Earache on the CCFP exam

Approach

• Clear wax that hides the drum before you decide. Look at both ears.
• Use a bright light and the largest speculum that fits the canal.
• The diagnosis needs three things: symptoms that came on suddenly, fluid behind the drum, and signs the middle ear is inflamed.
• Bulging is the key sign. A bulging drum, above all a yellow or bloody one, strongly suggests infection.
• Redness without bulging predicts infection poorly. Crying alone can redden the drum.
• A drum that barely moves when you puff air at it (pneumatic otoscopy) has fluid behind it.
• Fluid alone, or only a line of fluid and air, without bulging, rarely means acute infection.

Approach

• A normal canal and drum with real ear pain means the pain likely comes from somewhere else. Examine beyond the ear.
• Check the teeth and gums for an abscess. Tap on the back teeth.
• Feel the jaw joint as the patient opens and closes. Clicking, tenderness or pain on chewing points there.
• Look at the throat and tonsils. Throat infection and an abscess beside the tonsil can send pain to the ear.
• Brief electric stabs set off by touch, chewing or talking suggest trigeminal neuralgia, a facial nerve pain.
• Match the cause to the age. Jaw-joint and nerve pain are rare in young children.

Approach

• Pain or swelling over the bone behind the ear suggests mastoiditis, the most common complication of otitis media.
• Facial weakness, double vision, dizziness or signs of meningitis also mean the infection has spread.
• Spread beyond the middle ear needs antibiotics given systemically and an urgent assessment for imaging, such as a CT scan, or surgery.
• Ear pain with no other ear symptoms points strongly to a cause outside the ear.
• Red flags for a head and neck cancer: voice change, trouble or pain swallowing, shortness of breath, or a new neck lump. Smoking or alcohol use adds to the concern.
• Necrotizing otitis externa is an ear canal infection that can spread to the bone of the skull base. Older adults and people with diabetes or a weak immune system are most at risk.
• Suspect it with severe ear pain, pain worse than the exam shows, raw tissue (granulation) in the canal, or new weakness of a nerve in the head. Refer urgently.

Approach

• Waiting suits an otherwise healthy child 6 months or older with mild illness, or when the diagnosis is not certain.
• Mild means alert, settles with fever medicine, mild ear pain, and fever under 39 °C.
• Treat now if the drum bulges, the fever is 39 °C or more, and the child looks moderately to very ill. Also treat now for severe ear pain, or illness lasting 48 hours.
• Treat now if the drum has burst and pus drains.
• Children with cleft palate, Down syndrome, an immune disorder or a cochlear implant often need antibiotics right away.
• Pick a follow-up plan. Recheck in 24 to 48 hours, or ask the family to return if not better by 48 hours. Or give a prescription to fill only if no better.
• Tell the parents: many ear infections settle in 2 to 3 days. Antibiotics do not ease pain on day one, and they cause diarrhea, allergy and resistance.

Approach

• First choice: amoxicillin 75 to 90 mg/kg/day in 2 doses, or 45 to 60 mg/kg/day in 3 doses.
• Length: 5 days for most children 2 and older. 10 days under 2, with a burst drum, with repeat infections, or after a first drug fails.
• Amoxicillin in the past 30 days: amoxicillin-clavulanate is the prudent choice. No response to amoxicillin: switch to it. It is also first choice when pus drains from the eye too.
• Penicillin allergy that was not life-threatening: cefuroxime axetil or cefprozil. Not after swelling of the face or throat, wheeze or low blood pressure.
• Macrolides, such as azithromycin, kill the main ear germs less well. Keep them for true allergy.
• Fluid that lingers after treatment does not, on its own, need a new antibiotic.

Approach

• Start acetaminophen or ibuprofen for every child with ear pain, whether or not an antibiotic starts.
• Antibiotics do not ease pain in the first 24 hours, and only a little after. Pain medicine may be all the child needs.
• Check the parents' dose against the child's weight. Dose by weight and stay under the daily maximum.
• Never give acetylsalicylic acid (ASA) to children.
• Codeine is contraindicated under age 12 in Canada. The body turns it into morphine at an unpredictable rate, and the result can stop breathing.
• Codeine is not recommended from 12 to 18 either.

Approach

• A red drum that does not bulge does not explain a fever. Keep looking.
• Do not accept teething as the cause of a high fever.
• Examine the whole child: chest, throat, skin, neck and hydration.
• Under 2 with fever and no clear source, think of a urine infection. About 7% of these children have one.
• In a child who cannot talk, fever may be the only sign of a urine infection.
• In a child in diapers who looks ill, get urine by catheter, not a bag. Dipstick it, and send a culture if it shows pus cells or nitrite.
• Classic Kawasaki disease, an inflammation of blood vessels, needs at least 5 days of fever and 4 of 5 key signs. The signs are red eyes, mouth changes, hand and foot changes, rash, and a swollen neck gland. With 4 or more key signs, day 4 of fever can be enough.
• Fever for 5 days with only 2 or 3 key signs can still be incomplete Kawasaki disease. So can 7 days of unexplained fever in a baby.

Approach

• After 4 or more documented ear infections in 12 months, consult audiology and an ear, nose and throat specialist to check for hearing loss.
• Ask about speech, language, school work, and whether the child seems not to hear.
• A language delay, or a parent's worry about hearing, calls for a quick referral for a hearing test.
• Fluid can stay behind the drum for months after the infection clears.
• If the fluid lasts more than 3 months, consider a referral to audiology.