Otalgia

Aka: Otalgia, Ear Pain

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II. Physiology

  1. Ear shares sensory fibers from head, neck and chest
    1. Trigeminal Nerve (CN 5)
    2. Facial Nerve (CN 7)
    3. Glossopharyngeal Nerve (CN 9)
    4. Vagus Nerve (CN 10)
    5. Cervical nerves (C2 and C3)
  2. Primary Ear Pain sources
    1. Auricle (CN 5, 7, 10 and C2-3)
    2. External auditory canal (CN 5,7, 10)
    3. Tympanic Membrane (CN 7, 9, 10)
    4. Middle Ear (CN 5, 7, 9)

III. History

  1. Pain location, duration
  2. Palliative and provocative factors
  3. Prior episodes of Ear Pain
  4. Tobacco Abuse
  5. Alcohol Abuse
  6. Associated symptoms suggestive of primary Otalgia
    1. Otorrhea
    2. Tympanic Membrane fullness
    3. Vertigo
    4. Hearing Loss
    5. Continuous and progressive Ear Pain
  7. Associated symptoms suggestive of secondary Otalgia
    1. Pain worse with chewing
    2. Sinusitis
    3. Dental procedures
    4. Gastroesophageal Reflux
    5. Hearing Loss absent
    6. Intermittent Ear Pain

IV. History: Red Flags to suggest secondary cause

  1. Age over 50 years (malignancy, Temporal Arteritis)
  2. Excessive Tobacco use (malignancy, vascular disease)
  3. Cardiac Risk Factors (Coronary Artery Disease, thoracic aneurysm)

V. Exam

  1. External Ear exam
    1. Auricle
    2. Periauricular area
  2. Otoscopy
    1. External auditory canal
    2. Tympanic Membrane
  3. Mouth Exam
    1. Dental Infection or Dental Pain
    2. Pharyngitis
  4. Nasal Exam
    1. Paranasal Sinus tenderness
  5. Other regional exam
    1. Temporomandibular Joint exam

VI. Causes: Primary Ear Conditions (50-60% of Otalgia cases)

  1. Common
    1. Cerumen Impaction
    2. Ear Canal Foreign Body
    3. Otitis Externa
    4. Suppurative Otitis Media
    5. Serous Otitis Media
    6. Eustachian Tube Dysfunction (often with Upper Respiratory Infection)
    7. Ear Barotrauma
  2. Uncommon: Urgent
    1. Malignant Otitis Externa
    2. Cholesteatoma
    3. Mastoiditis
    4. Cellulitis (auricle)
  3. Uncommon: Other
    1. Ramsay Hunt Syndrome (Herpes Zoster Oticus)
    2. Relapsing Polychondritis
    3. Granulomatosis with Polyangiitis (previously known as Wegener's Granulomatosis)
    4. Ear Trauma

VII. Causes: Secondary, Referred Pain (40-50% of Otalgia cases)

  1. Common
    1. Dental causes (38%) such as Dental Caries, Periodontal Abscess
    2. Temporomandibular Joint Disorders (35%)
    3. Cervical Spine disorders (8%) or Myofascial Pain
    4. Parotitis
    5. Pharyngitis
  2. Uncommon: Urgent
    1. Head and Neck tumors
    2. Temporal Arteritis
    3. Carotidynia
    4. Angina Pectoris or Acute Coronary Syndrome
    5. Thoracic aneurysym
  3. Uncommon: Other
    1. Bell's Palsy
    2. Eagle's Syndrome (styloid process elongation)
    3. Gastroesophageal Reflux
    4. Oral Aphthous Ulcers
    5. Periauricular or cervical adenitis
    6. Sialolithiasis
    7. Sinusitis
    8. Thyroiditis (rare cause of isolated Otalgia)
    9. Trigeminal Neuralgia and other regional Neuropathy (5%)

VIII. Evaluation: Secondary Ear Pain (no primary ear source identified)

  1. Malignancy risk factors (age >50, Tobacco Abuse, Alcohol Abuse, weight loss)
    1. Nasolaryngoscopy
    2. CT or MRI imaging
    3. Otolaryngology
  2. Temporal Arteritis (age >50, Jaw Claudication, Polymyalgia Rheumatica)
    1. Erythrocyte Sedimentation Rate (>50 mm/h)
  3. Suspected thoracic source (e.g. Coronary Artery Disease)
    1. Electrocardiogram
    2. Chest XRay
    3. Evaluate for Coronary Artery Disease, thoracic aorta
  4. Temporomandibular Joint Dysfunction or dental source
    1. Symptomatic management (NSAIDs, soft diet)
    2. Dental referral (or Temporomandibular Joint clinic)

IX. Management

  1. Treat underlying cause
  2. Systemic Analgesics (e.g. Acetaminophen, Ibuprofen)
  3. Topical Anesthetics (if no TM Rupture)
    1. Aurodex (Benzocaine and Antipyrine)
      1. Not available in U.S. as of 2016
      2. Risk of Contact Dermatitis (use with caution)
      3. Risk of methhemoglobinemia (do not use under age 2 years)
      4. Avoid Auralgan (expensive trade name replacement) without improved efficacy

X. References

  1. Earwood (2018) Am Fam Physician 97(1): 20-7 [PubMed]
  2. Ely (2008) Am Fam Physician 77:621-8 [PubMed]
  3. Kuttila (2004) J Orofac Pain 18:226-34 [PubMed]
  4. Shah (2003) Otolaryngol Clin North Am 36: 1137-51 [PubMed]

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