Otalgia

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S [2]

Otalgia is one of the leading complaints among children either in the primary care or in emergency setting.

Acute Otitis media, Otitis externa, Otitis media with effusion are the three most common causes responsible for Otalgia in children. Otalgia is not always associated with ear disease. It may be caused by several other conditions, such as Impacted tooth, Sinus disease, Inflamed tonsils and infections in the nose and pharynx. The most common causes of ear pain can be identified through the description of the character, onset, and location (coupled with a physical examination).

There are two distinct types of otalgia: Primary Otalgia – pain that originates from pathologies within the ear, Referred Otalgia – pain that originates from pathologies outside the ear and is referred to it.

Otalgia or ear pain is one of the most common complaints in the pediatric age group presenting to the primary care or emergency room. Otalgia can be primary or referred. Primary being caused by diseases of the ear and referred being caused by diseases elsewhere. The ear canal is heavily innervated, and the skin lining the canal lies directly against the bone without an intervening subcutaneous layer; therefore, even mild pressure, swelling, or inflammation in this area can cause immediate and severe pain.

Otalgia can be caused by diseases involving the ear (e.g otitis media, otitis externa) or can be caused by diseases that cause referred pain to the ear (e.g dental caries, pharyngitis).

Otalgia is often due to otitis media which is predominantly an infectious disease of children. Otitis externa is less frequent and is often observed in swimmers.

An immature immune system, developmental alterations of the eustachian tube, and frequent infections are the major risk factors in children. In adults, smoking, alcohol and immunosuppression form the major contributors among risk factors.

Natural history, prognosis and complications depend on the disease per se. Acute otitis media, Otitis externa, mastoiditis, cholesteatoma have good prognosis as long as deeper structures of the neck are not involved. If the disease processes persist for more than 6 weeks they have a high chance of getting converted to chronic forms.

It is normally possible to establish the cause of ear pain based on the history. It is important to exclude cancer where appropriate, particularly with unilateral otalgia in an adult who uses tobacco or alcohol.^{[1] [2]}

Otalgia is one of the leading complaints in the pediatric age group. Otitis media, otitis externa, and ear trauma are among the leading causes of ear pain. When the ear is the source of the pain (primary otalgia), the ear examination is usually abnormal. When the ear is not the source of the pain (secondary otalgia), the ear examination is typically normal.

It is normally possible to establish the cause of ear pain based on the history. It is important to exclude cancer where appropriate, particularly with unilateral otalgia in an adult who uses tobacco or alcohol.^[3] Common lab tests include complete blood count, differential count of WBC, culture and screening of otorrhea, thyroid function studies – for thyroiditis, erythrocyte sedimentation rate- for temporal arteritis, throat swabs for tonsillitis and pharyngitis.

Otalgia is ear pain that can be caused by pathology in the ear itself, or pathology in a distant source which causes referred pain to the ear. A computed tomography (CT) scan is helpful in determining the underlying cause of ear pain. CT with contrast is indicated when the goal is to determine the extent of the disease. It is also used in evaluating temporal bone trauma.

An MRI is indicated in the evaluation of otalgia if there is any clinical or audiometric suspicion.

Other imaging studies in the evaluation of otalgia includes radiography, Panorex imaging, and PET scans.

Other diagnostic tests include tympanometry, audiometry, and upper aerodigestive tract endoscopy.

Treatment of otalgia lies in identifying the pathology, whether it exists within the ear or elsewhere. Antibiotics are used to treat infectious causes like otitis media, otitis externa, tonsillitis, and pharyngitis. Antivirals can be used for viral causes such as herpes zoster oticus, and antifungals can be used for oral thrush. NSAIDs are used if myalgias and neuralgias are suspected. The patient should be re-examined after a 2 week trial on the NSAIDs. Appropriate consultation with a neurologist, dentist, gastroenterologist etc., should be done.

Surgery forms the main stay of treatment for major ear pathologies like otitis media (OM), otitis externa, cholesteatoma, mastoiditis, etc., and some non-ear pathologies like TMJ disorders and retropharyngeal abscesses.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S [2]

There are two distinct types of otalgia: Primary Otalgia – pain that originates from pathologies within the ear, Referred Otalgia – pain that originates from pathologies outside the ear and is referred to it.

Otalgia may be classified according to origination into two groups:

• Primary (originates from ear)
• Secondary (originates other system)

Primary causes include,infectious,mechanical,neoplastic and inflammatory. Most of the secondary causes related to head and neck.^[1][2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S [2]

Otalgia or ear pain is one of the most common complaints in the pediatric age group presenting to the primary care or emergency room. Otalgia can be primary or referred. Primary being caused by diseases of the ear and referred being caused by diseases elsewhere. The ear canal is heavily innervated, and the skin lining the canal lies directly against the bone without an intervening subcutaneous layer; therefore, even mild pressure, swelling, or inflammation in this area can cause immediate and severe pain.

• Otitis media: Eustachian tube (ET) dysfunction is the most important factor in middle ear disease. Interference with this mucosa, at the pharyngeal end of the eustachian tube facilitates direct extension of infectious processes from the nasopharynx to the middle ear, causing OM. Developmental alterations of the eustachian tube, an immature immune system, and frequent infections of the upper respiratory mucosa all play major roles in acute otitis media development in children.^[1]

• Otitis externa: Excessive exposure to water results in an overall reduction in cerumen production in the ear. This reduction in cerumen can then lead to drying of the external auditory canal and pruritus. The pruritus can then lead to probing of the external auditory canal, resulting in skin breakdown and an entry site for infection. The most common offending organisms are Pseudomonas aeruginosa, Staphylococcal aureus, anaerobes and gram-negative organisms, and fungi such as the Aspergillus and Candida species.^{[2] [3]} It is common in swimmers and hence the name swimmer’s ear.

• Mastoiditis: The pathophysiology of mastoiditis is straightforward: bacteria spreads from the middle ear to the mastoid air cells, where the inflammation causes damage to the bony structures. Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms recovered in acute mastoiditis. Organisms that are rarely found are Pseudomonas aeruginosa and other gram-negative aerobic bacilli, and anaerobic bacteria.^[4]

• Cholesteatoma: Cholesteatoma may be congenital or acquired. Congenital cholesteatomas are usually epidermal cysts which have arisen as a result of a developmental abnormality.^[5] Acquired cholesteatomas predominantly arise following retraction of part of the ear drum in response to middle ear inflammation.^[6] Much less often they may arise as the result of migration of squamous epithelium through a perforation in the ear drum. ^[7] Cholesteatoma may also arise as a result of metaplasia of the middle ear mucosa ^[8] or implantation following trauma.

The ear is supplied by a number of different sensory nerves, including cranial nerves V, VII, IX, and X, as well as the cervical plexus. Diseases affecting structures innervated by these nerves may result in referred (ie, secondary) otalgia.

• The auriculotemporal branch of the mandibular division of cranial nerve V (ie, V3) innervates the skin of the tragus and part of the helix of the external ear, the anterior and superior walls of the external auditory canal, and the anterior portion of the tympanic membrane. Ear pain can also be referred via cranial nerve V from the teeth, gums, mouth, jaw, and face. Rarely, trigeminal neuralgia can cause otalgia.^[9]

• The facial nerve (VII) innervates the posterior tympanic membrane and part of the posterior wall of the external auditory canal. Disorders of teeth, temporomandibular joint and parotid glands can cause referred pain in ear.

• The glossopharyngeal nerve (IX) innervates the posterior portion of the external auditory canal and meatus, the posterior portion of the tympanic membrane, the mastoid, and the eustachian tube. The tympanic branch of cranial nerve IX ascends into the middle ear and forms the tympanic plexus before proceeding as the lesser petrosal nerve to the otic ganglion. Ear pain can also be referred via cranial nerve IX from the posterior tongue, tonsils, and pharynx.

• The auricular branch (Arnold’s nerve) of the vagus nerve (X) innervates part of the cavum conchae (the vestibule to the external auditory canal), the posterior wall of the external auditory canal, and the posterior portion of the tympanic membrane. Ear pain can also be referred via cranial nerve X from the heart,^[10] pharynx, larynx, trachea, diaphragm, thyroid gland, and esophagus, among other thoracic and abdominal structures.

• The upper cervical nerves (C2 and C3), particularly the posterior branch of the great auricular nerve, innervate the posterior surface of the external ear and some of the cavum conchae. Ear pain can also be referred via the cervical plexus from structures in the neck and cervical spine.

• Somatic afferent fibers from cranial nerves V, VII, IX, and X as well as the cervical plexus (C2 and C3) all synapse in the spinal trigeminal nucleus in the caudal medulla and the upper cervical spinal cord.

Hence any disease of the ear or in the areas innervated by the nerves which also supply the ear can cause ear pain. Psychogenic otalgia is when no cause to the pain in ears can be found, suggesting a functional origin. The patient in such cases should be kept under observation with periodic re-evaluation.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S[2]

Otalgia can be caused by diseases involving the ear (e.g otitis media, otitis externa) or can be caused by diseases that cause referred pain to the ear (e.g dental caries, pharyngitis).

• Otitis externa
• Otitis media
• Foreign body
• Barotrauma
• Cerumen impaction
• Cholesteatoma
• Dental caries
• Ear canal foreign body
• Ear trauma
• TMJ syndrome
• Mastoiditis
• Perforated eardrum
• Pharyngitis^[1]

• Malignant (necrotizing) otitis externa
• Ramsay Hunt syndrome (herpes zoster oticus)
• Cellulitis/chondritis/perichondritis
• Relapsing polychondritis
• Mastoiditis
• Wegener’s granulomatosis
• Viral myringitis^[1]

• Acoustic neuroma
• Acute otitis externa (Swimmer’s ear)
• Acute otitis media
• Arthritis of the temporomandibular joint
• Auricular erysipelas
• Auricular perichondritis
• Cellulitis
• Cerumen impaction
• Cervical spine disease
• Cholesteatoma
• Chronic otitis externa
• Chondrodermatitis nodularis chronica helicis
• Ear canal foreign body
• Eczema
• Eustachian tube dysfunction
• Eustachian tube syringitis
• Furunculosis
• Herpes zoster oticus
• High altitude sickness
• Keratosis obturans
• Malignant otitis externa
• Mastoiditis
• Mumps
• Myringitis bullosa
• Other acute barotrauma
• Psoriasis
• Ramsay Hunt syndrome
• Reaction to topical agents
• Perforated eardrum
• Sterile middle ear effusion
• Suppurative otitis media
• Trauma
• Tretinoin
• Tumor
• Tympanostomy tube obstruction
• Varicella
• Vinflunine

• Acute coronary syndrome ^[7]
• Angina
• Arnold nerve cough syndrome
• Arthritis
• Bell palsy ^[8]
• Carotidynia
• Cervical adenitis
• Cervical spine infection
• Dental caries
• Ear, nose, throat (ENT) deep-space infection
• Esophagitis
• Functional disorders
• Glossopharyngeal neuralgia
• Laryngeal carcinoma
• Laryngitis
• Lymphadenitis
• Mastoiditis
• Metastatic tumor
• Mumps
• Pahryngitis
• Parotiditis
• Post-tonsillectomy/adenoidectomy
• Retropharyngeal abscess
• Rhinitis
• Sialoadenitis
• Sinusitis
• Syphilitic meningitis
• Temporomandibular joint dysfunction (TMJ) ^[9]
• Tongue cancer
• Tonsil cancer
• Tonsilitis
• Tooth infection
• Trigeminal neuralgia
• Upper respiratory tract infection
• Wegener granulomatosis

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Based on the pain originates,differential diagnosis can be divided into primary and secondary categories.The causes of the Primary otalgia include,infectious,mechanical,neoplastic and inflammatory.Secondary otalgia originates other organ system. Most of the secondary causes related to head and neck.

Based on the pain originates,differential diagnosis can be divided into primary and secondary categories.The causes of the Primary otalgia include,infectious,mechanical,neoplastic and inflammatory.Secondary otalgia originates other organ system. Most of the secondary causes related to head and neck.^[1][2]

^[2][1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S[2]

Otalgia, or ear pain, is commonly due to otitis media which is predominantly an infectious disease seen in children. Otitis media ia an infection of the middle ear. Otitis externa is a less frequent cause of ear pain, and is often observed in swimmers and hence names swimmer’s ear.

• Acute otitis media (AOM) is predominantly a disease of children. It is the most common reason children are brought to their family physician, and the most common reason for the administration of antibiotics in children.^[1][2]
• Otitis media is most prevalent in infants. Immunization of infants with the 7 valent pneumococcal conjugate vaccine (PCV7) has decreased the incidence of otitis media.
• Males are affected more than females.
• Peak incidence is between 6-18 months of age.
• About 30% of children younger than 3 years of age visit their primary care physicians with AOM each year, and by their third birthdays 80% to 90% of children have experienced AOM.^[3]
• Although otitis media commonly occurs in children, it is a public health concern due to the seriousness of the complications that can result. This is due to the proximity of the middle ear to the mastoid area, and to the middle and posterior cranial fossa.

• Incidence of otitis externa is 400 out of 100,000 people in the USA.
• There is a higher incidence during the summer.
• No sex predilection.
• Frequently seen in people who are associated with aquatic activities.
• No association with age but a slight increase in prevalence is noted in patients aged more than 65 yrs was postulated to occur secondary to an increase in comorbidities, as well as an increase in the use of hearing aids, which may cause trauma to the external auditory canal. ^[4]

• Incidence is unknown.

• Incidence is 4 per 100,000 people in the USA.
• Common in children.
• Median age is 12-24 months.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S[2]

An immature immune system, developmental alterations of the eustachian tube, and frequent infections are the major risk factors in children. In adults, smoking, alcohol and immunosuppression form the major contributors among risk factors.

• Anatomic abnormalities
• Day care
• Siblings with otitis media
• Smoking in household
• Supine bottles
• Age older than 50 years, ESR greater than 50 mm per hour
• Coronary artery disease risk factors
• Diabetes or immunocompromised state
• Tobacco
• Alcohol
• Unilateral hearing loss
• Swimming

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S[2]

Natural history, complications and prognosis depend on the disease process which is involving the ear. For most of the diseases the prognosis is good with good patient recovery.

• Otitis media: The symptoms of disease typically develop in the first five years of life. The course of the disease is benign with most of the patients recovering without any sequelae. If the otorrhea persists for more than 6-12 weeks chronic otitis media develops.
• Otitis externa: The symptoms of disease typically develop in aquatic athletes. Disease course is benign but Chronic otitis externa develops if the disease process extends more than 6 weeks. Diabetic patients are at risk for development of Malignant otitis externa which is caused by Pseudomonas bacteria.
• Mastoiditis: The symptoms of this disease typically develop in children younger than 2 years old with the median age being 12 months.
• Cholesteatoma: The symptoms of this disease typically develop in adults. Progression of this disease causes destructive lesions in the ear and also hearing loss.

• Otitis media can be complicated by the development of:
  • Mastoiditis
  • Cholesteatoma
  • Labyrinthitis
  • Facial nerve paralysis
  • Epidural abscess
  • Lateral sinus thrombophlebitis
  • Brain abscess

• Otitis externa can be complicated by the development of:
  • Necrotizing otitis externa
  • Mastoiditis
  • Chondritis of the auricle
  • Bony erosion of the base of the skull
  • Central nervous system (CNS) infection

• Mastoiditis can be complicated by the development of:
  • Hearing loss
  • Facial nerve paralysis
  • Osteomyelitis
  • Periostitis
  • Intra cranial complications – Meningitis, Cerebral abscess, Epidural abscess, Subdural empyema
  • Labyrinthitis
  • Sigmoid sinus thrombosis
  • Abscess formation

• Cholesteatoma can be complicated by development of:
  • Erosion of the temporal bone
  • Brain dysfunction
  • Intra-cranial infections

• Otitis media:
  • Prognosis is excellent.
  • Intra-cranial and intra-temporal complications occur in less than 1% patients.
  • Otitis media in infants younger than 12 months predisposes to long-term speech and language problems.
  • It has also been reported to negatively affect pre-existing cognitive or language problems warranting careful follow-up and early referral.

• Otitis externa:
  • Prognosis is good. Swimmers can return to routine aquatic activities in less than a week.
  • Worse prognosis is seen in some Diabetic patients in whom it may progress to Malignant otitis externa.

• Mastoiditis:
  • Prognosis of Acute Mastoiditis is good as far as facial nerve, vestibule and intra-cranial structures are not involved. Recovery is complete from Surgical mastoiditis.

• Cholesteatoma:
  • Prognosis is good with early recognition, timely surgical intervention and use of appropriate antibiotics. 90% patients have tympanic membrane perforation.

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