The long hot days of summer are here, a time when kids are outdoors playing, especially when possible in a pool. The excitement of play and water frequent­ly make children forget any pain they may have. As the day winds down and the noises are replaced by the quiet evening, anything which may have been masked is brought to the surface.

Ear pain is a frequent complaint of young children. At which point does one take a child to an emergency room or an urgent care center? I do not feel that anyone should sit at home with a child who is in pain. Ibu­profen (Motrin) or acetaminophen (Tyle­nol) can be given which can provide tempo­rary relief, but ultimately the reason for pain needs to be found and treated.

The ear is divided into three parts; outer, middle, and inner ear. Inflammation of each part causes different symptoms. Pain usually is a symptom of either an outer ear infection or a middle ear infection. It is important to make a correct diagnosis because the treat­ment is different.

The outer ear extends from the ear drum to the outside portion of the head. This canal is crooked, dark and can trap water and bac­teria easily causing an infection commonly known as “swimmer’s ear” or otitis externa. The most frequent bacteria are the bacte­ria which commonly live on our skin, “staph aureus,” “pseudomonas,” and “strep.” Less fre­quently, and especially in chronic cases, we may find fungus as a cause. The two most common symptoms of “swimmer’s ear” or otitis externa are pain (otalgia) and dis­charge (otorrhea). Fever is not common. The diagnosis is made by examining the child. Pain is classically caused by pressing on the part of the external ear which is in front of the ear canal (tragus). Treatment is usually a topical antibiotic which can contain an an­ti-inflammatory agent, such as steroids, to alleviate the symptoms. The usual course is three to seven days. Oral antibiotics are gen­erally not necessary unless the symptoms are associated with fever or a middle ear in­fection. The use of pain medicine such as Tylenol or Motrin may be helpful. At times stronger pain management is necessary. Generally, otitis externa is easily managed and rarely has severe complications.

Otitis media, or middle ear infection, is an infection of the middle ear which is the part of the ear which contains the ossi­cles or three small bones which convert the vibration of the ear drum to waves of the fluid of the inner ear. Ultimately this translates to a signal to the brain. The hal­low cavity which is the middle ear can be filled with fluid when it is infected. This may cause pain or difficulty hearing. Mid­dle ear infections can be associated with cold symptoms which cause inflammation of the canal which drains the middle ear. This causes fluid buildup in the middle ear. Pain may be a symptom of a middle ear in­fection, but may not be present. Fever may also be present, as well as irritability or dif­ficulty hearing.

The diagnosis of a middle ear infec­tion is made by physical exam. Frequent­ly a dull, poorly mobile ear drum can be seen and a child will have fever, some irri­tability, nasal congestion, and ear pain. If the child is old enough to speak, he will frequently complain of some hearing loss or a feeling that he is under water. Un­less there is also a swimmer’s ear, there is no discharge from the external canal. The treatment is systemic antibiotics such as amoxicillin and pain management such as Motrin or Tylenol. Rarely do middle ear in­fections progress to something more seri­ous, such as sepsis, which is the presence of bacteria in the blood, and mastoiditis, in which bacteria spreads to the bony cav­ity (the mastoid bone) behind the ear. If a child continues to have high fever and irri­tability after starting antibiotics, he should be seen by a doctor.

Infections of the inner ear are less fre­quent and are usually viral. The symp­tom most associated with these infec­tions is vertigo or the sensation that the head is spinning or the room is spinning. Frequently, vomiting is present and walk­ing may be difficult or impossible. Tinnitus or constant ringing in the ear may be pre­sent. Luckily this is very rare in children.

It has been said, mostly by my grand­mother, that prevention is the best medi­cine. Bottle feeding should never be done while the child is lying down and there may be data to support that the use of pacifiers may increase the risk of middle ear infections. Although this is sound ad­vice, I do believe that the people who give it have never stayed up nights with a scream­ing child who can be soothed with the use of a binky.

By Dr. Pnina Feingold