PM Pediatrics
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Dr. Christina Johns
Senior Medical Advisor, PM Pediatrics

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My Ear Hurts!

I am not a fancy ORL doctor, as you know. My brother AND my dad are. The truly fancy name for ear, nose, and throat doctors is otorhinolaryngologist, frequently shortened to ORL, which is what I mostly call them nearly totally due to family pressure. My brother subspecializes in voice, and is a doctor to the stars. My dad focused on head and neck cancer surgery during his career. I focus on none of that as an emergency physician, but I feel like I could focus on ear pain because I see so much of it. So since we are getting close to swimming season, let’s review a few of the un-fancy causes of ear pain that I see every day in my practice. Most people assume that when kids (adults too) complain about ear pain it automatically mean they have an ear infection. Sometimes that’s true, but not always, so hopefully after reading this your understanding of the spectrum of possibilities will be widened just a bit. Let’s go.

IT MAY NOT BE THE EAR

First, ear pain can exist without having anything to do with the ear at all. One of the most common causes is teething. Lots of parents bring in their baby worried that their child is pulling on his ears and that must mean an infection is in there. But in fact, the eruption of teeth can cause some discomfort, and since babies aren’t great yet at precisely localizing anything (ever see a baby accurately try to feed themselves?), they pull on or grab at their ears to get in the general direction of what’s bothering them. This of course is less of an issue once the teeth erupt and the child gets older. But it’s a real thing for the baby crew.

image of erupting tooth

IT MAY BE SOMETHING STUCK IN THE EAR

Another reason for ear pain is that there is SOMETHING IN THE EAR CANAL. This really runs the gamut from a live insect (yes I’ve seen this plenty of times) to a bead to a tiny piece of a toy, like those googly plastic eyes that sometimes go on small stuffed animals. Having a foreign body in the ear canal doesn’t cause an infection per se, but it can be painful and lead to irritation and inflammation if left in there.

A few notes about this topic, because inquiring minds want to know: yes, we often have to kill the live insect before removing it using several different tool options including a little grabber we fondly call the “alligator forceps” and no, it’s not a total disaster if the urgent care office or emergency department can’t remove the foreign body at 10:30pm at night. Waiting until the next day to be seen by your local ORL is a perfectly reasonable thing to do as long as your child is comfortable and pain free. It’s always charming if the object or creature can be removed right away when you first catch wind that there’s something in the ear, but if it can’t be removed immediately and the child feels ok, then it’s not a crisis to have to wait a day or two.

IT MAY BE INFECTED

Sometimes it really is an ear infection, when viruses and bacteria get into the middle ear space and cause inflammation and fluid buildup. And this is often painful. This is quite different from swimmer’s ear, which is inflammation in the external ear canal space. Also often painful.

Middle ear infections (otitis media) are often (but not always) treated with antibiotics and external ear infections (otitis externa) are usually treated with ear drops. The best way to manage swimmer’s ear in the summer is not to get it in the first place by keeping the ear canal dry either by blowing cool air from a hair dryer into the ear or by using an ear wash mixture of half water or peroxide and half regular vinegar, since this particular combo is especially inhospitable to the germs that cause swimmer’s ear –and you or your child will also smell like a salad.

Diagram of otitis media and otitis externa. Swimmer's ear. Otitis externa is inflammation of the ear canal. Human anatomy. Vector illustration for medical use. Otitis media is a inflammatory diseases of the middle ear. Human anatomy. Vector illustration for medical use

IT MAY BE AN INJURY

Local trauma causes ear pain, too, and the most common culprit is of course, cotton tipped swabs. I don’t know a single ORL who doesn’t despise Q-tips used for this purpose. Lots of doctors say: “don’t try to put anything smaller than your elbow in your ear” and I think you can follow the point of that advice. Trying to clean the ear canals is unnecessary (if you or your child needs it, see an ORL) and often causes scratches or even an eardrum rupture that can be quite sore.

DO’S AND DON’TS

Regardless of the reason, there are a few things to do to help a child whose ear is hurting feel more comfortable:

  • First of course, is to give acetaminophen (Tylenol and others) or ibuprofen (Motrin, Advil, and others). These pain reducer medicines can really help, and it’s safe and ok to give them for ear pain.
  • Many people advocate for a heating pad (not set too hot) or warm towel right out of the dryer to place over the ear as a soothing compress, and this can work well sometimes.
  • The pain reducer ear drops that used to be widely available by prescription are no longer recommended by most physicians as the evidence is poor that they actually work to reduce pain in the first place. So stick to the systemic pain reducers mentioned above and don’t put anything in the ear other than the vinegar combo for prevention. I’ve heard a variety of things which are not backed by evidence, so remember: no ear candling, no olive oil, no onions, no garlic, no breastmilk in the ears.

Ultimately, we need to determine why the ear hurts in the first place. Never question or feel bad about getting an ear check: it’s as helpful to know what is NOT causing the ear pain as what IS causing it, and once we get a handle on that, then we can refine the treatment plan to include the right therapeutic cocktail, even if sometimes it’s nothing more than a cold teething ring.

As for the fancy stuff? I can hook you up with the ORL crowd if necessary. I know a few.

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