Otalgia Treatment & Management

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.