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Ear pain, or otalgia, is one of the most common pediatric outpatient chief complaints. The differential diagnosis is listed in Table 121-1. This chapter discusses acute otitis media, otitis media with effusion, otitis externa, acute mastoiditis, and foreign body. The ear is divided into three major parts: (1) the outer ear, which includes the auricle/pinna and the external auditory canal; (2) the middle ear, which is bound by the tympanic membrane laterally, contains the auditory ossicles, and is connected to the nasopharynx via the eustachian tube; and (3) the inner ear, which includes the semicircular canals, the cochlea, and the auditory nerve (Figure 121-1).

TABLE 121-1Differential Diagnosis of Acute Ear Pain
FIGURE 121-1.

Anatomy of the outer, middle, and inner ear.



Acute otitis media (AOM) is the acute onset of signs and symptoms of middle ear inflammation. Although the incidence is decreasing in the postpneumococcal vaccine era, otitis media remains the third most common diagnosis for ED visits in children under 15 years old, accounting for 6.1% of all ED visits.1

The peak incidence of AOM is between 6 and 12 months of age.2 Recent U.S. studies found that 23% to 46% of children had at least one episode of AOM by the age of 1 year,2,3 and this rate increased to 60% by the age of 3 years.2 Risk factors include male sex, non-Hispanic white race, family history of recurrent AOM, day care attendance, and early occurrence of the first episode of AOM before 1 year of age.2 The incidence is also higher in children with atopy,2 craniofacial anomalies, and immunodeficiency syndromes. Breastfeeding in infancy is protective and decreases the risk of AOM.2,3


In the healthy state, the middle ear is aerated via the eustachian tube and its connection to the nasopharynx (Figure 121-1). If the eustachian tube becomes obstructed due to inflammatory edema and/or mucus (often associated with a viral upper respiratory infection), middle ear secretions build up and create conditions favorable to the development of AOM. Compared with ...

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