Can Hand, Foot, and Mouth Disease (HFMD) cause ear pain in children?

Can HFMD Cause Ear Pain in Children?

Hand, Foot, and Mouth Disease (HFMD) does not typically cause ear pain as a primary symptom, but ear pain can occur indirectly through concurrent upper respiratory tract infections or secondary complications such as otitis media.

Primary Clinical Features of HFMD

HFMD presents with a characteristic constellation of symptoms that do not include ear pain:

• Typical manifestations include low-grade fever, malaise, myalgia, and a maculovesicular eruption on hands, feet, and oral mucosa 1, 2
• Oral lesions consist of vesicles and ulcerative lesions in the oral mucosa, which can be painful but are distinct from ear pain 1, 3
• Constitutional symptoms include fever (which can reach 39.4°C), vomiting, and headache 1, 3
• The disease is self-limiting in most cases, resolving spontaneously within a few days without complications 1, 2

Potential Mechanisms for Ear-Related Symptoms

While ear pain is not a hallmark of HFMD, several scenarios could explain its occurrence:

Secondary Otitis Media Development

• Viral upper respiratory infections always precede acute otitis media (AOM), causing inflammation of the nasopharyngeal and eustachian tube epithelium 4
• HFMD is caused by enteroviruses (most commonly Coxsackievirus A6, A16, and Enterovirus 71), which can trigger eustachian tube dysfunction similar to other viral URIs 1, 2, 5
• Eustachian tube dysfunction creates negative middle ear pressure, allowing secretions containing viruses and bacteria to enter the middle ear 4
• If AOM develops concurrently, ear pain would be the most consistent symptom, occurring in 50-60% of children with AOM 6, 7

Referred Pain from Oral Lesions

• Oral vesicles and ulcerative lesions in HFMD can cause significant discomfort 1, 3
• Young preverbal children may manifest pain through ear manipulation (tugging, rubbing, or holding), which could be misinterpreted as ear pain when the source is actually oral lesions 6, 7

Rare Neurological Complications

• Severe neurological complications can occur in HFMD, including meningoencephalitis and brainstem encephalitis, which account for 70% of neurological complications 3
• One case report documented sudden sensorineural hearing loss following HFMD in an adult, with ear fullness and tinnitus as accompanying symptoms 8
• These complications are rare but can present with headache, convulsions, and other neurological symptoms that might be confused with ear-related issues 3

Critical Diagnostic Considerations

Distinguishing HFMD from Primary Ear Disease

• Pneumatic otoscopy is essential to diagnose otitis media, showing minimal or sluggish tympanic membrane movement with middle ear effusion 6, 7, 9
• AOM requires three elements: acute onset, middle ear effusion, and signs of middle ear inflammation (bulging tympanic membrane, distinct erythema) 7
• HFMD diagnosis is clinical, based on the characteristic distribution of vesicles on hands, feet, and oral mucosa 1, 2

Age-Related Patterns

• HFMD commonly affects children under 5 years of age, with 97% of neurological complications occurring in children under 15 years 2, 3
• Peak AOM incidence occurs in the first year of life (45.3 episodes per 100 children per year), with highest rates in children 1-4 years (61 episodes per 100 children per year) 7, 4
• The overlapping age groups mean concurrent HFMD and otitis media are possible in young children

Clinical Pitfalls to Avoid

• Do not assume ear tugging in young children with HFMD indicates otitis media without proper otoscopic examination, as this behavior may reflect oral pain or general discomfort 6, 7
• Fever alone does not indicate ear infection; diagnostic criteria for AOM focus on acute onset, middle ear effusion, and signs of middle ear inflammation 7
• Most HFMD cases resolve spontaneously without complications, so aggressive investigation for ear disease is not warranted unless specific otologic symptoms or examination findings are present 1, 2
• Be vigilant for severe complications in children with HFMD who develop persistent fever, vomiting, myoclonic jerks, or altered consciousness, as these may indicate neurological involvement rather than simple otitis media 3

Management Approach

• If ear pain is reported in a child with HFMD, perform pneumatic otoscopy to assess for concurrent AOM 6, 7
• If AOM is confirmed, manage according to standard guidelines with consideration for antibiotic therapy in children under 2 years 7
• If otoscopy is normal, the discomfort likely stems from oral lesions or general malaise associated with HFMD 1, 2
• Provide supportive care including adequate analgesia (acetaminophen or ibuprofen) for pain management, whether from oral lesions or concurrent ear infection 6, 1