OTALGIA

SAMUEL DÁVILA SÁNCHEZ

NATALIA BELMONTE
MARTA CONTRERAS MUÑOZ
 OTALGIA = EAR PAIN

OTOGENIC OTALGIA = OTODYNIA Pain caused by diseases affecting the external, middle or inner
ear

NON-OTOGENIC OTALGIA = OTALGIA Referred pain that arises from pathologies outside the
ear
 CLINICAL CASE 1
Anamnesis
● A 16-year-old female patient.
● No significant pathological history.
● Refers itching and intense pain in the
right ear of 4 days of evolution.
● Right ear pain increases with touching.
● Swimming in the sea and in the pool
the week before. RISK FACTOR!!
● She has manipulated her ears with
cotton swabs. RISK FACTOR!!
● She complains of decreased hearing
in her right ear.
 PHYSICAL EXAMINATION

Inspection. INFLAMED AURICLE WITH TRACES OF SEROPURULENT OTORRHEA

 PHYSICAL EXAMINATION:
OTOSCOPY

● RE: external auditory canal swollen with

decreased caliber and yellowish exudate
● LE: no pathological findings

PALPATION

● RE: positive tragus sign

● Right pre and retroauricular adenopathy
 DIAGNOSIS

Acute external otitis

 TREATMENT
Treatment of inflammation and infection depends on the severity of external otitis. In this case:

● Otorrhea aspirate treatment

● Topical antibiotic: ciprofloxacin of choice, gentamicin, polymyxin
● Analgesics
● These preparations sometimes contain topical corticosteroids

Apply the drugs every 8 hours for 6-7 days.

Follow up in one to two weeks.

 PREVENTION
● Advise patients to avoid fall trauma caused by scratching and self-cleaning with various objects,
such as hairpins or cotton swabs.
● In patients who practice permanent or frequent water sports, the use of earplugs for swimming is
advisable.
 Questions
The cause of hearing loss in this disease is due to:

a) Injury to the organ of Corti.

b) Dislocation of the ossicular chain.

c) Electrolyte imbalance of fluids labyrinthine.

d) Obstacle to the sound conduction of the external auditory canal.

e) Traumatic perforation of the membrane tympanic.

 CLINICAL CASE 2
Anamnesis
● 68-years old patient
● Treated for presenting purulent otorrhea and otalgia in the
left ear of 3 weeks of evolution. The patient does not
respond to treatment.
● Diagnosed with type 2 diabetes 30 years ago with poor
glycemic control
Treated with ciprofloxacin ear
● Jaw pain
drops and systemic steroids
● Peripheral arterial disease without improvement
● Diabetic neuropathy
 PHYSICAL EXAMINATION
OTOSCOPY
RE: normal right ear.
LE: externa, auditory canal with inflammatory signs and
purulent exudate.

In other cases: we can find a

granulation tissue in the external
auditory canal (pathognomonic)
 PHYSICAL EXAMINATION
INSPECTION
● Pain on movement of the temporomandibular joint

COMPLEMENTARY TESTS
● Negative Rinne test on the left ear
● Weber test was lateralized to the left
● The rest of the cranial nerve examination was
normal.
● Nasofibrolaryngoscopy, cavum and pharyngolarynx
without pathological findings.
 COMPLEMENTARY TESTS
General laboratory findings Microbiology studies

● Glucose: 200 mg/dL (70-110 mg/dL) A sample of left otic exudate is taken.
● Urea: 52 mg/dL (7-20 mg/dL) Culture results: growth of P. Aeruginosa
● Creatinine: 1,4 mg/dL (0,6-1,2
mg/dL)
● CRP: 26 mg/L (0-10mg/L)
● HbA1c: 8,7% (4-5,6%)

Computed tomography Gallium scan

● Soft tissue thickening of the roof of the external auditory
Radiotracer uptake at the level
canal and the tympanic membrane with occupation of the
of the left petrous bone.
hypotympanum and mesotympanum.

● Occupation of the mastoid cells, observing erosion of the

external cortical bone at the level of the left mastoid.
 DIAGNOSIS

Malignant external otitis

 TREATMENT
1. Treatment of the underlying disease: 2. Treatment with intravenous ceftazidime 2g every 8
diabetes with basal-bolus insulin treatment hours, ciprofloxacin ear drops and systemic steroids

He presented good glycemic He was discharged 14 days after admission to continue

control during his stay in the treatment in the home hospitalization unit until
hospital completing 6 weeks of treatment. After that time the
patient responds to P. Aeruginosa infection therapy.

No biopsy!! We can rule out the differential diagnosis

. of carcinoma of the temporal bone or
malignant external otitis due to aspergillus spp.
 Question

Choose the false tense:

A) The most habitual germen that causes this disease is P.aeruginosa.

B) It is a rare disease but it produces a mortality rate of 50%.
C) It develops mainly in diabetic or inmunocompromised patients.
D) The initial otalgia and otorrhea improve with habitual treatment.
 CLINICAL CASE 3
Anamnesis
● 65-year-old female presents to the emergency department due to left ear
pain with irradiation to the neck of hours of evolution.

● Not known medical

allergies
● History of arterial hypertension treated with enalapril.

● The patient doesn’t report any other kind of symptomatology

PHYSICAL EXAMINATION
Good general condition.

Inspection
● Oropharynx: no pathological findings.
● Left and right auricle: no inflammation or pathological changes.

Otoscopy
● LE: normal tympanic membrane and erythematous external
auditory canal
● RE: no pathological findings.

Palpation
● LE: negative tragus sign

Given the non-specific physical examination, it was decided to establish analgesic treatment with ibuprofen
(600mg every 8h) and monitor progress
 PROGRESS
The patient returns to the emergency department 3 days after the onset of symptoms due to:
● Pain in the left side of the face, described as a burning pain.

● Paralysis of the left side of the face.

On physical examination we find:

● Vesicular lesions in the left auricle.

● Absence of vesicular lesions in any other otorhinolaryngological localization.

● Flaccid paralysis of the left side of the face, rest of cranial nerve examination is
normal.
 DIAGNOSIS

Herpes zoster oticus (Ramsay Hunt syndrome)

 TREATMENT

● Oral acyclovir (antiviral)

● Oral metamizole (analgesic and anti-

inflammatory)

● Lubricating eye drops/artificial tears

Lubrication of the eye and prevention of
corneal ulcers secondary to lagophthalmos

● Ocular protection measures

 OUTCOME AND FOLLOW UP
● The first electrophysiological study was performed 9 days after the onset of facial paralysis:

“No direct motor responses or reflex responses dependent on the left facial
nerve were obtained. Absence of spontaneous and voluntary electromyographic
activity. There are no data on a good prognosis”.

● The electrophysiological study is repeated after a month of rehabilitation:

«Regarding the previous study, there is still a lack of motor responses dependent
on the left facial nerve. Overall, poor prognostic data».

● At the same time, she was assessed by the ophthalmology service due to the
impossibility of occluding her left eye, and she was scheduled for surgery.
 CLINICAL CASE 4
ANAMNESIS:
-Joan, 2 years old,

-Not allergic to any medication

-Fever and congestion (48 hours of evolution)

-Ear pain on the right ear

PHYSICAL EXAM:
1)REMOVE 2)OTOSCOPY
CERUMEN
-RE: hyperemia and secretion
Tympanic membrane is
bulging from the middle ear
space
-LE: Normal

3)PNEUMATIC
OTOSCOPY:

-RE: Decreased mobility

-LE: Normal
DIAGNOSIS:

ACUTE OTITIS MEDIA

 TREATMENT:
TAKE CARE IF THERE
IS TYMPANIC Topical benzocaine can be
MEMBRANE introduced in the ear canal to
PERFORATION! provide timely pain relief

ANTIBIOTICS OR NOT?

Depends on the SEVERITY of illness

AMOXICILLIN is suggested (x2)

CLINICAL CASE 5
ANAMNESIS:
-Emma, 5 years old
-Not allergic to any medication

-Otalgia in left ear (less than 48h of evolution)

-Three days ago she developed cough, fever and

congestion
PHISICAL EXAM:

OTOSCOPY:
LE: Blistering on the tympanic membrane and ear
canal
Tympanic membrane is bulging from the middle
ear space

RE: Normal
 DIAGNOSIS:

BULLOUS MIRINGITIS
BULLOUS MYRINGITIS
 DIFFERENTIAL DIAGNOSIS
BULLOUS
ACUTE OTITIS MEDIA
MYRINGITIS

No bubbles. Bloody
Pus bubbles bubbles

In both tympanic membrane is bulging.

I
TREATMENT:

TOPICAL LIDOCAINE
AND ANTIBIOTICS

Is focused on providing pain

relief and treating the
underlying infection
Antibiotics are only to prevent
more infections!
 CLINICAL CASE 6
Anamnesis
● 2-year-old female admitted to the emergency department due to 2 days of
right postauricular area swelling.

● Not known medical

allergies
● Treatment with antibiotics during the last week at a local clinic for
bilateral acute otitis media.

● Parents reported absence of balance disorders, nausea and vomiting or

other symptoms of vertigo.

● Right severe otalgia, irritability and fever (39,3ºC) upon admission in

spite of antibiotic treatment.
PHYSICAL EXAMINATION
Inspection
● Protrusion of the right auricle outward and downward with
loss of the postauricular crease (Jacques’s sign).
● Right postauricular erythema and swelling.
● Oropharynx: no pathological findings

Palpation

● Tender fluctuancy overlying the right mastoid bone

● Poorly circumscribed, immobile.

Otoscopy

● LE: hyperemic and bulging tympanic membrane

● RE: hyperemic and bulging tympanic membrane

No pathological alterations in cranial nerve examination

 COMPLEMENTARY TESTS

BLOOD TEST TEMPORAL BONE CT

● C-reactive protein: 30,6 mg/dl
● Incomplete bilateral mastoid and
(>10 mg/dl)
middle ear opacification
● White blood cell count: 15720/ml
● Area of lucency overlying right
(4,5-11) with a 80% of neutrophils
mastoid cortex
(35-70%)
● Erosion of the mastoid cortex
● Rest of the analysis without
pathological findings.
 DIAGNOSIS

ACUTE MASTOIDITIS COMPLICATED WITH

SUBPERIOSTEAL ABSCESS
 TREATMENT
● Surgical mastoid drainage and surgical middle ear drainage by myringotomy with
tympanostomy tube placement.

● IV antibiotics therapy: empiric therapy with 3rd

generation cephalosporins (ceftriaxone)

● After 7-10 days, control CT and change to pathogen-specific therapy when

results of blood and ear culture and susceptibility testing are available.
 OUTCOME AND FOLLOW UP
After 2 days of hospitalization, persistent symptoms and physical findings in spite of 2 day of IV ATB treatment

SIMPLE MASTOIDECTOMY

Culture study Streptococcus pneumoniae only susceptible to vancomycin

● IV antibiotic treatment with vancomycin was immediately initiated and the child was discharged
after 13 days of surgery.

● During the 5 month follow up, the patient showed no signs or symptoms of recurrence.
ACUTE EXTERNAL OTITIS
INFLAMMATION OF THE EXTERNAL
AUDITORY CANAL
All ages
Summer
ANATOMY AND PATHOGENESIS:
Ear canal:

-Cartilaginous portion
-Bony portion

DEFENSE MECHANISMS:

Inhibit the entry of

contaminants

Creates an acidic ear canal

environment
BREAKDOWN OF THE
SKIN CERUMEN
BARRIER:

Inflammation
Edema of the skin
Alters cerumen RISK
production FACTORS
Obstruction
CAUSES:
Pseudomonas aeruginosa,
S. epidermidis
Staphylococcus aureus
SYMPTOMS: otalgia, pruritus, discharge, and hearing loss
EAR CANAL OTHORREA
INFLAMATION
DIAGNOSIS
DIFFUSE
ERYTHEMA OF EAR
CANAL OR
TYMPANIC
MEMBRANE

48 HOURS CELLULITIS OF THE

PINNA AND
TRAGUS SIGN ADJACENT SKIN
REGIONAL
ADENOPATHY
DIFFERENTIAL DIAGNOSIS!!!
 COMPLICATIONS:

-PERIAURICULAR CELLULITIS

-MALIGNANT EXTERNAL OTITIS

 TREATMENT:
-MILD/MODERATE: Topical preparation
(acidic+antibiotic+glucocorticoid)
CICLOFOLOXACIN-HYDROCORTISONE

-SEVERE: Topical therapy + oral antibiotics.

FLUOROQUINOLONES
CIPROFLOXACIN

EVOLUTION:
improvement 36 to 48 hours
 ACUTE OTITIS MEDIA
Acute, suppurative infectious process marked by the presence of infected middle ear fluid and
inflammation of the mucosa lining the cavities of the middle ear space.

Usually associated with impaired function of the

Eustachian tube

● Loss of ventilation
● NO clearance of secretions
 EPIDEMIOLOGY

Maximum incidence in

6-24 MONTHS OF AGE

● One of the leading causes of acute care
visits It also occurs in adults
● The most common reason for adm. of ATB

Direct relationship Age of first episode of AOM & recurrent AOM

More frequent in winter Upper respiratory infections

 ETIOLOGY AND PHYSIOPATHOLOGY
Bacterial etiology is more common

Bacterial or viral infection ● Streptococcus pneumoniae

● Haemophilus influenzae

Infection, inflammation and/or obstruction of the Eustachian tube

PATHOLOGICAL PROCESS AMBIENTAL/GENETIC FACTORS DYSFUNCTION OF THE ET

● Allergic rhinitis ● Smoking

● Cleft palate ● Primary ciliary dyskinesia
● Craniofacial anomalies ● …
● Cavum tumors
● Adenoid vegetations
● Upper respiratory infections
● …
 ETIOLOGY AND PHYSIOPATHOLOGY

Poor clearance of secretions and poor ventilation of the middle air

Inflammation of the mucosa ↑ vascular permeability ↑ secretions + retention

SUPERINFECTION
 CLINICAL PRESENTATION

Otodynia Fever Autophony

The most common complaint
Tinnitus

Pain and fever relief and

improvement of hearing loss

Hearing loss Otorrhea

Certain symptoms may go
● Conductive hearing loss Perforation of the tympanic unnoticed in young children
● Rinne negative membrane
● Webber lateralizes towards AE
 PHASES OF ACUTE OTITIS MEDIA
CLOSED COLLECTION SUPURATION RESOLUTION
CONGESTION PHASE
PHASE PHASE PHASE

● Erythematous TM ● Pathologic secretions ● Rupture of the ● Scarce supuration

● Mild TM retraction accumulation eardrum ● Perforation closing
● Pain, moderate ● Lancinating pain, high ● Otorrhea ● Persistent hearing loss
fever, hypoacusis fever, hearing loss and
and tinnitus tinnitus
 DIAGNOSIS
MIDDLE EAR EFFUSION
ACUTE SIGNS OF INFLAMMATION
(MEF)

● Otoscopy: bubbles, air-fluid level, ● Bulging of the eardrum ↑specific sign

opacity, abnormal color and impaired ● Marked erythema
mobility (pneumatic otoscopy) ● Fever
● Tympanometry ● Ear pain
● Acoustic reflectometry
CLINICAL DIAGNOSIS

● Bulge of the tympanic membrane

● Signs of acute inflammation and middle ear effusion.

● Perforation of the TM with acute purulent otorrhea (if AEO diagnosis is excluded)

INITIAL TREATMENT
TREATMENT
Analgesic & anti-inflammatory
treatment
Decongestants (mucolytic drugs)
Symptoms and signs worsen after
Antibiotic therapy
48/72h

● Children <2 years

● Severe symptoms (↑fever, bilateral AOM, Amoxicillin (high dosis x2)
otorrhea…)

● Children <6 months

● Children <2 years with severe symptoms Amoxicillin-clavulanate
● First grade relatives with atypical sequelae (high dosis amoxicillin x2)
● Recurrent AOM

Treat every episode

Recurrent AOM
>6 episodes → Consider myringotomy with TT placement
 OTHER FORMS OF AOM:
BULLOUS MYRINGITIS
Erythema and bullae on the
Upper airway viral infection
tympanic membrane

TREATMENT
● Anti-inflammatories

● Ear drops (otorrhea)

● Otorrhea
● Rupture of the blisters
● Bulge of the TM ● Antibiotics recommended
● Bloody content
● Intense pain
COMPLICATIONS OF ACUTE OTITIS MEDIA
CLASSIFICATION

INTRATEMPORAL INTRACRANIAL

● Hearing loss ● Meningitis

● Balance and motor problems ● Epidural, subdural and brain
● Tympanic membrane abnormalities: abscess
● Perforation ● Lateral sinus thrombosis
● Myringosclerosis ● Otitic hydrocephalus
● Retraction or collapse ● Cavernous sinus thrombosis
● Chronic suppurative otitis media ● Subdural empyema
● Cholesteatoma ● Carotid artery thrombosis
● Mastoiditis
● Petrositis
● Labyrinthitis
● Facial paralysis
 INTRATEMPORAL COMPLICATIONS
Acute Otitis Media
(infection and inflammation of the middle ear)
7. Tympanic membrane
abnormality:
Accumulation of fluid in the middle ear and Myringosclerosis
prolonged obstruction of eustachian tube

Increase in pressure Decrease in the

Transfer of pressure 6. Hearing loss: commonly
stretches tympanic conduction of
to inner ear conductive
membrane sound waves

Vestibular or
2. Perforation of Decreased pressure in 3. Retraction or
labyrinth
TM middle ear collapse in TM
dysfunction

1. Balance and 5. Chronic

Risk factor for
motor problems suppurative otitis
4. Cholesteatoma
media
 INTRATEMPORAL COMPLICATIONS
Mastoiditis
● Distal middle ear is connected to mastoid air cells:
movement of pathogens.
● Mucosal infection along with osteolysis of the
mastoid cells.
● More common in children but in adults is severe.
● Two phases:

1. Significant suppurative mastoiditis. Fever, posterior

ear pain, local erythema over the mastoid bone,
edema of the pinna or a posteriorly and downwardly
displaced auricle.

2. Coalescent mastoiditis. Infection in the mastoid air

spaces with destruction of the septae that
separates air spaces.
 INTRATEMPORAL COMPLICATIONS
Petrositis
Mastoiditis with destruction of
the tip of the petrous bone
● Gradenigo’s syndrome:
ocular pain (V nerve),
diplopia (VI nerve), otorrhea.
● Diagnosis: MRI or CT
● Treatment: intravenous
antibiotic therapy associated
with surgical treatment
Labyrinthitis
Clinically: nausea, vomiting,
vertigo, tinnitus, and hearing
loss.
Two phases:
1. Serous labyrinthitis
2. Purulent labyrinthitis.
Extension of the OAM
infection into the inner
ear.
Facial paralysis
Two mechanisms:
1. Direct spread of the
infection
2. Erosion of the bone
overlying the facial
nerve
 INTRACRANIAL COMPLICATIONS
Meningitis
● Most common
● Etiology: S. Pneumoniae
● Clinically: signs of meningitis
● Treatment: intravenous
antibiotics and surgical
intervention depending on the
evolution
Lateral sinus thrombosis
● Clinically: fever, earache, headache,
edema
● Diagnosis: arteriography and MRI
● Treatment: broad spectrum antibiotic and
surgical treatment
BIBLIOGRAPHY
● Antonio R, Magaña C. Ejercicio clínico patológico [Internet]. Available from:
https://www.medigraphic.com/pdfs/atefam/af-2012/af121f.pdf
● Arana-Alonso E, Contín-Pescacen MS, Guillermo-Ruberte A, Morea Colmenares E. Síndrome
de Ramsay-Hunt: ¿qué tratamiento precisa? SEMERGEN - Medicina de Familia. 2011
Oct;37(8):436–40.
● Sibbald A. Otitis Media: Un Caso Clínico [Internet]. Available from:
https://cdn.gn1.link/iapo/manuals/vii_manual_es_31.pdf
● ‌Bullous Myringitis [Internet]. WiscMed. [cited 2022 Oct 20]. Available from:
https://www.wiscmed.com/cases/bullous-myringitis-3/
● Kim SR, Choo O-S, Park HY. Two Cases of Acute Mastoiditis with Subperiosteal Abscess.
Korean Journal of Audiology. 2013;17(2):97
THANKS!!