What are the differential diagnoses for otalgia in a 5‑year‑old child?

Differential Diagnoses for Ear Pain in a 5-Year-Old Child

The most common causes of ear pain in a 5-year-old are acute otitis media (middle ear infection) and acute otitis externa (outer ear canal infection), with otitis media with effusion and referred pain from pharyngitis or temporomandibular joint syndrome as important additional considerations. 1, 2

Primary Otalgia (Pain Originating from the Ear)

Acute Otitis Media (AOM)

• Most common ear-related diagnosis causing otalgia in children, characterized by rapid onset of symptoms including ear pain, fever (though absent in 31% of cases), and irritability 3, 1, 2
• Diagnostic criteria require three elements: (1) acute onset of symptoms within 24-48 hours, (2) middle ear effusion (bulging tympanic membrane, cloudy appearance with impaired mobility, or air-fluid level), and (3) signs of middle ear inflammation (distinct erythema with tympanic membrane fullness) 1, 2
• Otoscopic findings: Bulging tympanic membrane has 96% specificity; cloudy tympanic membrane with impaired mobility shows 95% sensitivity and 85% specificity for middle ear effusion 1, 2
• Common bacterial pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 4
• Peak incidence: Highest rates occur in children 1-4 years of age (61 episodes per 100 children per year), making this highly relevant for a 5-year-old 2, 5

Acute Otitis Externa (AOE)

• Second most common primary cause, presenting with intense ear pain, tenderness with tragal pressure (hallmark finding), ear discharge, and canal edema 3, 1
• Diagnostic definition: Onset of symptoms within 48 hours, occurring within the past 3 weeks, together with ear canal inflammation (tenderness, edema, erythema, or otorrhea) 1
• Causative organisms: Pseudomonas aeruginosa (20-60% of cases) and Staphylococcus aureus (10-70% of cases) account for approximately 98% of bacterial AOE 1, 6
• Classic presentation: Pain disproportionate to visual appearance, worsened by movement of tragus or pinna 1, 6

Otitis Media with Effusion (OME)

• Fluid in middle ear without acute infection, typically presenting with hearing loss (conductive), absence of fever, and absence of acute ear pain 3, 2
• May cause mild ear discomfort despite lack of acute infection, with tympanic membrane appearing retracted or showing fluid level without acute inflammatory signs 1, 2
• Prevalence: Approximately 1 in 8 children aged 5-6 years have fluid in one or both ears when screened 3
• Associated symptoms: Language delays, behavioral issues, academic difficulties, or balance problems when hearing loss persists 2

Furunculosis (Localized Otitis Externa)

• Infected hair follicle on the outer third of the ear canal, presenting with otalgia, otorrhea, localized tenderness, focal swelling, and pustular lesions 3
• Causative agent: Staphylococcus aureus most common 3

Viral Infections

• Herpes zoster oticus (Ramsay Hunt syndrome): Vesicles on external ear canal and posterior auricle, severe otalgia, facial paralysis, loss of taste, and decreased lacrimation 3
• Requires prompt systemic antiviral therapy and systemic steroids 3

Secondary Otalgia (Referred Pain from Outside the Ear)

Temporomandibular Joint (TMJ) Syndrome

• Most common cause of referred ear pain, with pain radiating to periauricular area, temple, or neck 3, 1
• History clues: Gum chewing, bruxism, or recent dental procedure with subsequent malocclusion 3
• Examination findings: Tenderness over affected TMJ with possible crepitus; ear examination shows normal findings 3, 7

Pharyngitis and Tonsillitis

• Common in this age group, causing referred otalgia through shared cranial nerve innervation 3, 8
• Associated symptoms: Throat pain, difficulty swallowing, nasal obstruction 8
• Key finding: Normal tympanic membranes on otoscopic examination with pharyngeal erythema 2

Dental Pathology

• Dental caries or impacted molars can present with ear pain 3, 7
• Examination: Normal ear findings with dental tenderness or visible caries 7

Peritonsillar or Retropharyngeal Abscess

• Serious infections that can present with severe otalgia, fever, and difficulty swallowing 3
• Requires urgent evaluation and treatment 3

Critical Diagnostic Algorithm

Step 1: Perform Pneumatic Otoscopy on Both Ears

• Assess four key features: (1) Position (bulging, retracted, normal), (2) Color (distinct erythema vs. mild redness), (3) Translucency (cloudy vs. clear), (4) Mobility (impaired vs. normal) 3, 1, 2
• If bulging + distinct erythema + impaired mobility + acute onset: Diagnose AOM 1, 2
• If effusion without inflammation: Diagnose OME 2
• If normal tympanic membranes: Consider secondary otalgia 2, 7

Step 2: Assess External Ear Canal

• Check for tragal tenderness: If present with canal edema/erythema, diagnose AOE 1, 6
• Look for vesicles: If present with severe pain, consider herpes zoster oticus 3
• Examine for localized swelling/pustules: If present, consider furunculosis 3

Step 3: If Ear Examination is Normal, Evaluate for Referred Pain

• Palpate TMJ: Tenderness with crepitus suggests TMJ syndrome 3, 7
• Examine oropharynx: Pharyngeal erythema, tonsillar enlargement, or asymmetry suggests pharyngitis or abscess 3, 8
• Dental examination: Check for caries, tenderness, or gingival swelling 3, 7

Common Clinical Pitfalls to Avoid

• Do not rely on symptoms alone: History is poorly predictive for AOM in young children; otoscopic examination is mandatory 2, 8
• Do not assume fever is required: Fever is absent in approximately 31% of confirmed AOM cases 2
• Do not mistake mild erythema from crying for AOM: Only distinct erythema together with bulging or effusion confirms AOM 2
• Do not prescribe systemic antibiotics for uncomplicated AOE: Topical antimicrobials are first-line therapy 3, 1
• Do not miss malignancy in high-risk patients: Though rare in 5-year-olds, persistent otalgia with normal ear examination warrants thorough head and neck evaluation 3, 1
• Provide immediate pain management: Analgesics (acetaminophen or ibuprofen) provide relief within 24 hours for AOM, whereas antibiotics do not provide symptomatic relief in the first 24 hours 1, 5

Management Priorities Based on Diagnosis

For AOM

• Immediate analgesia is essential: Acetaminophen or NSAIDs should be provided promptly 1, 5
• Antibiotic decision: Based on age, severity, and laterality; children under 2 years typically require antibiotics regardless of severity 1, 2

For AOE

• Topical antimicrobials effective against Pseudomonas and Staphylococcus: First-line therapy 1
• Pain relief expected within 48-72 hours with appropriate topical therapy 1
• Avoid systemic antibiotics unless infection has spread beyond ear canal 3, 1

For OME

• Observation is appropriate for most cases, as 70% resolve spontaneously within 3 months 3
• Address hearing concerns if effusion persists beyond 3 months 3, 2