By Rod Moser, PA, PhD
The medical term for ear pain is otalgia, appropriately pronounced: Ohhhhhh talgia! Ear pain, regardless of the cause, can be severe and humbling for adults. When an adult gets middle ear pain, they usually want narcotics; the stronger the better. Children are also often the victims of ear pain, mostly from otitis media (a middle ear infection). Ear infections (middle ear infections) are among the most frequently diagnosed infections in the United States and the number one reason why children are given antibiotics. Sadly, ear pain is among the most frequently misdiagnosed conditions in America.
The ear has three main parts: the external ear (the part you can see, including the ear canal leading up to the eardrum), the middle ear (the air-filled space on the other side of the eardrum that is very prone to infections), and the inner ear (a tiny space that cannot be viewed on examination that contains the neurological connections for hearing and controls balance). Inner ear infections rarely cause pain but they do cause dizziness and tinnitus (ringing).
There are many causes of ear pain, and not all causes are due to infection. It seems that as soon as a medical provider hears the word “ear pain” they reach for their prescription pad and write the word ‘amoxicillin’ on it. While amoxicillin is still considered the drug of choice for middle ear infections it will not help an external or inner ear infection.
Ear Pain caused by Cold Temperatures
The external ear has an abundance of sensory nerves. One stimuli that can set them off may be cold temperatures. Don’t tell Grandma, but cold temperatures do not cause colds and do not cause ear infections. If you get ear pain while jogging in the winter, you can fix that by keeping your ears warm and covered. If you get ear pain swimming in cold water, then use protective ear plugs (or move to Hawaii). Surfers often get a condition called exostosis where the ear canal develops a painful lump due to cold water exposure. As a parent, if you put cold eardrops (inappropriately refrigerated) in a child’s ear, it is likely to cause a caloric response. Cold liquids in the ear will cause the eyes to twitch from side to side (nystagmus) and cause profound vertigo. People with vertigo tend to get nauseated and/or vomit.
Ear Pain caused by Q-tips and other instruments
Those touchy sensory nerves can also cause pain when they are scratched or irritated. Ear wax is a normal, protective coating for the external ear canal. It should NOT be removed no matter how yucky it appears. Not only do you risk rupturing the eardrum, you will predispose yourself to a painful infection (otitis externa) when this coating is removed. Otitis externa is exquisitely painful and is relatively easy to self-diagnose. If it hurts to move your pinna/auricle or push firmly on the tragus (the flap of tissue at the ear opening), then otitis externa is the most likely cause. One form of otitis externa is called swimmer’s ear. Frequent water exposure from bathing or showering can be as contributory as swimming. Otitis externa is treated with a prescription antibiotic eardrop, often containing a mild steroid to help with painful swelling. Minor infections may be prevented with a homemade solution of white vinegar diluted in half with water. Remember to instill those drops at body temperature!
Ear pain caused by blunt and barometric trauma
A slap on the side of the head or being hit in the ear by a soccer ball has the potential of rupturing the eardrum. Not only would the victim experience traumatic ear pain, a ruptured ear drum will tend to bleed. Ruptured eardrums should be medically evaluated. Most will heal without medical intervention, but they must be monitored.
Middle ear pressure causes pain. When you change altitude in a plane or even while driving in a car or scuba diving /snorkeling, you can experience sudden ear pain. Sometimes, the pressure variance will result in an eardrum rupture. Minor cases of barotitits (ear pain due to altitude changes) may resolve spontaneously as the Eustachian tubes try to equalize pressure, or may last several days or longer.
Ear pain caused by middle ear infections
Most middle ear infections are preceded by a stuffy cold. Children from six months old to six years, and especially those in group daycare are very prone to middle ear infections, but they can happen at any age. The Standard of Care in the past was to immediately start antibiotics, but study after study has proved this to be an over-treatment. Most middle ear infections – over 90% – will resolve without antibiotics if you give the body’s immune system a few days to work. Parents are often so bothered by the ear pain that they rush to get antibiotics, circumventing the body’s natural response. Treating ear infections too soon may actually make a child more prone to subsequent infections. Deciding not to immediately treat a middle ear infection (with antibiotics) does not mean the pain should be ignored or trivialized. Remember that ear pain can be severe and humbling. It needs to be treated appropriately, from over-the-counter medications to prescription pain meds, depending on the child’s tolerance. Europeans tend to hold the antibiotic for a week, but U.S. medical providers are not following this recommended “wait-and-see” approach. Old habits are hard to break, so parents can play a vital role by not allowing medical providers to do this. It is appropriate to just treat the pain and wait three days or so, unless your child has special medical needs.
I have long recommended that parents learn how to use a home otoscope so they can examine their child’s ears at home. A simple investment can save hundreds of dollars in unnecessary medical costs and unnecessary antibiotics, and help prevent those misdiagnoses. I feel that medical care – ANY medical care – should be highly participatory. Your medical provider should be regarded as a partner in your care, not necessarily the leader.