Ear pain-Otalgia
Otalgia – also called as earache or ear pain is an unpleasant experience in the ear. Can be primary – pain coming directly from the ear. Most commonly due to infection. Secondary- referred pain from somewhere outside the ear. Ear has a complex nerve supply and shares neural network with other organs ie there are several potential causes of referred ear pain.
Primary otalgia – Infections for e.g ○ otitis media ○ acute otitis externa ○ furunculosis ○ cellulitis ○ Herpes zoster oticus , Ramsay Hunt Syndrome ○ malignant otitis externa ○ mastoiditis ○ petrous apicitis Trauma ( e.g haematoma of pinna ) TM perforation Foreign body Impacted wax Eustachian tube dysfunction ○ OM with effusion ○ chronic OM Cancer ○ primary neoplasms of ear are rare and can usually be seen when they happen in auricular and peri-auricular regions ○ cancer of the temporal bone and external auditory canal are even more rare ○ squamous cell carcinoma ○ basal cell carcinoma ○ melanoma ○ cholesteatoma Inflammatory causes ○ chondrodermatitis nodularis helicis ○ Wegener’s granulomatosis ○ Bullous myringitis
Secondary
Sinus infections
Oral causes – Dental impaction Dental infection / abscess SCC of tongue
Pharynx – Tonsillitis Epiglottitis Post-tonsillectomy.
Salivary glands- parotid – Infection Stone Trauma Tumour
TMJ disorders
Neck problems – Goitre Lymph node enlargement Musculoskeletal causes Cervical neck Thyroiditis Thyroid carcinoma
Others – temporal arteritis Head and neck cancers Bell’s palsy Neuralgias for e.g trigeminal.
History – Onset Duration Review of pain Otorrhoea ( ear discharge ) Hearing loss / distrbance Itching ( common in otitis externa ) Vertigo Aural fullness Tinnitus Aggravating factors ( for e.g with chewing ) Associated symptoms as ○ oral cavity ○ dental symptoms / history ○ post-nasal drip ○ voice change ( e. g hoarseness ) ○ reflux symptoms pain on chewing may suggest as dental , parotid or TMJ problem ○ sore throat / tonsillitis ○ nasal obstruction and sinus passage symptoms Previous ear problems / grommets / surgery including recent dental procedures Recent swimming , trips abroad Neck symptoms as OA of spine.
Examination – Inspect external ear Pre- auricular and postauricular regions Surrounding skin for erythema , swelling or skin disease Vesicular lesions suggest herpes zoster infection ( called Ramysay Hunt Syndrome if it happens with facial palsy ) Moving the pinna / pressing the tragus may elicit pain Acute folliculitis can be quite painful , seen in lateral external auditory ear canal ( hairs present here ) -small abscess formations Otoscopy – pull the pinna upwards and backwards to inspect the ear canal ○ narrow canal , debris , discharge suggests otitis externa ( also known as swimmers ear ) ○ fluid behind the TM causing dullness , bulge or perforation indicated otitis media OME is otitis media with effusion ( known as glue ear ) AOM – fluid in the middle ear which is infected , often associated with viral URTr infections CSOM -a rare complication of AOM ( chronic suppurative otitis media ) presents with recurrent discharge through TM Otitis media and externa can co-exist Cranial N examination ( if abnormal findings in ear ) The facial N can be involved with AOM , mastoiditis , Bell’s palsy or a temporal bone fracture Based on clinical suspicion ○ head and neck examination ○ nasal and oral cavity , neck ○ TMJ palpation , parotids.
Red flags – History of smoking , alcohol use Age ( > 50 ) Immunosuppressed state Ear pain + 4 weeks duration in presence of risk factors and normal otoscopy No cause identified on otoscopy and physical examination Malignancy tends to present with unilateral symptoms-
Management of otalgia can be challenging , workup can be complex with no simple algorithms -the following clues may help you in determining the cause
Duration – Shorter duration of presentation usually suggests a benign cause whereas longer time frames indicate a secondary cause.
Pain characteristic – Pain due to infection is generally continuous and usually progressive ( intensity of pain may wax and wane ) Intermittent pain may suggest MSK , TMJ and other myofascial pain syndrome.
Referred pain- fever , sore throat , reflux symptoms , hoarseness , sinus symptoms , recent dental work , heart burn , chest pain , upper back pain , headache , diplopia , malaise , jaw claudication -these features may suggest a secondary cause Otalgia in children is commonly due to diseases of the ear.
Immunocompromised – inflammation or granulation tissue along the inferior canal floor suspect in cases where symptoms persist in susceptible individuals / elderly despite treatment here the diagnosis of necrotizing otitis externa should be considered.
Mastoiditis – usually develops from AOM and may happen despite antibiotic use ( ie a complication of OM ) it is an inflammation of a portion of the temporal bone referred to as the mastoid air cells suspect if AOM is resolving after about a week of therapy and presentation is with severe ear pain , fever , headache , post-auricular erythema tenderness and warmth and flatulence with protrusion of auricle Refer ENT same day as treatment is with IV antibiotics and untreated / undiagnosed mastoiditis can have disastorous complications as facial paralysis , labyrinthitis , extradural abscess , meningitis , brain abscess, sigmoid sinus thromobophlebitis and otitis hydrocephalus
Impacted wax- significant wax impaction can cause dull achy pain cotton buds may push the wax even further any compact it more tightly
Cholesteatoma abnormal extension of skin into the middle ear and the mastoid air cell spaces benign collection of keratinized squamous epithelium within the middle ear -but they have the ability to erode and can be locally destructive can be congenital or acquired presentation can be with persistent or recurrent discharge from the ear that is often foul smell and conductive hearing loss , dizziness otoscopy- retraction pocket in the attic or posterosuperior quadrant
Tests – Most cases history and examination is sufficient to start appropriate first line treatments Ear swabs should be considered in recurrent / chronic otitis externa Hearing test if patient reports associated hearing loss Investigate for secondary causes based on clinical suspicion for e.g imaging if high risk malignancy.
Management – Management is based on suspected cause Please refer to the charts on OE and OM for management which include guidance from NICE.
ENT referral- Suspected mastoiditis , necrotizing otitis externa , cellulitis involving the external ear -refer same day ENT Refractory otitis externa – with ear canal debris and narrowing of the ear canal for aural toilet / wick -refer urgent OP to be seen within 2 weeks Persistent or unexplained otalgia without an apparent cause and a normal examination Referred otalgia – based on clinical suspicion for e.g BMJ suggests a 2 week referral if symptoms have persisted for more than 4 weeks Unexplained referred otitis media or suspected cholesteatoma.
PATIENT INFORMATION
Ear pain in children- a good overview from Mottchildren org https://www.mottchildren.org/posts/your-child/ear-pain-children
Otitis externa printable leaflet from Guy’s and St Thomas’s https://www.guysandstthomas.nhs.uk/resources/patient-information/audiology/otitis-externa.pdf
Otex patient information leaflet from medicine compendium https://www.medicines.org.uk/emc/product/299/pil#gref
Royal Children’s Hospital of Melbourne – parent information on ear infections and glue ear https://www.rch.org.au/kidsinfo/fact_sheets/Ear_infections_and_Otitis_media/
CDC on OE ( swimmers ear ) 1 page printable leaflet https://www.cdc.gov/healthywater/pdf/swimming/resources/pseudomonas-factsheet_swimmers_ear.pdf
Safer Care Victoria on OE- printable leaflet https://www.bettersafercare.vic.gov.au/sites/default/files/2019-07/Otitis%20externa.pdf
Otitis media patient information from Stanford’s Children Health https://www.stanfordchildrens.org/en/topic/default?id=otitis-media-middle-ear-infection-90-P02057
References
- Otalgia doi:10.1136/bmj.39364.643275.47
- Recurrent otalgia in adults doi:10.1136/bmj.i3917
- Coulter J, Kwon E. Otalgia. [Updated 2020 Aug 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549830/
- Ryan E. Neilan, Peter S. Roland,Otalgia,Medical Clinics of North America, Volume 94, Issue 5, 2010, Pages 961-971, ISSN 0025-7125,
https://doi.org/10.1016/j.mcna.2010.05.004.(https://www.sciencedirect.com/science/article/pii/S0025712510000891) - Otalgia Elizabeth Harrison , Matthew Cronin Australian Family Physician Volume 45 July 2016 RACGP – Otalgia
- Kennedy KL, Singh AK. Middle Ear Cholesteatoma. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448108/
- Cholesteatoma – diagnosing the unsafe ear Philip Chang m Australian Family Physician Vol. 37, No. 8, August 2008 631
- Sahi D, Nguyen H, Callender KD. Mastoiditis. [Updated 2021 Feb 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560877/
- Kim, Sang Hoon et al. “Clinical Differences in Types of Otalgia.” Journal of audiology & otology vol. 19,1 (2015): 34-8. doi:10.7874/jao.2015.19.1.34
