Ear infection is one of the leading reasons why children visit their healthcare providers. If you’re a med-surg or general-practice nurse, you may rarely care for pediatric patients and thus may not be familiar with the nuances of pediatric ear assessment. Studies have found that in about 50% of cases, the pediatric ear exam yields an incorrect diagnosis. This statistic indicates the need for clinicians to improve their ear assessment skills. This article reviews ear anatomy and physiology and describes a brief but thorough method of performing the normal pediatric ear assessment.
About the ear
A complex organ, the ear is both internal and external. (See Ear anatomy by clicking on the PDF icon above.) Besides enabling hearing, it maintains the body’s equilibrium (balance) and produces speech. Ear dysfunctions may affect surrounding tissue, causing permanent systemic problems. In a child, ear abnormalities can impair hearing, possibly leading to difficulty communicating, learning, and socializing.
Ear development begins around the third week of gestation and is complete by about the third month of the embryonic life cycle. The ear and the kidney develop simultaneously, so an abnormality of
the ear should alert healthcare providers to possible renal problems, and vice versa.
Gathering the patient’s history
When taking the history, ask the parent if the child has had previous ear problems or syndromes associated with the cranium or the facial area. Inquire about pain; if the child is in pain, ask questions about its onset, location, duration, quality, and alleviating or aggravating factors. Find out if the child has associated symptoms, including fever, nasal congestion, vomiting, diarrhea, or upper respiratory infection. Also inquire about ear itching or discharge, hearing loss, ringing of the ears (tinnitus), dizziness, and balance problems.
Question the parent about risk factors for ear problems, such as smoking by others in the home, attendance at a day-care facility, bottle use and bottle propping, noise exposure, and swimming. Obtain a family history, focusing on a history of diabetes and kidney malformation. (Diabetes can slow the healing process and offer a source of nutrition for the bacteria often associated with otitis.)
Ask if any family members (especially siblings) experience frequent otitis or other ear ailments; research shows a genetic link to all otitis forms. Find out if anyone in the household has had a recent upper respiratory infection. The three main bacteria associated with ear infection are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. (However, keep in mind that visual inspection alone can’t pinpoint the cause of otitis as viral or bacterial.)
Physical examination
If age-appropriate, begin the physical examination by letting the child handle the otoscope; this promotes cooperation by decreasing the child’s anxiety and fear of pain. However, reserve the actual otoscopic exam for the end of the assessment.
Instead, start with inspection. Check for symmetry of the child’s head, neck, and ears. Assess for skin abnormalities and ear discharge. Discharge from Pseudomonas bacteria is malodorous and appears cheesy.
Next, inspect for lesions on or around the ears, and assess ear position. The upper portion of the pinna should align directly with the inner and outer canthus of the eye; ears that fall below this line are deemed low set. Ears that are low set or tilted more than 10 degrees may signify chromosomal abnormalities or renal disorders.
Then palpate and rotate the external ear, checking for masses, tenderness, and inflammation. Apply direct pressure to the mastoid process and tragus. Examine the size, shape, and color of the auricles; they should be similar bilaterally and their color should resemble that of the face. Preauricular skin tags and sinuses are normal findings. Inspect any ear piercings for inflammation and trauma.
Otoscopic exam
Finally, conduct the otoscopic exam. To broaden your visual field, use the largest speculum that fits comfortably into the child’s auditory canal. Start the exam at the external auditory canal. Manipulate the tragus to a forward position to straighten the canal; this causes less pain than pulling the pinna. Other techniques for examining the auditory canal and tympanic membrane (TM) include pulling the ear back and down in a young child and pulling the ear up and back in an older child. Determine patency, and check for discharge, odor, and foreign objects in the canal.
Moving on to internal ear examination, inspect the TM for shape, color, mobility, and intactness. Normally, the TM is concave and intact, with a silvery-grey translucence. Check for visual landmarks, including the ossicles and the light reflex.
If you have access to a pneumatic attachment, are experienced in using it, and understand its dynamics, use it to check for TM mobility. An immobile TM is a leading sign of otitis media. (See Otitis media: A case in point by clicking on the PDF icon above.) TM immobility or compromise indicates fluid, mucus, or pressure within the middle ear that is impeding TM movement. Keep in mind, though, that a red or pink TM may result from crying, irritation, or fever—not necessarily otitis. Pain associated with abnormal exam findings aids recognition of acute otitis media.
Common pediatric ear diagnoses
Besides otitis media, other common ear diagnoses include otitis externa, characterized by itching, irritation, or both that progresses to severe pain, pressure, and fullness of the ear, hearing loss (rare), otorrhea, or systemic complaints. Additional findings include severe pain with pinna or tragus movement; auditory canal erythema with debris (purulent discharge); poor visualization of the TM; possible regional lymphadenopathy; red, crusty, or pustular lesions; otalgia (earache); and eczema of the pinna. Generally, all forms of otitis are treated empirically.
Another common diagnosis is a foreign body in the ear, typically from the child placing an object inside the ear. A foreign body may cause otorrhea and complaints of buzzing, fullness, and pain. The foreign body should be visible with the naked eye or the otoscope.
Cholesteatoma is marked by an asymptomatic white accumulation of epidermal tissue that forms over the TM (for example, aural polyps). Findings may include vertigo, hearing loss, and a history of chronic otitis media with malodorous purulent otorrhea.
Enhanced skills set, healthier kids
With ear infections so common among children, all nurses should know how to perform pediatric ear assessment. Becoming proficient in this examination enables you to detect ear problems early and allow prompt treatment. Your assessment skills not only will promote your own practice and that of your colleagues but will help improve patient outcomes.
Selected references
Bradley R. Ear assessment for children and adolescents. Journal for Nurse Practitioners. 2007;3(2):122-123.
Casselbrant M, Mandel E, Rockette H, et al. The genetic component of middle ear disease in the first 5 years of life. Arch Otolaryngol Head Neck Surg. 2004;130:273-278.
Duderstadt K. Pediatric Physical Examination: An Illustrated Handbook. St. Louis, MO: Mosby; 2006.
Hall-Stoodley L, Hu F, Gieseke A, et al. Direct detection of bacterial biofilms on the middle-ear mucosa of children with chronic otitis media. JAMA. 2006: 296(2):202-211.
Patricia Vanderpool is a nurse practitioner (NP) primary-care provider for American Health Network in Edinburgh, Indiana; and owner of NP Housecalls, a private NP house-call practice in New Castle, Indiana.
