Otalgia

Question 1

What is otalgia?

Answer 1

Otalgia = ear pain that originates from the ear itself or can be referred from elsewhere in the head or neck (referred pain)

=> very common presentation in children in primary care

Question 2

What are the causes of otalgia?

Answer 2

1. Acute otitis media

=> child with severe ear pain and preceding upper respiratory tract infection

=> erythema, bulging ear drum, febrile

2. Otitis externa

=> severe pain with preceding itch and contact with water i.e. swimming

=> tender, narrow external auditory meatus and mucopus

3. Necrotising otitis externa (malignant otitis externa, skull base osteomyelitis)

=> elderly with severe pain, often with diabetes or other causes of immunocompromised

=> floor of ear canal showing granulation ± cranial nerve palsies

4. Temporomandibular joint dysfunction

=> pain anterior to trigs and worse when eating

=> normal eardrum, tender over temperomandibular joint and misaligned/clicking bite

5. Referred pain - look for red flags

=> moderate/severe intermittent pain

=> normal eardrum and palpable mass in head and neck

Question 3

What is referred otalgia?

Answer 3

Causes of ear pain not directly related to ears so important to ask about dental, nasal and throat symptoms, may be indicators of malignancy

Any pathology involving cranial nerves V, VII, IX and X and the upper cervical nerves C2 and C3 can cause sensation of referred otalgia.

Trigeminal neuralgia is the most common cranial neuralgia linked to referred otalgia

Question 4

Referred otalgia:

1. Cranial nerve V3 (most common) i.e. mandibular branch of trigeminal nerve

=> temporomandibular junction dysfunction

=> pathology involving 2 major salivary ducts

=> dental abscess

2. Cranial nerve V2 (maxillary branch of trigeminal nerve)

=> mucosal inflammation involving the sinuses

Answer 4

3. Cranial nerve IX (includes the jacobson nerve branch supplying cochlear promontory and Eustachian tube)

=> oropharyngeal pathology e.g. peritonsillar abscess

=> tonsilitis

=> oropharyngeal carcinoma

4. Cranial nerve X
   => laryngeal cancer
5. Cervical nerve (C2 and C3)
   => Cervical spine disease e.g. cervical spondylosis

Question 5

What is mastoiditis?

Answer 5

Swelling, erythema and tenderness over the mastoid process

Presenting with:

=> severe otalgia behind ear

=> fever

=> Hx of recurrent otitis media

=> ear discharge if tympanic membrane perforation

=> patient is very unwell