Otalgia is a common complaint of patients presenting to both general practice and otolaryngology clinics. In some cases, ear pain is classified as primary otalgia, or pain that originates as the result of pathology within the ear itself. Examples of primary otalgia include external otitis, otitis media, mastoiditis, and auricular infections. Diagnosis of these conditions is fairly straightforward, and standard treatment generally alleviates the problem. However, in up to 50% of adults complaining of ear pain, the pain is the result of referred otalgia arising from non-otological disease.1 Physicians need to keep in mind the unique and complex innervation of the ear and be familiar with the myriad conditions that can result in ear pain in order to accurately diagnosis and treat the source of referred otalgia.
The sensory innervation of the ear involves six nerves: two branches of the cervical plexus, derived from the second and third cervical roots, and four cranial nerves-trigeminal (V), facial (VII), glossopharyngeal (IX), and vagus (X).1 Noxious stimulation of any branch of these nerves by any of the structures receiving sensory input from these nerves can cause ear pain. This complex innervation can make diagnosis of the etiology of ear pain in the absence of primary ear pathology a challenge.
Because referred otalgia can be the result of a vast number of problems ranging from dental issues (e.g., temporomandibular disease) to a more serious condition requiring immediate diagnosis and intervention (e.g., hidden malignancy), the physician must use a structured, systematic approach to identify the etiology of the patient’s pain. A comprehensive history and exhaustive physical examination are crucial components of this approach. The findings of the history and physical examination will determine what interventions or additional testing may be indicated (see flowchart).
The physician must obtain a complete history regarding the patient’s chief complaint of ear pain. Ask the patient to describe his or her pain: onset, characteristics, severity, localization, radiation. Does anything done by the patient seem to alleviate or exacerbate the pain? It is important to remember that the severity of pain is not in any way indicative of the seriousness of pathology.
The physician should then question the patient regarding associated symptoms. For example: Does the patient suffer from tinnitus, hearing loss, vertigo, sinusitis, facial pain, myalgias, neuralgias, or arthritis?
Question the patient about constitutional symptoms. Specific questions by the physician may elicit information from the patient that he or she may not have considered pertinent and may not have mentioned otherwise. Specifically, the patient should be queried regarding:
- Dental problems
- Current or recent infections
- Sinus issues
- Cancer risk factors
- Recent trauma
- Gastrointestinal history
- Past otologic history
- Cardiopulmonary history
- Other constitutional symptoms.
Once the physician has obtained and documented a complete comprehensive history from the patient, he or she should perform an exhaustive physical examination. The exam should begin with an otologic and neurotologic examination to identify any primary ear pathology. This should be followed by a complete head and neck examination, including palpation of the neck to identify potential thyroid enlargement and any adenopathy or musculoskeletal disorders within the neck. Further head and neck exam should include the structures around the ear, the parotid, nose, and oropharynx. Flexible endoscopy can and should be used as indicated. Cranial nerves should be examined and compared bilaterally.
Gerard Gianoli, MD, of the Ear and Balance Institute in Baton Rouge, LA, considers an audiogram standard in examination of patients presenting with otalgia. He stated, Anyone presenting to my practice complaining of ear pain would get a hearing test. An audiogram can identify even minor hearing loss that the patient may not have even noticed. Additionally, Dr. Gianoli advises that physicians should not hesitate to perform rhinoscopy, nasopharyngoscopy, and indirect laryngoscopy as indicated.
John Li, MD, Past Chairman of the Section of Otolaryngology at Palm Beach Gardens Medical Center, finds the use of topical and injectable anesthesia very helpful in localizing the problem when history and physical examination findings are otherwise inconclusive. The nasal cavity may be sprayed with topical ponocaine or Cetacaine, or 4% lidocaine gargle can be used to anesthetize the oropharynx and larynx, and injectable 1% Xylocaine can be used to identify neuromuscular trigger points and can be useful in the diagnosis of myalgias and neuralgias.2 The idea is to kick the tires and try to stir up the pain, and then numb the area to take away the pain to see if the otalgia resolves, said Dr. Li.
When history and physical examination fail to definitively identify the source of the patient’s pain, additional studies may be useful.
Dr. Li stressed, It is critically important to try to find a source for the otalgia, because if you do not, the source might be a malignant tumor that comes back to haunt you. You must rule out a malignancy.
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
- Throat processes
- Tonsillitis and post-tonsillectomy complications (common in children)
- Complications from allergies (sinusitis, rhinitis)
- Bell’s palsy
- Skeletal conditions
- Cardiovascular disease
- Pulmonary disease
- Rheumatoid arthritis
- Charlett SD, Coatesworth AP. Referred otalgia: a structured approach to diagnosis and treatment. Int J Clin Prac 2007;61(6):1015-21.
- Li JC, Brunk J. Otalgia. Available at www.emedicine.com/ent/topic199.htm . Accessed Jan. 17, 2008.
©2008 The Triological Society