Earache (otalgia) and referred pain

Background

• Otalgia (ear pain) is common.  The source of pain, however, is not always the ear.  It is estimated that around a third of ear pain is secondary.  The most common cause of secondary ear pain is dental (38% of these patients).
  • Usually, if the ear is the source, examination of the ear will be abnormal.
  • If the ear is not the source and examination is normal, then it can often be difficult to identify the source as innervation of the ear comes from multiple nerves supplying a number of other structures

History

• Pain
  • Duration, Progression (including timing e.g. constant/intermittent) and Location of pain (ask the patient to point to it if possible); and radiation
  • Nature of pain
  • Aggravating factors (e.g. chewing, coughing, head movements, palpation etc)
  • Relieving factors (e.g. popping ears)
  • Any initial incident/trauma e.g cotton bud use, head trauma etc
• Associated symptoms
  • Redness
  • Ds- Deafness; Dizziness; Din-din; Discharge (+discomfort)
  • Systemic- fever, malaise, cough, weight loss etc
• PMHx
  • Otological history
  • General- including diabetes
    • Recent URTIs
  • Drugs
• Family Hx
• Social History
  • Particularly smoking/alcohol (in >50yo, this may be important risk factor for cancer) 
  • Ask about the use of cotton swabs
  • Ask about recent air travel, diving or swimming

Examination of the ear

see here

• Also examine the throat, oral cavity, TMJ and neck

Differential Diagnosis

• Ear pain: Abnormal Examination
  • Otitis Media
    • Recent URTI; red/cloudy tympanic membrane
  • Otitis Externa
    • Recent swimming; white discharge; Pain on palpation of the ear; swollen/red external canal
  • Foreign Body
  • Cholesteatoma
  • Barotrauma
    • Pain may be acute onset with change of altitude; TM haemorrhage/ serous/haemorrhagic middle ear fluid
  • Rarer causes include
    • Malignant (necrotising) Otitis Externa
    • Ramsay Hunt Syndrome (Herpes Zoster)
    • Auricular Cellulitis/Chondritis/perichondritis (and relapsing polychondritis)
    • Trauma
    • Mastoiditis
    • Tumours
    • Infected cysts
    • Wegener’s Granulomatosis
    • Viral myringitis
• Ear pain: normal examination
  • TMJ syndrome
    • Pain/crepitus with talking chewing, tender TMJ, restricted ROM
  • Dental causes
  • Pharygitis/Tonsillitis
  • Cervical Spine Arthritis
  • Other rarer causes:
    • Tumours
    • Neuralgias (e.g. trigeminal)
    • Bell’s Palsy
    • Temporal (Giant cell) Arteritis
    • Oral Ulcers

Referred Pain

• Theauriculo-temporal branchof trigeminal nerve (CN V)
  • Carious teeth, impacted molars; dental disease etc; TMJD; tongue pain
• The tympanic branch of the glossopharangeal nerve (CN IX)
  • Tonsillectomy; tonsillitis/quinsy; carcinoma of the base of the tongue/tonsil; glosso-pharyngeal neuralgia
  • Pharyngitis
• The sensory branch of the facial nerve (CN VII)
  • Herpes zoster
• The auricular branch of the vagus nerve (CN X)
  • Carcinoma of the larynx, piriform fossa or post cricoid cancer
• The great auricular nerve (C2-3) or lesser occipital nerve (C2)
  • Cervical spondylosis/stenosis