sinuses may become infected A small pit just anterior to the helix, which was present prior to the development of the infection, is noted in the center of the surrounding tender, red swelling Frostbite of the helix presents as a painful, pale ear that usually becomes hyperemic and swollen over time Vesicles may develop in the latter stages Rapid rewarming and analgesia are recommended Most authorities discourage debridement of vesicular or hemorrhagic lesions Cerumen impaction may cause ear pain, especially after attempts to remove accumulations push the ear wax up against the tympanic membrane (TM) Dry cerumen may be tightly adherent to the skin of the external canal which, when removed with a curette, causes abrasion and bleeding Saline irrigation of the canal or instillation of peroxide-containing ear drops or docusate liquid can remove, soften, or detach adherent wax and is recommended prior to attempting to remove dry cerumen with a curette Removal of cerumen with a curette is best accomplished under direct visualization Children may have ear pain from foreign bodies placed in the ear If the foreign body is difficult to remove or is close to the TM, removal under sedation by an otolaryngologist is advisable Occasionally, live insects are noted in the external canal and their movement causes great pain and distress Instillation of mineral oil will asphyxiate the insect prior to removal Viscous lidocaine may have the added benefit of paralyzing the insect, reducing painful movements more quickly than mineral oil Shingles of the ear, or herpes zoster oticus, presents with painful or pruritic vesicles of the external auditory meatus and may also involve the TM Although more common in adults, associated facial nerve palsy (Ramsay Hunt syndrome), hearing loss, or vertigo have been reported in children Antiviral agents and systemic corticosteroids may be helpful if administered in the early stages of this illness Labyrinthitis usually presents with vertigo that may be associated with nausea and vomiting, balance disturbance, and tinnitus It is usually caused by a viral or bacterial infection of the inner ear, but may also be associated with middle ear infection and ear pain OTITIS EXTERNA Otitis externa is inflammation of the skin of external auditory canal often associated with polymicrobial infection It is a common problem during childhood, especially during summer when children are swimming and humidity is high Cerumen is produced by glands in the external ear to coat the canal with a