5-year-old with Ear Pain

A 5-year-old presented to the Pediatric emergency department (ED) with complaints of ear pain and drainage. His mother reported the child had been well earlier in the day with no fevers, cough, congestion, or other signs of illness. As they were getting ready to go to swim class, the child told his mother he could not go because “his ear was bleeding.”  Her older son was recently treated for swimmer’s ear, so the mom placed a few drops of his medicine in the ear canal. This did not seem to help, so she brought him into the ED for evaluation.  In the ED, the child was afebrile and well-appearing. He had no tenderness or complaint of pain with manipulation of the external ear. The WiscMed Wispr digital otoscope exam is shown. 

What is the most likely etiology for this child’s complaints?

A. Injury to the external auditory canal
B. Otitis externa (OE)
C. Acute otitis media (AOM)
D. Atopic dermatitis of the external auditory canal

The child has a small blood clot with adjacent bleeding on the roof of his external auditory canal (EAC). In the video below, one can also visualize a few drops of nonclotted blood inferiorly at the entry to the canal.  The EAC does not appear inflamed, nor is there exudative drainage consistent with otitis externa, or “swimmer’s ear”.  The tympanic membrane (TM) appears normal without bulging; therefore, he should not be diagnosed with an acute otitis media (AOM).  Atopic dermatitis causes flaking and scaling debris in the EAC. Occasionally, this can be difficult to distinguish from OE; however, atopic dermatitis is typically pruritic and does not elicit tenderness with external ear manipulation as seen in swimmer’s ear.

Upon further questioning of the child, he admitted to sticking a Q-tip “really deep” into his ear earlier that morning. Q-tip injuries are a common cause of EAC trauma as well as perforations to the TM. Fortunately, in this case, the TM appears uninjured. While painful, most small injuries should heal with minimal intervention, such as the gentle placement of a cotton ball in the canal. If large, briskly bleeding, or involving the TM, then antibiotic drops should be considered with appropriate follow-up with otolaryngology (ENT).