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Otalgia

  • Author: John C Li, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Sep 18, 2015
 

Background

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.

Referred otalgia is a topic unto itself. Although many entities can cause referred otalgia, their relationship to ear pain must be identified. A categorical discussion of the workup, treatment, prognosis, demographics, and other issues is impossible because the various pathologies responsible for creating referred otalgia are so diverse.

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.

The picture below demonstrates the diversity of pathologies that can be the source of referred otalgia.

This picture demonstrates the diversity of patholo This picture demonstrates the diversity of pathologies that can be the source of referred otalgia.
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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.

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Epidemiology

In a study of US emergency department (ED) patients with otologic complaints, Kozin et al found that the most commonly diagnosed conditions were otitis media not otherwise specified (NOS) (60.6%), infected otitis externa NOS (11.8%), and otalgia NOS (6.8%). The data was drawn from a weighted total of 8,611,282 ED visits for otologic problems between 2009 and 2011.[1]

In a Korean study of 294 patients with otalgia, the prevalence of primary otalgia was found to be higher in children than in adults and in men than in women, while referred otalgia was more likely to occur in adults in general and in women in particular. The study, by Kim et al, also found that neuralgia occurred more frequently in women than in men with referred otalgia.[2]

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Contributor Information and Disclosures
Author

John C Li, MD Private Practice in Otology and Neurotology; Medical Director, Balance Center

John C Li, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Neurotology Society, American College of Surgeons, American Medical Association, American Tinnitus Association, Florida Medical Association, North American Skull Base Society

Disclosure: Received consulting fee from Synthes Power Tools for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development

Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Auditory Society, The Triological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, American Neurotology Society, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Otological Society

Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Michael E Hoffer, MD Director, Spatial Orientation Center, Department of Otolaryngology, Naval Medical Center of San Diego

Michael E Hoffer, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Received royalty from American biloogical group for other.

Acknowledgements

Jared Brunk, PA-C Physician Assistant Certified, Office of John Li, MD

Disclosure: Nothing to disclose.

Thomas Ulrich, PA-C Physician Assistant Certified, Office of John Li, MD

Disclosure: Nothing to disclose.

References
  1. Kozin ED, Sethi RK, Remenschneider AK, et al. Epidemiology of otologic diagnoses in United States emergency departments. Laryngoscope. 2015 Aug. 125 (8):1926-33. [Medline].

  2. Kim SH, Kim TH, Byun JY, Park MS, Yeo SG. Clinical Differences in Types of Otalgia. J Audiol Otol. 2015 Apr. 19 (1):34-8. [Medline].

  3. Adour KK. Acute temporomandibular joint pain-dysfunction syndrome: neuro-otologic and electromyographic study. Am J Otolaryngol. 1981 May. 2(2):114-22. [Medline].

  4. Al-Sheikhli AR. Pain in the ear--with special reference to referred pain. J Laryngol Otol. 1980 Dec. 94(12):1433-40. [Medline].

  5. Frankel VH. Whiplash injuries to the neck. Hirsch C, Zotterman Y, eds. Cervical Pain. New York, NY: Pergamon Press; 1971.

  6. Pinheiro TG, Soares VY, Ferreira DB, Raymundo IT, Nascimento LA, Oliveira CA. Eagle's Syndrome. Int Arch Otorhinolaryngol. 2013 Jul. 17 (3):347-50. [Medline].

  7. Gibson WS Jr, Cochran W. Otalgia in infants and children--a manifestation of gastroesophageal reflux. Int J Pediatr Otorhinolaryngol. 1994. Jan;28(2-3):213-8.

  8. Kuttila S, Kuttila M, Le Bell Y. Characteristics of subjects with secondary otalgia. J Orofac Pain. 2004 Summer. 18(3):226-34.

  9. Scarbrough TJ, Day TA, Williams TE. Referred otalgia in head and neck cancer: a unifying schema. Am J Clin Oncol. 2003. Oct;26(5):e157-62.

  10. Shah RK, Blevins NH. Otalgia. Otolaryngol Clin North Am. 2003 Dec. 36(6):1137-51. [Medline].

  11. Subramaniam S, Majid MD. Eagle's syndrome. Med J Malaysia. 2003 Mar. 58(1):139-41. [Medline].

  12. Travell JG, Simons DG. Myofascial pain and dysfunction. The Trigger Point Manual. Baltimore, Md: Lippincott Williams & Wilkins; 1983.

 
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This picture demonstrates the diversity of pathologies that can be the source of referred otalgia.
 
 
 
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