are not present.

●Audiometry – Hearing tests are indicated within 12 to 24 hours in cases in which traumatic injury to the ossicles or disease of the inner ear is evident. (See "Hearing loss in children: Screening and evaluation", section on 'Formal audiology'.)

DIAGNOSTIC APPROACH — The algorithms provide an approach to the child with earache (algorithm 1A-D).

The critically ill patient — For patients with altered mental status, abnormal vital signs, or other signs of severe illness, resuscitation and emergency therapy precedes evaluation (algorithm 1A). In patients with traumatic injury and altered mental status, basilar skull fracture or intracranial hemorrhage and increased intracranial pressure should be suspected (algorithm 2). (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Ongoing management'.)

In patients with otitis media who have altered mental status in conjunction with cardiovascular instability, fever, focal neurologic findings, meningismus, and/or severe headache, complications, such as venous sinus thrombosis, meningitis, or brain abscess should be suspected. Evaluation should include head CT, lumbar puncture (as long as increased intracranial pressure or focal neurologic deficit is not evident), and prompt initiation of antibiotic therapy. (See "Pathogenesis, clinical manifestations, and diagnosis of brain abscess" and "Cerebral venous thrombosis: Etiology, clinical features, and diagnosis" and "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Evaluation'.)

Stable patients with earache and facial nerve palsy are likely to have acute otitis media (AOM) with or without mastoiditis. (See "Acute otitis media in children: Epidemiology, microbiology, and complications", section on 'Mastoiditis'.)

Ear pain in the trauma patient — Among stable patients with ear pain, it is useful to consider separately those patients with history or signs of traumatic injury to the ear, including blunt, penetrating, and barometric trauma (algorithm 1B). Patients with ear trauma should also be evaluated for traumatic injury to adjacent structures, particularly brain injury, basilar skull fracture, and neck injury. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation" and "Evaluation and acute management of cervical spine injuries in children and adolescents".)

Inspection of the external ear identifies simple abrasions or lacerations to the ear canal, external lacerations, and auricular contusion. Lacerations to the external ear that involve the cartilage and perichondrium require a layered repair and may lead to permanent cosmetic deformity. Simple contusions with mild swelling or ecchymosis of the ear can be managed with supportive measures (eg, application of ice, oral acetaminophen or nonsteroidal antiinflammatory medications) and observation.

Auricular hematomas present as fluctuant masses near the superior aspect of the pinna, often in patients with a history of wrestling or boxing. The assessment and management of auricular hematomas is discussed in detail separately. (See "Assessment and management of auricular hematoma and cauliflower ear".)

Hemotympanum, otorrhea, or tympanic membrane (TM) rupture may indicate direct traumatic perforation of the TM, barotrauma, or basilar skull fracture. (See "Complications of SCUBA diving", section on 'Ear barotrauma' and "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fractures'.)

Traumatic hearing loss may indicate a deficit in air conduction because of the accumulation of fluid (usually blood) in the middle ear, large perforation of the TM, traumatic disruption of the ossicles, or inner ear injury, which may occur with basilar skull fracture or barotrauma. New onset of vertigo also suggests inner ear injury. Urgent otolaryngology consultation is appropriate. In most cases, the child should also undergo CT scan of the temporal bones without contrast, including fine (0.6 mm) cuts in the axial and coronal planes. (See "Evaluation and management of middle ear trauma".)

Nontraumatic ear pain

External ear disease — Patients with redness, swelling, warmth, and apparent protrusion of the auricle are often suffering from cellulitis, which typically results from insect bites, ear piercing, or minor trauma (algorithm 1C). Cellulitis causes pain, tenderness, and induration, in contrast to local allergic reactions (as with insect bites or poison ivy) or juvenile spring eruption, which typically cause pruritus but little or no pain and tenderness. Fever is sometimes present with cellulitis but is not a feature of allergic reactions. In some instances, the redness and swelling is caused by a retained earring. (See "Foreign bodies of the outer ear (pinna [auricle] and external auditory canal): Diagnosis and management", section on 'Foreign bodies of the pinna (auricle)' and "An overview of angioedema: Pathogenesis and causes".)

Rare cases of perichondritis can be distinguished from cellulitis by the sparing of the ear lobe (which has no cartilage) or by the presence of focal subperichondrial abscesses. There is usually a history of antecedent blunt trauma or ear piercing. Children with perichondritis may need incision and drainage and are typically admitted to the hospital for intravenous (IV) antibiotic therapy. (See "Pseudomonas aeruginosa infections of the eye, ear, urinary tract, gastrointestinal tract, and central nervous system", section on 'Perichondritis'.)

Other causes of redness and swelling of the auricle include sunburn and frostbite, which in most cases will be evident from the history and will frequently involve both ears symmetrically. Minor redness of the ear, especially in the concha, may be seen in cases of otitis externa (see below). However, most cases of simple otitis externa do not lead to swelling or diffuse redness of the auricle. (See "Frostbite: Emergency care and prevention", section on 'Clinical manifestations' and "Sunburn", section on 'Diagnosis'.)

Patients with vesicular lesions in the ear canal and pinna, especially with pruritus or burning discomfort to the region, likely have herpes zoster oticus. In some cases, the pruritus, pain, or sensory abnormalities may precede the development of visible skin lesions by several days, so clinicians should consider the diagnosis in older children with hyperesthetic ear discomfort and no visible lesions. (See "Epidemiology, clinical manifestations, and diagnosis of herpes zoster", section on 'Ramsay Hunt syndrome (herpes zoster oticus)'.)

Finally, some patients with apparent abnormality of the auricle may actually be suffering from mastoiditis (algorithm 1D). In mastoiditis, the inflammation of the mastoid region behind the ear leads the auricle to protrude outward. Typically, however, the tissue of the auricle itself is normal, with no redness, swelling, or tenderness. Examination of the middle ear and the mastoid region will provide additional clues to the diagnosis. (See 'Auditory canal and middle ear' above.)

Tragal motion tenderness — Tenderness of the tragus is the hallmark of otitis externa [3]. Redness, discharge, or flaking of the ear canal may be seen, but in some mild cases, tragal tenderness may be the only abnormal finding. Patients with a focal area of redness, swelling, and pain in the ear canal likely have furunculosis. Patients with more severe or deep-seated pain, often with fever and usually with a history of immunocompromise, should be evaluated for the rare diagnosis of malignant otitis externa [4]. If malignant otitis externa is suspected, a complete blood count (CBC), erythrocyte sedimentation rate (ESR), CT scan of the head, and otolaryngology consultation are warranted. (See "External otitis: Pathogenesis, clinical features, and diagnosis" and "Malignant (necrotizing) external otitis" and "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis", section on 'Skin abscess'.)

Auditory canal mass — Masses in the ear canal will usually be readily evident on physical examination, although they may at times be obscured by surrounding cerumen. Cerumen impaction itself commonly causes hearing loss or a feeling of ear fullness and may occasionally present as ear pain. Thus, removal of cerumen should be pursued whenever possible to aid in diagnosis and sometimes provide therapeutic relief. Foreign bodies, if present, should be removed. If a foreign body cannot be removed, otolaryngology consultation is indicated. (See "Cerumen" and "Foreign bodies of the outer ear (pinna [auricle] and external auditory canal): Diagnosis and management", section on 'Foreign bodies of the external auditory canal'.)

A red or yellow mass in the posterior aspect of the TM may indicate a cholesteatoma, especially if there is an antecedent history of chronic otitis media with effusion (OME). Rarely, cases of malignancy may present similarly. Granulomas of the ear canal may sometimes be an inflammatory reaction to the chronic presence of a foreign body. In other cases, a mass of the wall of the ear canal may indicate a more serious diagnosis, such as eosinophilic granuloma or rhabdomyosarcoma. If the diagnosis is uncertain, otolaryngology consultation is indicated. (See "Cholesteatoma in children" and "Rhabdomyosarcoma in childhood and adolescence: Clinical presentation, diagnostic evaluation, and staging", section on 'Head and neck' and "Clinical manifestations, pathologic features, and diagnosis of Langerhans cell histiocytosis".)

Pruritus — Other diseases of the ear canal typically cause more pruritus than pain. Redness, flaking, and scaliness of the ear canal may indicate eczema, especially if the symptoms are chronic or recurring. Contact dermatitis of the ear canal often follows from the use of topical antibiotics or anesthetic drops and may present with a pink-red, bumpy rash in the ear canal and on the adjacent skin of the concha. Fungal otitis externa should also be considered, especially if the symptoms have a relatively recent onset and if there is a prior history of topical antibiotic use. In cases of fungal otitis externa, there may be an abnormal odor and/or discharge in the canal. Culture of the discharge will aid in the diagnosis. (See "External otitis: Pathogenesis, clinical features, and diagnosis", section on 'Otomycosis' and "Allergic contact dermatitis in children" and "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis".)

Patients with pain of the external ear and none of the above findings should be evaluated for middle ear disease (algorithm 1D) and for causes of secondary otalgia.

Middle ear disease — Most children with ear pain have AOM (algorithm 1D). On physical examination, these patients have a visible abnormality of the TM (eg, bulging and red) and/or discharge from the middle ear. (See 'Middle and inner ear' above and "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

For patients with middle ear disease, pain, swelling, tenderness, and/or discoloration of the mastoid region indicate likely mastoiditis. With mastoiditis, the auricle may protrude outward but should appear uninflamed. (See "Acute mastoiditis in children: Clinical features and diagnosis".)

Facial nerve palsy can sometimes result from serious cases of otitis media or mastoiditis (algorithm 1A) [6]. Other cases of otitis media may be associated with inner ear dysfunction, presenting as severe hearing loss or vertigo [6]. In cases of otitis media associated with facial nerve or inner ear dysfunction, otolaryngology consultation should be pursued to consider possible surgical intervention. CT of the head with contrast, specialized slices, and image reconstructions may be performed to assess for associated mastoiditis, cranial, or intracranial extension of the infection. (See "Facial nerve palsy in children", section on 'Otitis media'.)

Patients with otorrhea have usually experienced spontaneous rupture of the TM as a complication of AOM. Otorrhea also commonly occurs in patients with tympanostomy tubes and AOM. Occasionally, culture of the fluid may help in guiding antibiotic therapy, although empiric therapy is usually sufficient. Typically, the copious amount and thin consistency of the draining fluid, the absence of tragal tenderness, and a history of preceding nasal symptoms distinguish the otorrhea of otitis media from the discharge sometimes seen in otitis externa. (See "Acute otitis media in children: Epidemiology, microbiology, and complications", section on 'Tympanic membrane abnormalities'.)

Patients with retraction or impaired mobility of the TM or an air-fluid level have middle ear effusion. (See 'Auditory canal and middle ear' above.)

Some patients may have visible abnormality of the TM but no evidence of fluid in the middle ear. Redness or bullae of the TM indicates myringitis [19]. (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Bullous myringitis'.)

Patients with no visible abnormality of the TM may have secondary otalgia or psychogenic disease, but these patients may be suffering from Eustachian tube dysfunction [10]. Eustachian tube dysfunction usually results from nasal disease (viral respiratory infection, nasal allergy, adenoid hypertrophy, or sinusitis) and can lead to painful pressure disturbances in the middle ear. Symptoms resulting from eustachian tube dysfunction are often more prominent in settings of altered atmospheric pressure, such as air travel or scuba diving. Although Eustachian tube dysfunction is typically associated with middle ear effusion and/or abnormal mobility of the TM (ie, OME), in some cases, physical examination may be essentially normal. Eustachian tube dysfunction is an unlikely explanation for ear pain in patients without a history of recent nasal symptoms. (See "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis", section on 'Clinical features'.)

Secondary causes of otalgia — Attention should be given to anatomic regions that are known for causing referred ear pain (see 'Secondary otalgia' above):

●Parotid region, evaluating for parotid swelling and tenderness or loss of the mandibular angle that indicate parotitis

●Pre- and postauricular lymph nodes, looking for primary lymphadenitis, conjunctivitis, skin infections behind the ear, or signs of Epstein Barr virus infection (see "Cervical lymphadenitis in children: Diagnostic approach and initial management")

●Temporomandibular joint (TMJ), assessing for tenderness, crepitus, or pain with motion that suggest TMJ dysfunction syndrome (see "Temporomandibular disorders in adults")

●Facial nerve disease (ie, Bell's palsy), suggesting sensory symptoms of pain adjacent to the ear (see "Facial nerve palsy in children")

●Oropharyngeal lesions, including dental abscess, suppurative pharyngitis, and stomatitis (see "Evaluation of sore throat in children" and "Soft tissue lesions of the oral cavity in children", section on 'Infections')

●Prolonged purulent nasal drainage or maxillary sinus tenderness, indicating sinusitis (see "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Acute bacterial rhinosinusitis')

Finally, the possibility of psychogenic pain or malingering should also be considered if no clinical findings suggest an alternative diagnosis.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Outer ear infection (The Basics)")

●Beyond the Basics topic (see "Patient education: External otitis (including swimmer's ear) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Primary versus secondary otalgia – The differential diagnosis of ear pain can be categorized by the anatomic site from which the pain originates (table 1). Patients with primary otalgia have pain originating from the ear itself. Secondary otalgia is referred pain, originating in another anatomic site but causing the sensation of arising from the ear. (See 'Differential diagnosis' above.)

Cases of secondary otalgia will be distinguished from primary otalgia by the absence of findings in the ear itself and by the findings of inflammation, infection, or injury to adjacent structures. The referred pain arises from nerves that partially innervate the auricle or external auditory canal and include spinal nerves C2 and C3 and cranial nerves V, VII, IX, and X. (See 'Secondary otalgia' above.)

●Diagnostic approach – A careful history and physical examination typically provide the etiology of most cases of ear pain. Ancillary testing may be appropriate in cases where more serious diagnoses are suspected (eg, patients with serious trauma, abnormal mental status, or ill appearance). (See 'Evaluation' above and 'Diagnostic approach' above.)

•Stabilization – For patients with altered mental status, abnormal vital signs, or other signs of severe illness, resuscitation and emergency therapy precedes evaluation (algorithm 1A). In patients with traumatic injury and altered mental status, basilar skull fracture or intracranial hemorrhage and increased intracranial pressure should be suspected (algorithm 2). (See 'The critically ill patient' above.)

•Ear pain in the trauma patient – Among stable patients with ear pain, it is useful to consider separately those patients with history or signs of traumatic injury to the ear, including blunt, penetrating, and barometric trauma (algorithm 1B). Patients with ear trauma should also be evaluated for traumatic injury to adjacent structures, particularly brain injury, basilar skull fracture, and neck injury. (See 'Ear pain in the trauma patient' above.)

•Nontraumatic ear pain – The diagnostic approach to nontraumatic ear pain in stable patients consists of careful examination of the external and middle ear (algorithm 1C and algorithm 1D). (See 'Nontraumatic ear pain' above.)