Otalgia

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, IX, 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.

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.[4]

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.[5]

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]

Frequently, the workup suggests that otalgia may be a problem of dental origin.

A complete blood 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.[3]

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.

See the list below:

• 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.

These include the following:

• Audiography

• Vestibulocochlear testing

• Nasal endoscopy

• Upper aerodigestive tract endoscopy, laryngoscopy

• Blood tests - CBC count, white blood cell (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.

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. Reexamine 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.

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

Physical examination should include the following:

• Nasopharyngoscopy
• Laryngoscopy

Preliminary testing (appropriate to symptoms) should include the following:

• Audio
• Barium swallow
• Electrocardiography (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.

A retrospective study by Roberts et al indicated that when medical therapy for otalgia fails, the condition can be successfully treated with tympanic plexus neurectomy. The study, which involved 12 patients (13 ears) who underwent the operation, reported that pain completely resolved in nine ears (69.2%) and partially resolved in two ears (15.4%), after either a single procedure or revision surgery.[16]

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.

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

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.

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.

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.

Class Summary

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting. Resort to empiric antimicrobial therapy only after an exhaustive search for a source of pain has failed.

Amoxicillin and clavulanate (Augmentin)

Treats bacteria resistant to beta-lactam antibiotics.

Amoxicillin (Amoxil, Trimox)

Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.

Clarithromycin (Biaxin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing cessation of RNA-dependent protein synthesis.

Ciprofloxacin (Cipro)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis, and consequently, growth.

Class Summary

Nucleoside analogs are initially phosphorylated by viral thymidine kinase to eventually form a nucleoside triphosphate.

Acyclovir (Zovirax)

Has demonstrated inhibitory activity against both HSV-1 and HSV-2. Selectively incorporated into infected cells.

Famciclovir (Famvir)

Prodrug that when biotransformed into active metabolite, penciclovir, may inhibit viral DNA synthesis/replication.

Valacyclovir (Valtrex)

Prodrug rapidly converted to the active drug acyclovir. More expensive but has a more convenient dosing regimen than acyclovir.

Class Summary

Mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.

Fluconazole (Diflucan)

Synthetic PO antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation.

Nystatin (Mycostatin)

Fungicidal and fungistatic antibiotic obtained from Streptomyces noursei. Effective against various yeasts and yeastlike fungi. Changes permeability of fungal cell membrane after binding to cell membrane sterols, causing cellular contents to leak.

Class Summary

These agents can be used for esophagitis or gastroesophageal reflux disease.

Famotidine (Pepcid)

Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and reduced hydrogen concentrations.

Ranitidine (Zantac)

Inhibits histamine stimulation of the H2 receptor in gastric parietal cells, which reduces gastric acid secretion, gastric volume, and hydrogen concentrations.

Lansoprazole (Prevacid)

Inhibits gastric acid secretion.

Omeprazole (Prilosec)

Inhibit gastric acid secretion by inhibiting H+/K+ ATPase enzyme system at secretory surface of gastric parietal cells.

Esomeprazole magnesium (Nexium)

S-isomer of omeprazole. Inhibits gastric acid secretion by inhibiting H+/K+ -ATPase enzyme system at secretory surface of gastric parietal cells.

Used in severe cases of and patients not responding to H2 antagonist therapy.

Used for up to 4 wk to treat and relieve symptoms of active duodenal ulcers; may be used up to 8 wk to treat all grades of erosive esophagitis.

Class Summary

Pain control is essential to quality patient care.

Ibuprofen (Motrin, Advil)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Hydrocodone and acetaminophen (Lortab, Vicodin)

Drug combinations indicated for moderate to severe pain.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for the relief of moderate to severe pain.

For patient education resources, see the Ear, Nose, and Throat Center, as well as Earache and Tinnitus.