CNS/HN - Ear Pain

Question 1

Differential Diagnosis - Ear Pain

Answer 1

*Cholesteatoma

Ear pain

 Probability diagnosis 
Otitis media (viral or bacterial)
Otitis externa
Boils and furuncles of canal
TMJ arthralgia
Eustachian tube dysfunction 

Serious disorders not to be missed  
Neoplasia of external ear
Cancer of other sites (e.g. tongue, throat)
Herpes zoster (Ramsay—Hunt syndrome)
Acute mastoiditis
**Cholesteatoma
Necrotising otitis externa

Pitfalls (often missed)
 Foreign bodies in ear
Hard ear wax
Trauma including barotrauma
Dental abscess
Referred pain:
 neck, throat (e.g. tonsillitis)
Unerupted wisdom tooth and other dental causes
TMJ arthralgia
Chondrodermatitis nodularis helicus
Facial neuralgias, esp. glossopharyngeal
Post tonsillectomy:
•from the wound
•from TMJ due to mouth gag 

Masquerades checklist
Depression
Spinal dysfunction (cervical)

Is the patient trying to tell me something?
Unlikely, but always possible with pain. More likely in children. Consider factitious pain.

Question 2

Key History - Ear Pain

Answer 2

Key history

• Assess the site of pain and radiation, details of the onset of pain, nature of the pain, aggravating or reliving factors
• associated features such as
• vertigo,
• tinnitus,
• sore throat and
• irritation of the external ear.
• Ask about trauma, especially the use of a cotton bud to clean the ear.

Question 3

Key PE - Ear Pain

Answer 3

Key examination
•The external ear with manipulation of the ear
•Check helix for chondrodermatitis nodularis helicus
•Palpate the face and neck to include the parotid glands, regional lymph nodes and skin and temporomandibular joint (TMJ)
•Inspect both empty ear canals and tympanic membrane (TM) with the auroscope using the largest possible earpiece
•Look for causes of referred pain:
cervical spine, nose, postnasal space and mouth including teeth

Question 4

Key Investigation - Ear Pain

Answer 4

Key investigations
Seldom necessary.
•Consider hearing tests, audiometry
•Any ear discharge for MC but swabs of no value if the TM is intact

Question 5

Key Diagnostis - Ear Pain

Answer 5

Diagnostic tips
•The pain of otitis media may be masked by fever in babies and young children.
•If an adult presents with ear pain but normal auroscopy, examine possible referral sites, namely TMJ, mouth, throat, teeth and cervical spine.

Question 6

History - Cholesteatoma

Answer 6

• Severity Pain> Allergy> Pain killer
• HOPI - SIQORAA1
  Associated symptoms
• Hearing loss>hear better with noise?
• Discharge>CCVO
• nausea and vomiting
• vertigo/dizziness
• tinnitus
• cough and colds
• fever
  Ddx/Risk Factors
• previous history of ear infection
• Neck rigidity
• Trauma
  (head injury, swimming, diving, air travel)
• occupation
• previous surgery
• medications
• Family history
  Complications
• Any problem with your muscle of expression like smiling or blowing cheeks?

General
PMH
SADMA

Question 7

PE - Cholesteatoma

Answer 7

Physical examination
- General appearance and asymmetry/weakness of face
- Vital signs
- Ear: Whisper test, Rinne test and Weber test
Nose and throat

(+ perforation of TM, Whisper test + on affected side, Rinne test BC>AC on affected side, Weber lateralizes to the affected ear, nose and throat normal)

Question 8

Diagnosis - Cholesteatoma

Answer 8

Condition -
Most likely you have a condition called cholesteatoma and a conductive hearing loss. It is an abnormal skin growth in the middle ear behind the ear drum. When this growth increases in size, it destroys the delicate bones of the middle ear

Common
Not uncommon

Cause

• Chronic Ear infection
• Chronic Sinus infection
• Colds
• Poorly functioning Eustachian tube

Clinical feature
- hearing loss and when infected, it can lead to ear pain and discharge.

Complication

• Chronic ear infection
• swelling of inner ear
• Paralysis of facial muscles
• Meningitis - Life threatening brain infection
• Brain abscess - collection of pus in the brain

Question 9

Management - Cholesteatoma

Answer 9

• Refer to ENT
• Investigation - CT Scan and Audiogram, hearing test before deciding for surgery
• Initial treatment - ear toilette
• Antibiotic - Ofloxacin
• Surgery - removal of mass
• SNAP
• 2nd surgery - reconstruction of damaged middle ear bones
• Review
• Reading Materials
• Redflags
  facial nerve injury
  Brain Abscess
  Meningitis