OTALGIA CAUSES

&MANAGEMENT
introduction
 Otalgia is defined as ear pain. Two separate
and distinct types of otalgia exist. Pain that
originates within the ear is primary otalgia;
pain that originates outside the ear is referred
otalgia
 Typical sources of primary otalgia are external
otitis, otitis media, mastoiditis, and auricular
infections. Most physicians are well trained in
the diagnosis of these conditions. When an
ear is draining and accompanied by tympanic
membrane perforation, simply looking in the
ear and noting the pathology can make the
diagnosis. When the tympanic membrane
appears normal, however, the diagnosis
becomes more difficult.
Neurophysiology of pain

 Pain may be nociceptive or neuropathic.

 Peripheral nocireceptors respond to noxious
stimuli such as phycical trauma,thermal or
chemical injury or inflammation.
 Neuropathic pain results from core damage to
the peripheral or cns systems or from an
abnormality in pain processing system
 Most otalgia is mediated by via unmyelinated
pain fibres which characteristically cause a
dull ache .
Pathophysiology
 The sensory
innervation of the ear
is served by the
auriculotemporal
branch of the fifth
cranial nerve (CN V),
the first and second
cervical nerves, the
Jacobson branch of
the glossopharyngeal
nerve, the Arnold
branch of the vagus
nerve, and the
Ramsey Hunt branch
of the facial nerve.
 A central common pathway for otalgia ,whether
primary or reffered , is probabaly the spinal
tract of the trigeminal nerve
 Fibres from cranial nerve V,VII,IX,X and
cervical nerves c1,c2 converge here and all
play some role in sensory supply of the ear
and temporal bone.
Otalgia causes
 Otologic causes Non otologic causes
 External ear Referred pain
 Middle ear  Throat
 inner ear  Teeth
 Nose &
nasopharynx
 Neuralgia
 tumors
Etiology of Primary Otalgia
Pinna
 Laceration & bite
 Hematoma
 Otitis externa
 Perichondritis (cortilage)
 Infected pre-auricular
sinus
 Frostbite( extreem cold)
sunburn
 Neoplasm
External auditory canal
 Impacted wax
 Foreign body
 Otitis externa
 Herpes zoster
 Exostoses ( benign
growth of new bone)
 Neoplasm( abnormal
growth of tissue)
External ear
 External auditory
canal
 Block ear
 Hearing loss
 Pain with impaction
 Associated infection
 Treatment by removal
syringing
suction
curettage
External ear
 Foreign body in the
ear
External ear
 Otitis externa
-severe pain
-tenderness
-postaural swelling
-Sweling in canal
-discharge
External ear
es
 Intense itching,
 Discomfort
 pain
External ear
 Malignant otitis externa
 Diabetes mellitus
 Infiltrating infection
 Invades bone
 Affects cranial nerves V,VII,IX,X
 Sometimes life threatening
 Treatment: high dose antibiotics,
surgery to debride dead bone
hyperbaric oxygen.
Middle ear causes

 Acute otitis media

 secretory otitis media
 Traumatic perforation
 Hemotympanum
 Otitic barotrauma
 Neoplasm
Middle ear
 Acute otitis media
Bacterial or viral infection of middle ear
Usually accompanying a URTI
OTOSCOPY:bulging ,congested TM,loss of
land marks,impaired mobility,acute otalgia
Middle ear
 Chronic otitis media
Middle ear
 Complications of otitis media
 Mastoiditis
 Petrositisis
 Labyrinthitis
 Facial paralysis
 Bezold’s abscess
 Intracranial spread -meningitis
-brain abscess
-subdural empyema
-lateral sinus thrombosis
Middle ear
 Otitis media with effusion
• Pain ,block/fullness ear
• Deafness
• Autophony (unusual loud
hearing of persons own
vice)
Middle ear
 Traumatic perforation of tympanic membrane
• Pain ,block,hearing loss
• h/o blast injury or being hit on ear
• Often seen in antero-inferior TM
• Do not put eardrops
Inner ear
 Acoustic trauma
 Meniere’sdisease

(vertigo spinning)
 Vestibular schwannoma (non cancerous
tumour)
Meniere’s disease
 Ménière disease is associated with a
sensation of aural fullness, in addition
to vertigo,tinnitus, and fluctuating hearing loss.
 The perception of aural fullness may be
described as ear pain in conditions associated
with endolymphatic hydrops
Vestibular schwannoma
 Otalgia due to VS has been variously attributed to
involvement of the nervus intermedius or dural
stretching.The former suggestion is favoured by the
mastoid location of pain and by the remarkably high
prevalence (95· percent reported) of hypoaesthesia of
the posterior wall of the external auditory canal (the
basis of Hitselberger's sign) due to involvement of
sensory fibres of the facial nerve. Innervation of the
possibly stretched dura of the posterior fossa is via
the meningeal (recurrent) branch of CN X, although
this is questioned, meningeal branches of CN XII, but
primarily from the first three cervical nerves ascending
through the foramen magnum. The little publicized
association of otalgia with VS further reinforces the
case for imaging.
Causes of reffered otalgia
A. Via trigeminal nerve
 Teeth: infection, impacted 3rd molar, malocclusion
 Oral cavity: infection, ulcer, malignancy, Ludwig’s
angina, sialadenitis, salivary calculus
 Temporo-mandibular joint: arthritis, dysfunction
 Nose :sinusitis, neoplasm
 Nasopharynx: infection, post- adenoidectomy,
adenoiditis, tumor
 Trigeminal neuralgia
B. Via glossopharyngeal nerve
 Tonsil: tonsillitis, peritonsillar abscess, post-
tonsillectomy, neoplasm
 Oropharynx: infection, ulcer, retropharyngeal +
parapharyngeal abscess, trauma, neoplasm
 Glossopharyngeal neuralgia
C. Via facial nerve:

Herpes zoster oticus, vestibular schwannoma

D. Via vagus nerve: Larynx + hypopharynx:

neoplasm, infection,
tuberculosis, trauma,
foreign body

E. Via second & third cervical nerves:

Herpes zoster, cervical spondylosis & arthritis
Non otologic causes
 Neuralgias
• Trigeminal N
• Glossopharyngeal N
• Sphenopalatine N
Non otologic causes
 Others
• Dental conditions
• stylalgia
• Cervical spine disorders
How to arrive at a diagnosis?
History
Features suggestive of primary otalgia (due
to ear disease):
• hearing loss;
• aural discharge;
• vertigo;
• unilateral rather than bilateral symptoms
Onset
-Sudden : furunclosis ,acute otitis media ,otiticbarotrauma
-Gradual :otitis externa secondary to CSOM ,malignancy,
malignant otitis externa
Duration
-Short duration:asom ,perichondritis of eatpinna
-Long duration:malignancy
Nature of pain
-Dull:exematous otitis externa,secretory otitis media,impacted
wax
-Sharp:furunculosis ,otitic barotrauma
-Throbbing pain:ASOM
 Relieving facors :pain relieved with discharge
from the ear-acute suppurative otitis
media(ASOM)
 Aggravating factors:

-Pain increasing on swallowing –ASOM

-Pain increasing on yawning and chewing-
furunculosis arising from anterior canal wall.
 Symptoms suggesting referred otalgia:
 pain on chewing/trismus;
 dysphagia/odynophagia;
 hoarseness;
 risk factors (smoking/alcohol history);
 neck swelling/goitre;
 cervical musculoskeletal symptoms;
 dental history/recent treatment
 Features of neuropathic pain:
 radiation, e.g. to throat;
 typical time course/duration;
 quality of pain;
 trigger zone/precipitating factors, e.g
swallowing
 Examinatiom
Primary otalgia:
• inspection of ear and otoscopy;
• palpation for tenderness;
• aural examination with teleotoscope and microscope;
• tympanometry.
Referred otalgia:
• cranial nerve (CN) examination, especially V, VII, IX and X;
• palpation of cervical lymphatic chain;
• assessment of cervical spine mobility/tenderness;
• exclude trismus;
• dental inspection for caries, absent dentitionand malocclusion;
• direct and fibreoptic examination oropharynx andlaryngopharynx;
• palpation of oropharynx to seek induration trigger zone or styloid bone
WORKUP
 Frequently, the workup suggests that otalgia may be a
problem of dental origin.
 A complete blood cell count may indicate an occult
infection.
 Thyroid function and erythrocyte sedimentation rate
(ESR) studies may reveal thyroiditis and temporal
arteritis. Chest radiography to seek bronchogenic
pathology may be necessary.
 The perception of aural fullness may be described as
ear pain and is observed in conditions associated with
endolymphatic hydrops and eustachian tube
dysfunction.
 Ménière disease can be diagnosed by history,
audiometrics, and a battery of laboratory tests.
Preliminary testing (appropriate to
symptoms) should include the following:
 Barium swallow

 ECG

 C-spine radiography

 Chest radiography

 Panorex imaging
IMAGING STUDIES
 Dental radiography
 CT scanning: Obtain CT scans of the head or
temporal bone, sinuses, and/or neck when no
obvious source of the pain can be found. The
scan usually includes a brief survey of the sinuses
and intracranial contents. CT scanning can reveal
significant information about the
temporomandibular joint or can be used to
diagnose intratemporal lesions.
 MRI: If indicated by clinical or audiometric
suspicion, an MRI may be necessary to define a
cerebellopontine angle or other intracranial tumor.
 PET scanning: As this emerging modality for
identifying malignant tumors becomes more
readily available, it may be possible to diagnose
cancer earlier. PET images fused with CT or MRI
adds tremendously detailed information about the
location of head and neck neoplasms.
Symptoms

•Drainage from the ear

•Ear pain

•Painful movement of the any part of the pinna

•Redness

•Hearing loss

•Itching of the ear

fever
management

The gaol of treatment is to cure the PAIN

1) Ear irrigation ( clean the external auditory

canal, remove the debris)

2) Analgesics ( NSAID AND OPIODS)

3) Use antibiotics such as amoxicillin , augment

in
4) Application of heat by warm compress ,eating
soft diet ,providing quite environment.
PREVENTION

• Decrease exposure to water

• Do not insert instruments

• Try to keep ear free of wax