Physicians caring for children frequently see patients who have complaints about the ear, including pain, itching, drainage, and decreased hearing. Often, the initial concern is focused on middle ear abnormalities, but external auditory canal (EAC) abnormalities may cause complaints that are similar to those caused by middle ear pathology. Common diseases of the EAC include otitis externa (affecting up to 10% of the population), impacted cerumen, trauma, and foreign bodies in the ear.

There are many variations in cerumen, and canal size and shape. Flaky, dry cerumen may be found in East Asian patients. In some cases, as in Down syndrome, the canals may be narrowed, making it difficult for the examiner to evaluate the tympanic membrane on routine otoscopy.

• School-aged children may be exceptionally precise in their description of pain. Therefore, it is important to ask them to describe what they are feeling. Often, when parents report pain, the child instead reports ringing or fullness. For example, one child with water in his ear reported, “It sounds like I am under water.”

• The use of cotton swabs or other objects to clean the ear may result in trauma to the EAC and tympanic membrane, and retained pieces of cotton may cause irritation and/or subsequent inflammation.

• The placement of a foreign body in the ear may lead to trauma and most often presents with pain. If the foreign body is not promptly removed, the EAC may become infected.

• Tinnitus and bleeding, in addition to pain, may be symptoms that occur from trauma to the external ear canal.

• Decreased hearing often occurs with cerumen impaction, fluid in the external canal, or otitis externa, but it may also be seen in trauma, particularly when perforation of the tympanic membrane exists.

• Drainage from the EAC may occur in acute otitis media with perforation, otitis externa, and external fluid in the canal (residual from swimming or bathing).

• The drainage seen with acute otitis media with perforation is often described as brownish and sticky, but at other times may be whitish and creamy.

• Pseudomonal and fungal infections should be considered in children with chronic symptoms of otitis externa.

• History of frequent swimming or submersion of ears while in the bathtub is suggestive of otitis externa (also known as swimmer’s ear). Water from the pool or tub is believed to cause alterations in the normal flora of the EAC.

• Patients with eczema, seborrhea, or psoriasis may have the involvement of the epidermis of the EAC and may complain of pruritus.

• The use of medication or topical substances to the ear may result in an eczematous dermatitis.

• Earrings, particularly those made of alloy metals, may cause inflammation at the earring site and an eczematous dermatitis of the surrounding tissues.

• Pain preceding development of a vesicular rash suggests varicella zoster virus infection, which when associated with an acute facial neuropathy is known as Ramsay Hunt syndrome.

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