What is the management for a child with otalgia (earache) secondary to coughing?

Management of Earache Due to Coughing in Children

For children with earache secondary to coughing, examination of the ear canal should be performed to identify and remove any foreign material or hair resting on the eardrum, as this may be triggering Arnold's ear-cough reflex. 1

Understanding the Mechanism

Earache secondary to coughing in children is often related to the Arnold's ear-cough reflex, which occurs in approximately 2.3% to 4.2% of people. This reflex is mediated by the auricular branch of the Vagus nerve and can be triggered by stimulation of the ear canal.

Key points about Arnold's ear-cough reflex:

• Present bilaterally in 0.3%-2% of people
• Can be elicited by palpation of the postero-inferior or antero-inferior wall of the external ear canal
• May be triggered by foreign material or structures (like a hair) resting on the eardrum

Diagnostic Approach

1. Examine the ears thoroughly:

   • Use pneumatic otoscopy to visualize the tympanic membrane
   • Look for foreign material in the ear canal
   • Clear the external auditory canal of cerumen if needed
   • Assess for signs of acute otitis media (bulging tympanic membrane, limited mobility, distinct erythema)

2. Differentiate from other causes:

   • Acute otitis media (AOM) requires:
     • History of acute onset of signs and symptoms
     • Presence of middle-ear effusion
     • Signs of middle ear inflammation 1
   • Referred pain from other conditions (temporomandibular joint issues, dental infections)

Management Algorithm

Step 1: Address the Ear Canal

• Remove any foreign material or hair resting on the eardrum 1
• Clean the ear canal of excessive cerumen if present

Step 2: Pain Management

• If pain is present, provide appropriate analgesia:
  • Paracetamol (acetaminophen) or ibuprofen are effective for ear pain relief 2
  • Low quality evidence indicates both are more effective than placebo for relieving ear pain 2
  • Ibuprofen may have advantages including less frequent dosing (every 6-8 hours vs every 4 hours for paracetamol) and longer duration of action 3

Step 3: Address the Underlying Cough

• If cough is persistent (>4 weeks), follow a systematic approach using pediatric-specific cough management protocols 1
• For cough associated with respiratory infections:
  • Honey may offer relief for cough symptoms (10ml mixed with milk or warm water before bedtime) for children over 1 year of age 4
  • Avoid cough suppressants in children as they are not recommended 4

Step 4: Monitor for Complications

• If earache persists despite addressing the cough and providing analgesia, re-evaluate for:
  • Development of acute otitis media
  • Other causes of secondary otalgia

Special Considerations

When to Consider Antibiotics

• Only if acute otitis media is diagnosed with:
  • Bulging of the tympanic membrane
  • Limited or absent mobility of the tympanic membrane
  • Distinct erythema of the tympanic membrane 1

When to Refer

• Persistent earache despite appropriate management
• Abnormal findings on ear examination suggesting pathology beyond the Arnold's reflex
• Signs of complications (hearing loss, vertigo, facial weakness)

Common Pitfalls to Avoid

1. Misdiagnosing otitis media with effusion (OME) as acute otitis media (AOM), leading to unnecessary antibiotic use 1

2. Failing to examine the ear canal thoroughly for foreign material that could be triggering the reflex

3. Not addressing the underlying cough, which is the primary trigger for the earache

4. Overlooking the possibility of referred pain from other structures innervated by the same cranial nerves

By following this systematic approach, most cases of earache secondary to coughing in children can be effectively managed, improving both the cough symptoms and the associated ear pain.