1. OTALGIA
• 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.

2. • Typical sources of primary otalgia are external
otitis, otitis media, mastoiditis, andauricular
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.

3. • Reports document that not all otalgia originates from
the ear. Many remote anatomic sites share dual
innervation with the ear, and noxious stimuli to these
areas may be perceived as otogenic pain. By
definition, referred otalgia is the sensation of ear pain
originating from a source outside the ear.
• To better understand referred otalgia, the physician
first must understand the anatomic distribution of
nerves associated with the ear. Irritation of these
nerves, as well as irritation of distant branches of these
nerves, can cause the perception of pain within the ear.

4. 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.
• Neuroanatomically, the sensation of otalgia is thought
to center in the spinal tract nucleus of CN V. Not
surprisingly, fibers from CNs V, VII, VIV, and X and
cervical nerves 1, 2, and 3 have been found to enter
this spinal tract nucleus caudally near the medulla.
Hence, noxious stimulation of any branch of the
aforementioned nerves may be interpreted as otalgia.

5. PHYSICAL EXAMINATION
• The physical examination should include an
exhaustive otologic, neuro-otologic, head, and
neck examination. Careful
rhinoscopy, nasopharyngoscopy, and indirect
laryngoscopy are mandatory.
• Palpation of the neck is important to look for
thyroid disease, adenopathy, and
musculoskeletal disorders.

6. CAUSES
• Dental disorders are the most common cause of referred pain to
the ear. Of this group of disorders, temporomandibular
dysfunctions account for most patients.[1]Bruxism, degenerative
joint disease, or stress can lead to internal derangements within the
joint. The third division of the trigeminal nerve and the
auriculotemporal nerve mediate pain, which is often perceived
deep within the ear. Other odontogenic causes range from
abscessed teeth to poorly fitting dentures.
• Within the oral cavity, the sensory innervation becomes quite
complex. The tongue receives fibers from the glossopharyngeal
nerve, the facial nerve receives fibers from the chorda tympani, and
the trigeminal nerve receives fibers from the lingual branch and
vagus nerve posteriorly. All these nerves have distributions in the
ear as well.

7. • Sinusitis is another very common source of
ear pain. The neural pathway is along the
second branch of the trigeminal nerve and the
auriculotemporal nerve. Because the
trigeminal nerve supplies the nasal cavity,
patients with inflammatory mucosal contact
points and nasal obstruction may develop
symptoms in their ears. The proximity of the
eustachian tube orifice also contributes to the
problem.

8. • Neck problems can also refer pain to the ears.
These disorders include cervical
osteoarthritis, cervical myofascial pain
syndrome, and traumatic injuries.[2, 3] The
cervical spine is sensitive and well supplied by
the cervical nerve roots. Muscular pain from
the trapezius or sternocleidomastoid may
project postauricularly to the mastoid and
occipital area.

9. • Sensory branches of the vagus and
glossopharyngeal nerves supply upper
aerodigestive tract mucosal areas such as the
nasopharynx, oropharynx, hypopharynx, and
larynx. The vagus continues caudally and
supplies sensory enervation to the bronchus,
esophagus, and heart as well. Irritative lesions
at any of these sites may mimic stimulation of
Arnold and Jacobson nerves.

10. • Tonsillitis and pharyngitis are very common
causes of earaches in children. Less
commonly, laryngitis, laryngeal
tumors, esophagitis, and even angina
pectorismay manifest as otalgia. Eagle
syndrome, in which the elongated styloid process
irritates branches of CN VIV and CN IX, is even
rarer. This crossing of signals works both ways;
thus, stimulation of the ear canal may be felt as a
tickle in the throat or may produce the cough
reflex.

11. • Sometimes, pain may be from irritation of the nerves
themselves without an inciting source. These disorders are
termed neuralgias. Neuralgias are typified by lancinating
pain in the distribution of the involved nerve. Otologic
symptoms of trigeminal neuralgia are referred along its
auriculotemporal branch. Geniculate neuralgia is rare but
can be observed in Ramsey Hunt syndrome. This neuralgia
involves the irritation of facial nerve sensory fibers, which
corresponds to the pain sensation felt within the auricle.
Sphenopalatine and vidian neuralgias cause similar aural
pain via crossing fibers of the greater superficial petrosal
nerves and the facial nerves. Glossopharyngeal
neuralgia, which causes a phantom tonsillar pain, may also
cause otalgia by simulating excitation of the Jacobson
nerve.

12. • A number of otologic conditions can produce ear
discomfort without altering the external appearance of
the auditory canal and tympanic membrane. Ménière
disease is associated with a sensation of aural
fullness, in addition to vertigo,tinnitus, and fluctuating
hearing loss. Tumors of the temporal bone, such
asmeningiomas, glomus jugulare, and cerebellopontine
angle lesions, have been associated with
otalgia, possibly by nerve root compression. Bell
palsy is often associated (as many as 60% of cases) with
otogenic pain thought to emanate from the sensory
fibers of the facial nerve.

13. • Eustachian tube dysfunction causing an
intermittent inability to equalize middle ear
pressures may manifest with such minimal
tympanic membrane bulging or retraction that
even otomicroscopy does not detect an
abnormality. The problem may be as simple as
a sensitive ear canal that requires protection
from cold winds along with reassurance that
nothing is actually wrong.

14. D/D
• Acute Laryngitis
• Adenoidectomy
• Allergic Fungal Sinusitis
• Allergic Rhinitis
• Barosinusitis
• Bell Palsy
• Chronic Laryngitis, Infectious or Allergic
• Complications of Otitis Media
• Contact Granulomas
• Deep Neck Infections
• Eustachian Tube Function
• External Ear, Benign Tumors
• External Ear, Infections
• External Ear, Inflammatory Diseases
• External Ear, Malignant External Otitis

15. • Fractures, Mandibular, Alveolar
• Fractures, Maxillary, Zygomatic
• Malignant Nasopharyngeal Tumors
• Malignant Tumors of the Base of Tongue
• Malignant Tumors of the Floor of the Mouth
• Malignant Tumors of the Nasal Cavity
• Malignant Tumors of the Sinuses
• Malignant Tumors of the Temporal Bone
• Malignant Tumors of the Tonsil
• Middle Ear, Acute Otitis Media, Medical Treatment
• Middle Ear, Acute Otitis Media, Surgical Treatment
• Middle Ear, Eustachian Tube, Inflammation/Infection
• Middle Ear, Mastoiditis
• Middle Ear, Otitis Media with Effusion
• Neck Cancer, Unknown Primary Site
• Neck, Cervical Metastases, Detection
• Neck, Cervical Metastases, Surgery

16. • Parapharyngeal Space Tumors
• Parotitis
• Sinusitis, Acute, Medical Treatment
• Sinusitis, Chronic, Medical Treatment
• Sinusitis, Maxillary, Acute, Surgical Treatment
• Sinusitis, Maxillary, Chronic, Surgical Treatment
• Sinusitis, Sphenoid, Acute, Surgical Treatment
• Skull Base, Petrous Apex, Infection
• Skull Base, Petrous Apex, Tumors
• Temporal Bone Fractures
• Thyroid Cancer
• Tonsillectomy
• Tonsillitis and Peritonsillar Abscess

17. 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.

18. • In the absence of obvious fluid within the middle
ear, aural fullness secondary to eustachian tube
dysfunction may manifest with a practically
imperceptible bulging or retraction of the tympanic
membrane. If autoinsufflation is not effective in
relieving this pressure, consider a diagnostic
myringotomy.
• Despite the full battery of testing, a group of patients
always remains for whom an etiology is not evident. If
not contraindicated, a brief course of nonsteroidal anti-
inflammatory agents (NSAIDs) may be helpful.

19. 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.

20. • Panorex imagery: Panorex imagery is quite useful in
diagnosing temporomandibular joint
dysfunction, odontogenic pathology, and styloid
abnormalities. The high prevalence of dental-related otalgia
in the authors' study group underscores the need for an
alliance with a person well trained in temporomandibular
joint–related disorders. Referral to a competent dentist or
oral surgeon may be indicated.
• 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.

21. OTHER TESTS
• Audiography
• Vestibulocochlear testing
• Nasal endoscopy
• Upper aerodigestive tract
endoscopy, laryngoscopy
• Blood tests - CBC count, WBC count (to look
for infection), sickle cell anemia, thyroid
function studies and antibodies for thyroiditis

22. T/t & Management
• Identification of a causative etiology is often necessary to
successfully treat referred otalgia. Once determined, most causes of
referred otalgia can be readily treated. Use antibiotics in treating
various types of infections (eg, tonsillitis, pharyngitis, sinusitis). Use
antivirals if the causative agent is suspected to be viral such as in
cases associated with herpes zoster or shingles. Antifungals are
indicated if the source is caused by a fungus (eg, oral
thrush/candidiasis). Antiulcer/antacid medications can be used for
esophagitis and gastroesophageal reflux disease. Use NSAIDs when
myalgias and neuralgias are suspected. Re-examine the patient
after a 2-week trial of NSAIDs. Strong narcotic analgesics are not
indicated and should not be used to treat referred otalgia. Narcotics
may mask symptoms, making the correct diagnosis difficult to
reach.

23. • Perform a detailed search for the underlying
diagnosis before initiating treatment. Starting
analgesics before reaching a diagnosis increases
the difficulty of determining the cause and may
possibly obscure a life-threatening condition such
as an occult cancer.
• Any of the previously mentioned treatments can
be implemented when the exact cause of
referred otalgia is suspected. If the problem
persists after a 2- to 3-week trial, a more
advanced algorithm is indicated.

24. History should include the following:
• Otologic history - Tinnitus, hearing, vertigo
• Sinuses
• Pulmonary history
• Cardiac history
• Dental history - Mastication
• GI history - Dysphagia, esophagitis, reflux
• Neurologic history - Neuralgias
• Musculoskeletal history - Arthritis
• Cervicofacial history
• Myalgias
• Trauma - Cervical spine (C-spine)
• Infections - Tonsillitis, pharyngitis

25. Physical examination should include the
following:
• Nasopharyngoscopy
• Laryngoscopy

26. Preliminary testing (appropriate to symptoms)
should include the following:
• Audio
• Barium swallow
• ECG C-spine radiography
• Chest radiography
• Panorex imaging

27. • Treat the underlying problem appropriately
with trial medications (eg, antibiotics, NSAIDs)
and 2-week follow-up or with appropriate
consultation
(eg, dentist, gastroenterologist, neurologist, rh
eumatologist, neurosurgeon).
• If the findings on history, physical
examination, and testing are
inconclusive, consider local anesthesia to
block the source of pain as follows:

28. • Nasal cavity pathology: Spray may localize the
problem to the sinus or sphenopalatine oral
cavity; consider specific nerve blocks.
• Larynx: Use gargle or transtracheal 4%
lidocaine.
• Ear canal: Use topical agent for sensitive ear
canal; consider injection for chorda tympani.
• Muscular trigger points: Lidocaine injection
can be useful in diagnosis.

29. If history and physical examination findings are
inconclusive, perform other diagnostic procedures if
suspicion still exists for the following conditions:
• Upper respiratory tract tumor - Panendoscopy, chest
radiography, CT scanning, or MRI as needed
• Sinus disease - Sinus CT scanning
• Intracranial/intratemporal disease - Audiometric battery
and CT scanning or MRI as needed
• Autoimmune disease - ESR, thyroid function studies
(thyroiditis, temporal arteritis)
• Endolymphatic hydrops - ESR, thyroid function test
(TFT), fluorescent treponemal antibody absorption (FTA-
Abs) test, fasting glucose, lipid profile
• Eustachian tube dysfunction - Autoinsufflation (consider
myringotomy)
• Psychiatric disorder - Consider psychiatric consultation.

30. MEDICATION
• Use antibiotics in treating various types of
infections (eg, tonsillitis, pharyngitis, sinusitis).
Use antivirals if the causative agent is suspected
to be viral such as in cases associated with herpes
zoster or shingles. Antifungals are indicated if the
source is caused by a fungus (eg, oral
thrush/candidiasis). Antiulcer/antacid
medications can be used for esophagitis or
gastroesophageal reflux disease. Use NSAIDs
when myalgias and neuralgias are suspected.
Reexamine the patient after a 2-week trial of
NSAIDs.

31. • Perform a detailed search for the underlying
diagnosis before initiating treatment. Starting
analgesics before reaching a diagnosis increases
the difficulty of determining the cause and may
possibly obscure a life-threatening condition such
as an occult cancer.
• Any of the previously mentioned treatments can
be implemented when the exact cause of
referred otalgia is suspected. If the problem
persists after a 2- to 3-week trial, a more
advanced algorithm is indicated.

32. • Thank you