Ear Pain

Ear Pain

Ear pain or otalgia is one of the common reasons of primary care visits. While its common to find primary otalgia caused by ear infections, it is also not uncommon to find ear pain secondary to other causes called as referred otalgia. It requires a detailed history collection and comprehensive assessment for an NP to diagnose the source of otalgia, especially when a referred pain is suspected. Considering the increased rate antibiotic resistance, seen in many communities, it is very crucial that antibiotics are prescribed after carefully considering the patient’s age group, risk factors, severity of signs and symptoms, source of otalgia, risk factors, and medical history. Acute Otitis Media is the predominant cause of ear pain in pediatric population. Due to the disfunction of Eustachian tube caused by an on obstruction or a viral or bacterial infection, fluid stasis in the middle ear occurs which in turn leads to colonization of bacteria, virus etc. The most common bacterial organisms that cause ear infection are S pneumoniae, H influenzae, M catarrhalis (1)

Stage -1 Abstract Conceptualization

Abstract Conceptualization

Stage-2 Active experimentation

Active experimentation

Acute Otitis Media (AOM)

Management of AOM

During history collection, ask all relevant questions to identify the cause of otalgia. Verify the duration of ear pain, any associated symptoms such as fever, lethargy, dizziness, neck stiffness, tooth infection, facial pain, ear discharge, hearing loss, tinnitus, headache, total duration of symptoms etc.

Milder infections that are associated with upper respiratory tract infection are often caused by virus and spontaneously resolves without treatment.Children above 6 months who have a mild or moderately bulging TM, low grade fever (less than 39°C), mildly ill, alert, responding to antipyretics, and mild ear pain can be safely managed with a‘watchful waiting’ approach for 24 h to 48 hours. Children with AOM, bulging TM, fever ≥39°C, and moderately to severely systemically ill, or children who have severe otalgia or have been significantly ill for 48 h should be treated with antimicrobials. children ≥2 years of age with uncomplicated AOM will require only a 5-day course of antibiotic; however, a 10-day course should be considered for younger children (six to 23 months) and cases with a perforated TM or recurrent AOM (1,2,5).

Pharmacotherapy

Recommended pharmacotherapy in children, dosing, and classification of mild, moderate,severe AOM etc., can be viewed here: https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/otitis-media#part1_pharmacological. Amoxicillin is the recommended 1st line agent in adults and children to manage AOM.

Otitis Media with Effusion (OME)

Otitis media with effusion indicates fluid in the middle ear without any acute infection. OME occurs either spontaneously or associated with an inflammatory process. 70% to 90% of OME resolves spontaneously within 1-3 months and doesn’t require any antibiotic treatment. Viral URTI, second hand smoking, sinusitis etc. are some of the reasons of OME (5).

Chronic Suppurative Otitis Media (CSOM)

CSOM implies chronic, recurrent middle ear infection with the following key features: TM perforation, malodorous ear discharge, and hearing loss.Patients with wet ear( dangerous) CSOM, will benefit from a combination of both oral and topical fluoroquinolone (e.g cipro 500mg BID with ciprodex) than topical or oral antibiotic alone. Pseudomonas aeruginosa and Staphylococcus aureus are the most predominant pathogens that cause CSOM. Antibiotic drops with aural toileting can be a safer alternative for patients with dry CSOM (4).

AcuteOtitis Externa

Acute otitis Externa represents diffuse inflammation of external ear canal, which may also extend to pinna or tympanic membrane. Classic signs/ symptoms include: rapid onset, tragus/ pinna tenderness, severe otalgia, swelling / erythema of ear canal, lymphadenitis, tympanic membrane erythema, or cellulitis of the pinna and adjacent skin. Topical antibiotic or steroid therapy is recommended without oral antimicrobials, unless an extension of inflammation to connective tissue or pinna is suspected (3,5)..

Referred pain

Any ear pain presenting to primary care needs careful examination to rule out secondary causes of otalgia. If a diagnosis of primary otalgia caused by ear infection is not evident in physical exam, rule out secondary otalgia. Most common causes of secondary otalgia include the following: temporomandibular joint syndrome, pharyngitis, dental disease, and cervical spine arthritis. More careful evaluation should be done for patient who are immunocompromised, smokers, or living with chronic condition such as diabetes, CKDetc. If the underlying reason of ear pain is not identified through physical exam and history, consider referral to ENT specialist, and / ordering investigations such as MRI, CT scan. To learn further about common and uncommon causes of referred pain, refer the following link: (table 1- 3). https://www.aafp.org/afp/2008/0301/p621.html

Clinical Management Of Ear Pain ( 1,2,4,5)

Clinical Management Of Ear Pain

Stage-3

Concrete Experimentation

SOAP NOTE

C/o fever x 2 days, Temp between 38 C-39 C

Mild cough, runny nose, no sob, appetite reduced

No h/o travelling, No vomiting or diarrhea, no rashes

Sister was sick with viral URTI

Past h/oAOM, last episode was 6 months ago

o/e

General: NAD, appears well-perfused/well-hydrated, alert, good eye contact, no jaundice/palor/cyanosis/diaphoresis

ENT: Fontanelles n, TM bulging (L), /erythema+ ear canal erythematous, conjunctiva n, no erythema/eye discharge, oropharynx n, no tonsillar enlargement/exudate, no LAD, no nuchal rigidity

Resp: no distress, no increased work of breathing, no indrawing, no tracheal tug, no accessory muscle use, AE=AE, no wheeze/crackles/rales

Abdo: soft, non-distended, non-tender to palpation, no guarding/rebound, no peritoneal signs, no mass/HSMNAD

A

AOM

P

Antibiotic as directed

Discussed s/s that requires immediate medical attention (persisting fever, neck rigidity, rash, lethargy, sob)

Fever management with Tylenol

f/u in 24-48 hrs if no improvement with the prescribed treatment

Stage-4 Reflection

Reflection

Learning activity

Describe your learning experience on managing ear infection. Illustrate the use of ELT in this process. What your reflections from your learning experience? When possible, narrate a case that you found interesting during this learning experience.

Reference

1.Sakulchit,S., Goldman, R. (2017)., Antibiotic therapy for children with acute otitis media. Canadian Family Physician.Sep 2017, 63 (9) 685-687; Retrieved from http://www.cfp.ca/content/63/9/685

2. Saux, N., Robinson, J. (2016)., Management of acute otitis media in children six months of age and older. Pediatric Child Health. February 6;21(1):39-44. Retrieved from https://www.cps.ca/en/documents/position/acute-otitis-media

3.Ely, W., Hansen, M., Clark, C., Diagnosis of ear pain. American Family Physician. 2008 Mar 1; 77(5): 621–628. Retrieved from https://www.aafp.org/afp/2008/0301/p621.html

4. Mittal, R., Lisi, C. V., Gerring, R., Mittal, J., Mathee, K., Narasimhan, G., Azad, R. K., Yao, Q., Grati, M., Yan, D., Eshraghi, A. A., Angeli, S. I., Telischi, F. F., … Liu, X. Z. (2015). Current concepts in the pathogenesis and treatment of chronic suppurative otitis media. Journal of medical microbiology, 64(10), 1103-16.

5. Anti infective Review Panel. Anti-Infective guidelines for community acquired infections. Toronto: MUMS Guideline Clearing house;2013.