Otalgia Clinical Presentation

The algorithm to systematically reduce the vast differential diagnosis for otalgia begins with a thorough history and physical examination. The history should be complete and specifically encompass a review of otologic symptomatology, swallowing disorders, sinus problems, cervicofacial pain syndromes (eg, myalgias, neuralgias, arthritis), recent trauma, and cardiopulmonary background. Patient history can guide the clinician in the selection of subsequent testing.

The physical examination should include an exhaustive otologic, neuro-otologic, head, and neck examination. Careful rhinoscopy, nasopharyngoscopy, and indirect laryngoscopy are mandatory. Despite the low prevalence of malignant upper aerodigestive tract tumors in the authors' study, a well-known strong association (as high as 19% in some studies) between cancer and otalgia exists, and the results of a missed diagnosis can be devastating. Because of its high relative prevalence, actively seek sinus pathology. Palpation of the neck is important to look for thyroid disease, adenopathy, and musculoskeletal disorders.

Dental disorders are the most common cause of referred pain to the ear. Of this group of disorders, temporomandibular dysfunctions account for most patients. ^[6] A study by Mejersjö and Näslund, for instance, indicated that aural symptoms frequently occur in cases of temporomandibular pain and/or dysfunction, including feelings of fullness of the ear and impaired hearing, with greater ear pain and sound sensitivity being reported by females. ^[7]  A Brazilian study, by Magalhães et al, found that 58.2% of patients aged 15 years or older with temporomandibular disorder had one or more otologic symptoms. ^[8]

Bruxism, degenerative joint disease, or stress can lead to internal derangements within the temporomandibular joint. (For example, Kim reported the case study of a female patient aged 29 years in whom bruxism-associated temporomandibular joint disorder caused otalgia. ^[9] ) 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.

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.

Neck problems can also refer pain to the ears. These disorders include cervical osteoarthritis, cervical myofascial pain syndrome, and traumatic injuries. ^{[10, 11]} 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.

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.

A literature review by Myers found 52 case reports in which jaw pain and/or otalgia were referred from laryngopharyngeal and noncardiac thoracic sources, with these, plus data from a multicenter, prospective study, indicating “that the laryngopharyngeal and thoracic portions of the vagal receptive field are capable of referring pain orofacially.” The investigation also suggested that the abdominal portion is not capable of causing such referred pain. ^[12]

Tonsillitis and pharyngitis are very common causes of earaches in children. Less commonly, laryngitis, laryngeal tumors, esophagitis, and even angina pectoris may manifest as otalgia. Eagle syndrome, in which the elongated styloid process irritates branches of CNs IX and X, is even rarer. ^[13] 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.

A retrospective study by Sussman et al of patients with otalgia indicated that migraine is a cause of referred otalgia. The investigators found that among their study subjects, the criteria for migraine were met in 71% of those with unexplained otalgia. Moreover, 87% of patients who were treated for migraine experienced significant improvement of otalgia, with 57% achieving complete earache resolution. ^[14]

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.

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 as meningiomas, 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.

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.

A few other diagnoses should always be considered when dealing with otalgia. Temporal arteritis, parotid neoplasms, and herpes zoster are all treatable diseases in which early diagnosis may be critical to ensure a favorable outcome.

A retrospective study by Ali et al of adult patients indicated that the symptoms of intratonsillar abscess differ from the classic symptoms of peritonsillar abscess, with a lower incidence of otalgia, trismus, and voice alterations. ^[15]