Otalgia Treatment & Management

  • Author: John C Li, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Mar 16, 2010
 

Medical Care

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.

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, as follows:

  • History
    • 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
  • Physical examination
    • Nasopharyngoscopy
    • Laryngoscopy
  • Preliminary testing (appropriate to symptoms)
    • Audio
    • Barium swallow
    • ECG C-spine radiography
    • Chest radiography
    • Panorex imaging
  • Treat the underlying problem appropriately with trial medications (eg, antibiotics, NSAIDs) and 2-week follow-up or with appropriate consultation (eg, dentist, gastroenterologist, neurologist, rheumatologist, neurosurgeon).
  • If the findings on history, physical examination, and testing are inconclusive, consider local anesthesia to block the source of pain as follows:
    • 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.
  • 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.
  • If no diagnosis is reached, consider watchful surveillance for 1-3 months and then re-evaluate.
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Consultations

In patients with odontogenic problems, either a dentist or an oral surgeon may be very helpful. Neurologists and pain management specialists (anesthesiologists) may treat neuralgias. Other consultations may be necessary, including a gastroenterologist for persons needing a further evaluation that requires a barium swallow or upper endoscopy or a rheumatology consultation for the evaluation of arthritis and other joint disorders.

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Diet

Diet may be relevant if the patient has dental problems. A soft mechanical diet may be necessary to avoid exacerbation of the problem.

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Activity

Because of the diversity of the causes of referred otalgia, listing activity restrictions on a general basis is impossible. Activity considerations are case specific. For example, patients with temporomandibular joint dysfunction should consider activities that involve jaw clenching.

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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 College of Surgeons, American Medical Association, American Neurotology Society, American Tinnitus Association, Florida Medical Association, and North American Skull Base Society

Disclosure: Nothing to disclose.

Coauthor(s)

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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: American biloogical group Royalty Other

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Peter S Roland, MD  Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of 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 Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Laryngological Rhinological and Otological Society, American Neurotology Society, American Otological Society, North American Skull Base Society, and Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Alcon labs Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; Advanced Bionics Honoraria Board membership; Cochlear corp Honoraria Board membership; Med El corp travel grants Consulting

Christopher L Slack, MD  Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, 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, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position

References

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  4. 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.

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  10. Sataloff RT, Price DB. Distention of the stylomandibular ligament as a cause of styloid pain syndrome. Ear Nose Throat J. Sep 1984;63(9):412-5. [Medline].

  11. 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.

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

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

  14. Thaller SR, De Silva A. Otalgia with a normal ear. Am Fam Physician. Oct 1987;36(4):129-36. [Medline].

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

  16. Wazen JJ. Referred otalgia. Otolaryngol Clin North Am. Dec 1989;22(6):1205-15. [Medline].

  17. Williamson EH. The interrelationship of internal derangements of the temporomandibular joint, headache, vertigo, and tinnitus: a survey of 25 patients. Facial Orthop Temporomandibular Arthrol. Jan 1986;3(1):13-7. [Medline].

  18. Yules RB. Differential diagnosis of referred otalgia. Eye Ear Nose Throat Mon. May 1967;46(5):587-8. [Medline].

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