CHAPTER 58 ■ PAIN: EARACHE MARK D JOFFE INTRODUCTION Ear pain or otalgia is a very common chief complaint in children seeking emergent or urgent care In younger, preverbal children, ear pain is usually inferred by parents from various child behaviors Ear tugging in younger infants, however, is often not associated with ear disease While acute otitis media (AOM) may be the main parental concern, astute clinicians must consider a broader range of potential causes Otalgia may result from diseases in all parts of the ear, and also from a variety of nonotogenic conditions When ear pain is accompanied by neurologic signs and symptoms such as cranial nerve palsies, vertigo, or altered mental status, a more extensive evaluation is required DIFFERENTIAL DIAGNOSIS Ear pain may be the presenting symptom of problems in external, middle, or inner ear ( Fig 58.1 ), as well as referred pain from other anatomic structures Causes of auricular pain are often readily apparent from the history Trauma to the auricle results in contusions, abrasions, hematomas, and lacerations that are easily noted on physical examination In younger children, and in particular in cases of inflicted injury, a history of ear trauma may be lacking Swelling and/or bruising of the external ear, especially the medial aspect of the auricle, from forcible traction is a well-recognized manifestation of child abuse Hematomas of the auricle are of particular concern because, interposed between the perichondrium and underlying avascular cartilage, the accumulation of blood disrupts the diffusion of nutrients to the cartilage Necrosis of auricular cartilage leads to deformity and results in the characteristic “cauliflower ear.” Pressure dressings on injured external ears may prevent the accumulation of significant auricular hematomas Larger auricular hematomas may need to be drained The popularity of body piercing, and in particular multiple piercings of the ear, has increased the number of patients requiring treatment for complications Infections of the ear lobe or of the cartilaginous portions of the auricle after piercing should be treated with topical and sometimes systemic antibiotics While Staphylococcus aureus is the most frequent pathogen, cartilaginous infection with Pseudomonas aeruginosa is well described Drainage, debridement, and treatment with fluoroquinolone antibiotics may be necessary Preauricular cysts or