Otalgia, or ear pain, can be caused by primary sources within the ear or referred sources outside of the ear. Primary sources include infections like otitis externa or media, while referred sources commonly originate from structures innervated by the trigeminal, facial, or cervical nerves such as the teeth, throat, neck, or sinuses. A thorough history and physical exam seeking features of primary versus referred pain, along with inspection of the ear canal and eardrum, can often reveal the source to guide appropriate treatment. Further testing may include imaging if a non-otologic cause is suspected.

1. OTALGIA CAUSES
&MANAGEMENT
By dr humra shamim

2. introduction
 Otalgia is defined as ear pain. Two separate
and distinct types of otalgia exist. Pain that
originates within the ear is primary otalgia;
pain that originates outside the ear is referred
otalgia

3.  Typical sources of primary otalgia are external
otitis, otitis media, mastoiditis, andauricular
infections. Most physicians are well trained in
the diagnosis of these conditions. When an
ear is draining and accompanied by tympanic
membrane perforation, simply looking in the
ear and noting the pathology can make the
diagnosis. When the tympanic membrane
appears normal, however, the diagnosis
becomes more difficult.

4. Neurophysiology of pain
 Pain may be nociceptive or neuropathic.
 Peripheral nocireceptors respond to noxious
stimuli such as phycical trauma,thermal or
chemical injury or inflammation.
 Neuropathic pain results from core damage to
the peripheral or cns systems or from an
abnormality in pain processing system

5.  Most otalgia is mediated by via unmyelinated
pain fibres which characteristically cause a
dull ache .

6. Neuroanatomy
 The common sensory supply of the ear reflects
a watershed between brachial and
postbranchial innervation between cranial and
cervicospinal nerves.
 There is both overlap of relative contribution
from sensory afferent nerves and individual
variatins in distributions

7. Pathophysiology
 The sensory
innervation of the ear
is served by the
auriculotemporal
branch of the fifth
cranial nerve (CN V),
the first and second
cervical nerves, the
Jacobson branch of
the glossopharyngeal
nerve, the Arnold
branch of the vagus
nerve, and the
Ramsey Hunt branch
of the facial nerve.

8.  Neuroanatomically, the
sensation of otalgia is
thought to center in the
spinal tract nucleus of CN
V. Not surprisingly, fibers
from CNs V, VII, IXand X
and cervical nerves 1, 2,
and 3 have been found to
enter this spinal tract
nucleus caudally near the
medulla. Hence, noxious
stimulation of any branch
of the aforementioned
nerves may be interpreted
as otalgia.

9.  Reports document that not all otalgia originates
from the ear. Many remote anatomic sites share
dual innervation with the ear, and noxious stimuli
to these areas may be perceived as otogenic
pain. By definition, referred otalgia is the
sensation of ear pain originating from a source
outside the ear.
 To better understand referred otalgia, the
physician first must understand the anatomic
distribution of nerves associated with the ear.
Irritation of these nerves, as well as irritation of
distant branches of these nerves, can cause the
perception of pain within the ear.

10.  A central common pathway for otalgia ,whether
primary or reffered , is probabaly the spinal
tract of the trigeminal nerve
 Fibres from cranial nerve V,VII,IX,X and
cervical nerves c1,c2 converge here and all
play some role in sensory supply of the ear
and temporal bone.

11.  The auriculotemporal branch of V nerve
innervates the anterosuperior external canal and
pinna along with temporomandibular joint
 Cranial nerve IX innervates the posterior external
canal ,meatus and tympanic membrane,but also
the ipsilateral oropharynx
 Tympanic branch of IX nerve (jacobson’s nerve
forms the tympanic plexus ,innervating middle ear
cleft.
 The auricular branch of vagus (arnold’s nerve)has
a similar otologic ,but cranial nerve X has a vast
dispersion to the viscera of neck and even
mediastinum.

13.  The upper cervical nerves c2 ,c3 via the great
auricular nerves and lesser occipital nerve
supply the cranial surface of the pinna ,but
also the skin and muscles of the neck and
cervical spine
 This rich innervation of the ear allows central
misinterpretation of the origin of pain arising
from throughout the head and neck and is the
basis for referred otalgia

14. Otalgia causes
 Otologic causes
 External ear
 Middle ear
 inner ear
 Non otologic causes
Reffered pain
 Tmj
 Throat
 Teeth
 Nose &
nasopharynx
 Neuralgia
 tumors

15. Etiology of Primary Otalgia
Pinna
 Laceration & bite
 Hematoma
 Otitis externa
 Perichondritis
 Infected pre-auricular
sinus
 Frostbite, sunburn
 Neoplasm
External auditory canal
 Impacted wax
 Foreign body
 Keratosis obturans
 Otitis externa
 Herpes zoster oticus
 Exostoses
 Neoplasm

16. External ear
 External auditory
canal
 Block ear
 Hearing loss
 Pain with impaction
 Associated infection
 Treatment by removal
syringing
suction
curettage

17.  Foreign body in the
ear
External ear

18. External ear
 Otitis externa
-severe pain
-tenderness
-postaural swelling
-Sweling in canal
-discharge

19. External ear
 Otomycosis-produces
 Intense itching,
 Discomfort
 pain

20. External ear
 Malignant otitis externa
 Pseudomonas aeroginosa
 Diabetes mellitus
 Infiltrating infection
 Invades bone
 Affects cranial nerves V,VII,IX,X
 Sometimes life threatening
 Treatment: high dose antibiotics,
surgery to debride dead bone
hyperbaric oxygen.

21. External ear
 Ramsay hunt syndrome
 Herpes zoster of VII nerve
 Varicelliform rash over pinna
 Severe otalgia
 Facial palsy
 Bullous myringitis
 Large vesicles on drum & canal
 Extreme otalgia
 Sensorineural deafness
 Probably a viral neuropathy of VIII nerve

22. Middle ear causes
 Bullous myringitis
 Acute otitis media
 secretory otitis media
 Traumatic perforation
 Hemotympanum
 Otitic barotrauma
 Neoplasm

23. Middle ear
 Acute otitis media
Bacterial or viral infection of middle ear
Usually accompanying a URTI
OTOSCOPY:bulging ,congested TM,loss of
land marks,impaired mobility,acute otalgia

24.  Chronic otitis media
Middle ear

25. Middle ear
 Complications of otitis media
 Mastoiditis
 Petrositisis
 Labyrinthitis
 Facial paralysis
 Bezold’s abscess
 Intracranial spread -meningitis
-brain abscess
-subdural empyema
-lateral sinus thrombosis

26. Middle ear
 Otitis media with effusion
• Pain ,block/fullness ear
• Deafness
• Autophony
• popping

27. Middle ear
 Traumatic perforation of tympanic membrane
• Pain ,block,hearing loss
• h/o blast injury or being hit on ear
• Often seen in antero-inferior TM
• Most heal spontaneously
• Do not put eardrops

28. Inner ear
 Acoustic trauma
 Meniere’s disease
 Vestibular schwannoma

29. Meniere’s disease
 Ménière disease is associated with a
sensation of aural fullness, in addition
to vertigo,tinnitus, and fluctuating hearing loss.
 The perception of aural fullness may be
described as ear pain in conditions associated
with endolymphatic hydrops

30. Vestibular schwannoma
 Otalgia due to VS has been variously attributed to
involvement of the nervus intermedius or dural
stretching.The former suggestion is favoured by the
mastoid location of pain and by the remarkably high
prevalence (95· percent reported) of hypoaesthesia of
the posterior wall of the external auditory canal (the
basis of Hitselberger's sign) due to involvement of
sensory fibres of the facial nerve. Innervation of the
possibly stretched dura of the posterior fossa is via
the meningeal (recurrent) branch of CN X, although
this is questioned, meningeal branches of CN XII, but
primarily from the first three cervical nerves ascending
through the foramen magnum. The little publicized
association of otalgia with VS further reinforces the
case for imaging.

31. Causes of reffered otalgia

32. A. Via trigeminal nerve
 Teeth: infection, impacted 3rd molar, malocclusion
 Oral cavity: infection, ulcer, malignancy, Ludwig’s
angina, sialadenitis, salivary calculus
 Temporo-mandibular joint: arthritis, dysfunction
 Nose & PNS: impacted DNS, sinusitis, neoplasm
 Nasopharynx: infection, post- adenoidectomy,
adenoiditis, tumor
 Trigeminal neuralgia

33. B. Via glossopharyngeal nerve
 Tonsil: tonsillitis, peritonsillar abscess, post-
tonsillectomy, neoplasm
 Oropharynx: infection, ulcer, retropharyngeal +
parapharyngeal abscess, trauma, neoplasm
 Eagle’s syndrome (stylalgia)
 Glossopharyngeal neuralgia

34. C. Via facial nerve:
Herpes zoster oticus, vestibular schwannoma
D. Via vagus nerve: Larynx + hypopharynx:
neoplasm, infection,
tuberculosis, trauma,
foreign body
E. Via second & third cervical nerves:
Herpes zoster, cervical spondylosis & arthritis

35. Non otologic causes
 Neuralgias
• Trigeminal N
• Glossopharyngeal N
• Sphenopalatine N

36. Non otologic causes
 Other
• TMJ disorder
• Dental conditions
• stylalgia
• Cervical spine disorders

37. Dental causes
 Dental disorders are the most common cause
of referred pain to the ear. Of this group of
disorders, temporomandibular dysfunctions
account for most patients.[1]Bruxism,
degenerative joint disease, or stress can lead
to internal derangements within the joint. The
third division of the trigeminal nerve and the
auriculotemporal nerve mediate pain, which is
often perceived deep within the ear. Other
odontogenic causes range from abscessed
teeth to poorly fitting dentures.

38. Oral cavity
 Within the oral cavity, the sensory innervation
becomes quite complex. The tongue receives
fibers from the glossopharyngeal nerve, the
facial nerve receives fibers from the chorda
tympani, and the trigeminal nerve receives
fibers from the lingual branch and vagus nerve
posteriorly. All these nerves have distributions
in the ear as well

39.  Sinusitis is another very common source of ear
pain. The neural pathway is along the second
branch of the trigeminal nerve and the
auriculotemporal nerve. Because the
trigeminal nerve supplies the nasal cavity,
patients with inflammatory mucosal contact
points and nasal obstruction may develop
symptoms in their ears. The proximity of the
eustachian tube orifice also contributes to the
problem.

40.  Eustachian tube dysfunction causing an
intermittent inability to equalize middle ear
pressures may manifest with such minimal
tympanic membrane bulging or retraction that
even otomicroscopy does not detect an
abnormality. The problem may be as simple as
a sensitive ear canal that requires protection
from cold winds along with reassurance that
nothing is actually wrong.

41.  Neck problems can also refer pain to the ears.
These disorders include cervical osteoarthritis,
cervical myofascial pain syndrome, and
traumatic injuries.[2, 3] The cervical spine is
sensitive and well supplied by the cervical
nerve roots. Muscular pain from the trapezius
or sternocleidomastoid may project
postauricularly to the mastoid and occipital
area.

42.  Sensory branches of the vagus and
glossopharyngeal nerves supply upper
aerodigestive tract mucosal areas such as the
nasopharynx, oropharynx, hypopharynx, and
larynx. The vagus continues caudally and
supplies sensory enervation to the bronchus,
esophagus, and heart as well. Irritative lesions
at any of these sites may mimic stimulation of
Arnold and Jacobson nerves.

43.  Tonsillitis and pharyngitis are very common
causes of earaches in children. Less
commonly, laryngitis, laryngeal
tumors, esophagitis, and even angina
pectorismay manifest as otalgia. Eagle
syndrome, in which the elongated styloid
process irritates branches of CN VIV and CN
IX, is even rarer. This crossing of signals
works both ways; thus, stimulation of the ear
canal may be felt as a tickle in the throat or
may produce the cough reflex

44. How to arrive at a diagnosis?
History
Features suggestive of primary otalgia (due
to ear disease):
• hearing loss;
• aural discharge;
• vertigo;
• unilateral rather than bilateral symptoms

45. Onset
-Sudden : furunclosis ,acute otitis media ,otitic barotrauma
-Gradual :otitis externa secondary to CSOM ,malignancy,
malignant otitis externa
Duration
-Short duration:asom ,perichondritis of eat pinna
-Long duration:malignancy
Nature of pain
-Dull:exematous otitis externa,secretory otitis media,impacted
wax
-Sharp:furunculosis ,otitic barotrauma
-Throbbing pain:ASOM

46.  Relieving facors :pain relieved with discharge
from the ear-acute suppurative otitis
media(ASOM)
 Aggravating factors:
-Pain increasing on swallowing –ASOM
-Pain increasing on yawning and chewing-
furunculosis arising from anterior canal wall.

47. Symptoms suggesting referred otalgia:
 pain on chewing/trismus;
 dysphagia/odynophagia;
 hoarseness;
 risk factors (smoking/alcohol history);
 neck swelling/goitre;
 cervical musculoskeletal symptoms;
 dental history/recent treatment

48. Features of neuropathic pain:
 radiation, e.g. to throat;
 typical time course/duration;
 quality of pain;
 trigger zone/precipitating factors, e.g
swallowing

49.  Otologic history - Tinnitus, hearing, vertigo
 Sinuses
 Pulmonary history
 Cardiac history
 Dental history - Mastication
 GI history - Dysphagia, esophagitis, reflux
 Neurologic history - Neuralgias
 Musculoskeletal history - Arthritis
 Cervicofacial history
 Myalgias
 Trauma - Cervical spine (C-spine)
 Infections - Tonsillitis, pharyngitis

50. Examinatiom
Primary otalgia:
• inspection of ear and otoscopy;
• palpation for tenderness;
• aural examination with teleotoscope and microscope;
• tympanometry.
Referred otalgia:
• cranial nerve (CN) examination, especially V, VII, IX and X;
• palpation of cervical lymphatic chain;
• assessment of cervical spine mobility/tenderness;
• palpation of TMJ and pterygoid muscles;
• exclude trismus;
• dental inspection for caries, absent dentition and malocclusion;
• direct and fibreoptic examination oropharynx and laryngopharynx;
• palpation of oropharynx to seek induration trigger zone or styloid bone

51. WORKUP
 Frequently, the workup suggests that otalgia may be a
problem of dental origin.
 A complete blood cell count may indicate an occult
infection.
 Thyroid function and erythrocyte sedimentation rate
(ESR) studies may reveal thyroiditis and temporal
arteritis. Chest radiography to seek bronchogenic
pathology may be necessary.
 The perception of aural fullness may be described as
ear pain and is observed in conditions associated with
endolymphatic hydrops and eustachian tube
dysfunction.
 Ménière disease can be diagnosed by history,
audiometrics, and a battery of laboratory tests.

52. Despite the full battery of testing, a group of
patients always remains for whom an etiology
is not evident. If not contraindicated, a brief
course of nonsteroidal anti-inflammatory
agents (NSAIDs) may be helpful.

53. Preliminary testing (appropriate to
symptoms) should include the following:
 Barium swallow
 ECG
 C-spine radiography
 Chest radiography
 Panorex imaging

54. IMAGING STUDIES
 Dental radiography
 CT scanning: Obtain CT scans of the head or
temporal bone, sinuses, and/or neck when no
obvious source of the pain can be found. The
scan usually includes a brief survey of the sinuses
and intracranial contents. CT scanning can reveal
significant information about the
temporomandibular joint or can be used to
diagnose intratemporal lesions.
 MRI: If indicated by clinical or audiometric
suspicion, an MRI may be necessary to define a
cerebellopontine angle or other intracranial tumor.

55.  Panorex imagery: Panorex imagery is quite
useful in diagnosing temporomandibular joint
dysfunction, odontogenic pathology, and styloid
abnormalities. Referral to a competent dentist or
oral surgeon may be indicated.
 PET scanning: As this emerging modality for
identifying malignant tumors becomes more
readily available, it may be possible to diagnose
cancer earlier. PET images fused with CT or MRI
adds tremendously detailed information about the
location of head and neck neoplasms.

56. If history and physical examination
findings are inconclusive, perform other
diagnostic procedures if suspicion still
exists for the following conditions:
 Upper respiratory tract tumor - Panendoscopy, chest
radiography, CT scanning, or MRI as needed
 Sinus disease - Sinus CT scanning
 Intracranial/intratemporal disease - Audiometric battery
and CT scanning or MRI as needed
 Autoimmune disease - ESR, thyroid function studies
(thyroiditis, temporal arteritis)
 Endolymphatic hydrops - ESR, thyroid function test
(TFT), fluorescent treponemal antibody absorption
(FTA-Abs) test, fasting glucose, lipid profile
 Eustachian tube dysfunction - Autoinsufflation
(consider myringotomy)
 Psychiatric disorder - Consider psychiatric
consultation.

57.  Whilst there is an individual variation in pain
threshold and perception, it is often an alarming
symptom to the patient. Chronic pain in true ear
disease can indeed suggest dural and skull base
extension.
 A presenting history of 'recurrent ear infection‘ must
be questioned and may represent a self diagnosis of
cause of recurrent earache, reinforced by inexpert
otoscopy in primary care .
 Earache, in the absence of discharge,hearing
loss,audiovestibular upset or otoscopic abnormality
during an attack, should suggest a secondary,
referred otalgia.
 Expert dental examination may reveal

58.  Careful direct and endoscopic evaluation of the
uppeaerodigestive tract is vital in unilateral otalgia and
should not be neglected even with positive findingsas
above. A tender TMJ does not exclude a diagnosisof
tonsillar carcinoma.
 Perform a detailed search for the underlying
diagnosis before initiating treatment. Starting
analgesics before reaching a diagnosis increases
the difficulty of determining the cause and may
possibly obscure a life-threatening condition such
as an occult cancer