Ear pain resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Samah Obaiah, MD[2]

Synonyms and keywords: Approach to ear pain, Ear pain workup, Ear pain management

Ear pain resident survival guide Microchapters
Overview
Causes
Diagnosis
Treatment

Overview

Ear pain or otalgia is a pain that originates from ear or the surrounding tissues. The etiology can be difficult to establish because of the complex innervation of the ear. Branches of the fifth, seventh, ninth, and tenth cranial nerves along with cervical nerves 1, 2, and 3 all contribute to sensation of the middle ear, external auditory canal, auricle, and peri-auricular tissues. Irritation of any portion of these cranial nerves can result in otalgia. Otalgia can be the manifestation of myocardial ischemia (ie, an angina equivalent) because the vagus nerve provides sensory innervations for both structures. Intermittent pain is much more likely to be associated, for example, with musculoskeletal conditions as temporomandibular joint (TMJ) dysfunction and other myofascial pain dysfunction syndromes. otalgia classified as primary, which originated from the ear, and secondary, which originated from outside the ear. When the ear examination is abnormal, the source of the pain from the ear (primary otalgia); when the ear examination is typically normal, the pain source is not the ear (secondary otalgia). The examination that should be carried out include inspection of nasal cavity, oral cavity, neck, and possibly the larynx.

Causes

Life Threatening Causes

Otalgia is not life-threatening, but some characteristics make a serious diagnosis more likely in patients with Otalgia. Otalgia may also be the first sign of:

• Temporal arteritis
• Myocardial infarction
• Thoracic aneurysms
• Subdural hematoma
• lung cancer
• Central line placement
• Carotid artery aneurysm
• Pott puffy tumor
• Malignant neoplasms

Common Causes

Common causes for Primary Otalgia

• Otitis media
• Otitis externa
• Barotrauma
• Eustachian tube dysfunction
• Foreign object
• Cellulitis of auricle
• Cholesteatoma

Common causes for Secondary Otalgia

• Bell palsy
• Carotidynia
• Cervical adenopathy
• Cervical spine arthritis
• Cricoarytenoid arthritis
• Dental infections
• Gastroesophageal reflux
• Head and neck tumors
• Temporomandibular joint syndrome
• Myofascial pain
• Neuralgias (trigeminal, glossopharyngeal, geniculate, sphenopalatine)
• Oral aphthous ulcers
• Pharyngitis or tonsillitis
• Salivary gland disorders
• Sinusitis
• thyroiditis

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Ear pain according to the American Family Physician AFP 2008 guidelines.

patient present with history of ear pain Pain (factors should be considered location, duration, aggravating factors, alleviating factors, associated symptoms, previous episodes, medical history, smoking status, and alcohol abuse.) Symptoms of primary otalgia such as - Otorrhea Tympanic membrane fullness Vertigo Symptoms of secondary otalgia Pain with chewing Sinusitis Dental procedures A history of gastroesophageal reflux. No hearing loss

ear examination include:- inspection of the auricle and periauricular region otoscopic examination, which may require cerumen removal.

abnormal findings with apperant the causes identified( primary otalgia)

normal or equivocal findings

Treat underlying cause

more evaluation and examine nose, throat, neck, chest(consider audiometry,tympanometry,pneumetic otoscopy)

dental etiology

temporomandibular joint syndrome

Dental referral

pain killer as primary care and soft diet if the pain presistent, refer to dental care

HX of smoking, alcohol use, age older than 50 years,

Coronary artery disease risk factors

HX of headache, malaise, wight loss, fever, or anorexia and age older than 50 years

No risk factors of serious diagnosis

more evaluation by nasolaryngoscopy, tympanometry, audiometry,or magnetic resonance imaging,and computed tomography (if there is a history of cancer, positron emission tomography may be performed to provide)

ECG,chest radiography ,troponin maeseurment

ESR reat

Otolaryngology referral

send to emergency department

depends on the rate of patient more than 50mm per hour immedate otolaryngology or ophthalmology consultation

Observe or treat empirically as pain killer, soft diet if pain presistent more evaluation and refer

Treatment

Shown below is an algorithm summarizing the treatment of Ear pain according the the American Family Phsyician guidelines.

patient with ear pain

Infection treat with antibiotics topical or systemic, cleaning of the area, and oral analgesics for comfort

referred ear pain

If no responsed refered to evaluation by otorhinolaryngology, IV antibiotics, and hospital admission.

There is procedural management by a health professional, in addition to antibiotic therapy as:- Removal of impacted desquamated keratin debris in the ear canal in case Keratosis obturans. Surgical debridement, Surgical drainage could be required in case of Chronic perichondritis. When the development of bullae on the tympanic membrane can be punctured to give pain relief. Foreign bodies in the ear canal can cause pain and be treated with careful removal. Infected sebaceous cyst is treated with incision and drainage of the cysts, oral antibiotics, and otorhinolaryngology assessment.

depends on the underlying cause