Otalgia

OTALGIA

Local Causes

1. furuncle (boil), usually as a result of a Staph Aureus infection
2. foreign body in external auditory canal/impacted cerumen
3. infection
   1. otitis externa
   2. acute otitis media and its complications
   3. acute mastoiditis and its complications
4. trauma to tympanic membrane and canal
   1. barotrauma

Referred (10 T’s + 2)

1. CN V and CN X refer to external canal and CN IX to middle ear
   1. eustachian Tube
   2. TMJ (tempromandibular joint) syndrome
   3. Trismus (i.e. pterygoids, quinsy)
   4. Teeth – impacted
   5. Tongue
   6. Tonsillitis, tonsillar cancer, post tonsillectomy
   7. Tic (CN IX) – glossopharyngeal neuralgia
   8. Throat – cancer of larynx, vallecula, pyriform fossa
   9. Trachea – foreign body, tracheitis
   10. Thyroiditis
   11. Geniculate herpes and Ramsey Hunt Syndrome
   12. +/– CN VII palsy

Primary or Secondary – Primary otalgia is pain coming directly from the ear where secondary otalgia is referred pain by cranial nerves from somewhere outside the ear (Trigeminal, facial, glossopharyngeal, vagus, cervical plexus, Require higher index of suspicion, More common in adults)

• Primary causes
  • Infection
  • Trauma
  • Foreign bodies
  • Impacted cerumen
  • Neoplasms of the ear
  • Cancers of temporal bone/EAC are rare – consider otalgia and chronic discharge
  • Malignant otitis externa (skull base osteomyelitis)
    • consider immunosupressed/diabetes with severe pain and history OE.
    • Pseudomonas or fungal.
    • Severe, throbbing, radiates into jaw,
    • Causes cranial nerve palsies . 7> 9 > 10
    • Granulation tissue on floor of ear canal
    • Differential SCC – needs biopsy
  • Herpes zoster oticus – Ramsay Hunt

• Secondary causes
  • Dental – inflammation/infection, particularly posterior teeth
  • TMJ disorders – might be worse with chewing
  • Trigeminal neuralgia
    • Unilateral attacks of pain, commence abruptly, last up to two minutes, excrutiating
    • Can get neuralgia other cranial nerves – follow the distribution
  • Consider cancers of the head and neck – oropharyngeal can refer to ear
    • Other symptoms – dysphagia, odynophagia, sore throat
    • Risks – chronic EtOH, smoking
    • Examine oropharynx, neck, lymph nodes
    • Complete exam needs nasoendoscopy – refer
  • Eagles syndrome – calcification stylohyoid ligament – palpable in tonsillar fossa

• Assess history
  • Otorrhea, hearing loss, vertigo, aural fullness, tinnitus
  • Timeframe – shorter often primary or benign
  • Dental history
  • Oropharyngeal symptoms – tonsil infections, nasal and sinus symptoms
  • Smoking and alcohol
  • Red flags – dysphagia, dysphonia, odynophagia, hemoptysis, weight loss, smoking, hearing loss, eye symptoms, immunosuppressed/diabetes

• Examination
  • General ear and otoscopy
  • If abnormal – assess cranial nerves for complications
  • Pain with insertion otoscope indicated otitis externa
  • Acute mastoiditis – post auricular swelling, erythema and protrusion of auricle, loss of sulcus
  • If ear/otoscopic exams don’t reveal cause – then do a complete head and neck exam with CN examination – oral cavity, oropharynx, teeth, TMJ, soft palate, posterior pharyngeal walls, tonsils, trismus, crepitus of TMJ, neck palpation

• Image if high risk of malignancy
• Referral if persistent or unexplained