‘Doctor, My Ear Hurts’: Diagnosing Referred Otalgia

Simple laboratory studies, including a complete blood count (CBC) to rule out infection, testing for sickle cell anemia, and thyroid function studies may prove helpful. Based on the findings of the history and physical examination, barium swallow may be indicated to identify gastroesophageal problems. Also, based on history and physical findings, studies such as vestibulocochlear testing and nasal endoscopy may be indicated.

Said Dr. Gianoli, It is important to think about imaging at some point when a diagnosis cannot readily be made. If everything is normal on physical exam, then consider imaging, especially if the patient’s symptoms have persisted for several weeks, and particularly if they’ve had other therapies and the pain persists. Imaging studies that may be useful include:

• Dental radiography.
• CT scanning-can reveal significant information about the temporomandibular joint or can be used to diagnose intratemporal lesions.
• MRI-may be necessary to define a cerebellopontine angle or other intracranial tumor.
• Panorex imagery-useful in diagnosing temporomandibular joint dysfunction, odontogenic pathology, and styloid abnormalities.
• PET scanning-fused with CT or MRI, it adds tremendously detailed information about the location of head and neck neoplasms.2

Dr. Gianoli further advised, If other findings are negative, rigid endoscopy in the OR may be warranted in a smoker with persistent ear pain, especially if the patient is also experiencing hoarseness, to rule out head and neck neoplasm.

Any abnormality identified must followed up and treated. Treatment may be as simple as prescribing an appropriate medication or recommending modifications in the patient’s diet or activity. Alternately, findings may require referral to another medical specialist, such as a dentist or oral surgeon, neurologist, rheumatologist, pain management specialist, gastroenterologist, or general surgeon.

Otalgia is a symptom that the physician should never consider insignificant or idiopathic until all possible etiologies, local and distant, have been ruled out. Dr. Li summed it up quite simply: When it comes to otalgia, what you see is not always what you get.

Differential Diagnosis of Referred Otalgia

Differential diagnoses for referred otalgia can include, but are not limited to:

• Neoplastic process
• Temporomandibular joint syndrome
• Other dental pathology
• Eagle’s syndrome
• Gastroesophageal reflux disease
• Parotid disease
• Neuralgia
• Throat processes
• Tonsillitis and post-tonsillectomy complications (common in children)
• Complications from allergies (sinusitis, rhinitis)
• Trauma
• Laryngitis
• Bell’s palsy
• Skeletal conditions
• Cardiovascular disease
• Pulmonary disease
• Rheumatoid arthritis

References

1. Charlett SD, Coatesworth AP. Referred otalgia: a structured approach to diagnosis and treatment. Int J Clin Prac 2007;61(6):1015-21.
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2. Li JC, Brunk J. Otalgia. Available at www.emedicine.com/ent/topic199.htm . Accessed Jan. 17, 2008.
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©2008 The Triological Society