Otalgia 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.

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.

In the authors' study group, 44% of patients without an obvious cause for their ear pain experienced spontaneous resolution. Those in whom symptoms do not resolve must be seen on a regular basis. Follow-up is essential in these cases because of the possibility of discovering a tumor that was initially too small to detect.

• 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.
• 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.

• 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

When the history and physical examination findings are inconclusive, use of local anesthesia may help localize the problem.

The nasal cavity may be sprayed with topical Pontocaine with a vasoconstrictor. After a few minutes of decongestion, some patients with sinus-related pathology experience a relief of headaches, facial pain, and aural fullness.

Cetacaine or a 4% lidocaine gargle to anesthetize the oropharynx and larynx can numb pharyngitis or other problem causing referred otalgia.

Injectable 1% Xylocaine can be used to identify neuromuscular trigger points and can be useful in the diagnosis of myalgias and neuralgias.

Referred signals from the chorda tympani may be numbed via a transcanal or transtympanic injection approach. A few drops of 4% lidocaine or eutectic mixture of local anesthetics 14 (EMLA 14) in the external auditory meatus may help differentiate between a sensitive ear canal and deep temporal pain. Maintain a high index of suspicion for an occult upper respiratory tract tumor, intracranial tumor, intratemporal disease, sinus-related pathology, autoimmune disease, and eustachian tube dysfunction. Consider laboratory evaluation.