Otalgia (ear pain) divides into two broad categories: primary and secondary otalgia. Primary otalgia is ear pain that arises directly from pathology within the inner, middle, or external ear. Secondary or referred otalgia is ear pain that occurs from pathology located outside the ear. A complex neural network innervates the ear as a result of complex embryologic development. The ear shares this neural network with other organs, which leads to numerous potential causes of referred ear pain.
Cranial nerves V, VII, IX, X, C2, and C3 also innervate organs outside of the ear, leading to numerous potential causes of referred ear pain.
Otalgia classifies into primary versus secondary or referred causes. The differential diagnosis is extensive and receives more detailed coverage below. Thus, a comprehensive and systematic approach to otalgia is essential. Primary otalgia classifies into infectious, mechanical, neoplastic, and inflammatory causes. Secondary otalgia is best classified based on organ systems. More proximal causes of the head and neck include dental and temporomandibular pathology. Distant etiologies include cardiac, gastrointestinal, and lung pathology.
Ear complaints are a relatively common complaint in primary care. Otalgia divides into primary and secondary or referred causes. The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), contains no specific code for primary otalgia or secondary otalgia. There is a formal classification in the medical literature. However, medical coding does not reflect this. No recent studies in the United States have delineated a precise ratio of primary to secondary otalgia.
Overall, primary causes tend to be more common. Men tend to have a primary cause, while women tend to have a secondary cause. The majority of pediatric cases of otalgia are primary, with acute otitis media (AOM) being the most common. One study stated that 80% of children would have otitis media before three years of age . Acute otitis media (AOM) has a significant disease burden in the United States. From 1997 to 1999, it accounted for 9.5% of all outpatient visits for children. Streptococcus pneumoniae caused most cases of AOM. In 2000 and 2010, PCV-7 and PCV-13 vaccines were released to provide immunity against Streptococcus pneumoniae. After their release, the percent of outpatient visits for AOM decreased from 9.5% to 5.5% from 2012 to 2014. Non-typeable Haemophilus influenzae took over as the most common cause of AOM. A vaccine exists for encapsulated Haemophilus influenzae Type B, but not yet for the non-typable strain (unencapsulated).
While primary causes tend to be more common, two studies stated that secondary causes account for nearly 50% of cases of otalgia. Adults and women with otalgia are more likely to have a secondary cause. While the literature is inconsistent, temporomandibular, and dental pathology tends to get cited as the most common causes of secondary otalgia. While dental pathology tends to get cited as the most common cause, one article published in Ireland mentioned that mechanical disorders of the neck and jaw were much more common. Patients over 65 years of age are more likely to experience otalgia from cervical spine disease. Women 20 to 40 years old are more likely to experience temporomandibular joint disease. Malignancies or distant secondary causes such as thyroid cardiac, gastrointestinal, or lung pathology are rare. Other secondary etiologies, such as petrous apicitis, malignant otitis externa, and Eagle syndrome, are also uncommon.
Primary otalgia occurs most commonly from infection. Acute otitis media (AOM) ranks as the number one cause of primary otalgia in children. The disease is typically associated with an upper respiratory tract infection that causes congestion and swelling of the eustachian tube. Between the middle ear and the eustachian tube, there is a narrowing of the eustachian tube called the bony-cartilaginous junction or isthmus. The swelling of the eustachian tube at this location can prevent the middle ear drainage. This collection of middle ear secretions can initially generate an effusion, leading to obstruction and potential bacterial growth. In adults, chronic otitis media is the most common primary disease. Its pathophysiology is the same as AOM and can result from upper respiratory infections or allergic rhinitis. Infections can also directly affect the auricle or ear canal in perichondritis or otitis externa, respectively. If the infection spreads to adjacent bone, it can cause petrous apicitis, mastoiditis, or malignant otitis externa.
Secondary or referred otalgia occurs as a result of the complex cranial nerve network that innervates the ear. These cranial nerves have a shared connection between the ear and organs outside of the ear. One theoretical mechanism of referred otalgia is the convergence-projection theory, which states that these nerves converge onto a shared neural pathway. Given the extent of different organs that share innervation pathways with the ear, secondary otalgia can arise from many different organs.
A comprehensive history and physical examination are vital to evaluate otalgia. The clinician must consider both primary and secondary causes. History should include the following:
Red flags associated with otalgia include:
Key features on history include:
The following associated symptoms could indicate the following referred origins:
It is also possible for patients to experience otalgia during the early postoperative phase of tonsillectomies.
Physical examination should include the following:
The first step in evaluating otalgia includes a comprehensive history and physical examination. Evaluation should exclude red flags and risk factors for a serious diagnosis. If found, then head & neck CT and MRI, panendoscopy, including nasolaryngoscopy and direct visualization of the upper aerodigestive tract, can be ordered. Gastrointestinal red flags should prompt a barium swallow or referral to gastroenterology for esophagogastroduodenoscopy (EGD). Chest pain and cardiac risk factors should prompt a full cardiac work-up. Clinical signs of temporal arteritis should prompt an ESR. An ESR greater than 50mm per hour indicates the need for an urgent referral to ophthalmology and otolaryngology.
The next step should include an assessment of primary otalgia. Evaluation beyond a comprehensive history and physical examination is rarely necessary for primary otalgia. Acute otitis media is the most common cause of primary otalgia. Pneumo-otoscopy will reveal opacification, bulging, and immobility of the tympanic membrane. Eustachian tube dysfunction is another common cause of otalgia. A tympanometry will reveal abnormalities such as negative pressure within the middle ear. The Eustachian Tube Dysfunction Questionnaire (EDTQ-7) can also be an option in the primary care setting. Audiometry could be a consideration if hearing loss is also present.
If the ear exam is normal and without an obvious cause of otalgia, then the next step is to perform a comprehensive evaluation for secondary causes. Clinical assessment should guide the need for lab or imaging studies. Dental and the temporomandibular joint are common sources of secondary or referred otalgia. Orthopantogram can provide a fast and easy way to give a panoramic view of the lower jaw and teeth. Imaging studies are not routinely required to evaluate temporomandibular joint disorder. CT imaging of the temporal bone may be used to assess for petrous apicitis. CT and MRI imaging can also evaluate malignant otitis externa. MRI of the cranial nerves can be ordered to evaluate cranial neuropathy. A complete blood count (CBC) can help screen for infection.
If the patient has not red flags, no risk factors for a serious diagnosis such as malignancy, no clinical signs of referred otalgia, then it is reasonable to trial non-steroidal analgesics such as ibuprofen or acetaminophen. If symptoms persist for over four weeks, then specialty referral and all of the above studies can be re-considered.
Treatment of otalgia is dependent on the diagnosis. This section will review the salient points. Infections cause most primary otalgia and are treated with antibiotics, while mechanical receive treatment with decongestants, nasal steroids, or myringotomy. Secondary causes include a wide variety of diagnoses. One notable management point is the need for urgent referral and steroid treatment for temporal arteritis, a rare cause of secondary otalgia. Therapy otherwise addresses the underlying medical condition, such as malignancy, dental caries, temporomandibular joint disease, coronary artery disease, or gastroesophageal reflux. Patients who have an unremarkable clinical evaluation and no red flags or risk factors for serious disease can be treated conservatively with analgesics and re-evaluated in 4 weeks.
Both primary and secondary otalgia can arise from a wide variety of etiologies, each of which is treatable. Prognosis will depend on how early these diagnoses are made and, thus, relies on a comprehensive and systematic evaluation.
Complications from otalgia are also dependent on early diagnosis and treatment of the underlying cause. This section will review the salient points. Infections, if left untreated, can spread to the adjacent bone. This invasion can lead to more serious infections such as petrous apicitis, mastoiditis, or malignant otitis externa. Herpes zoster oticus is an otic viral infection. Ramsay Hunt Syndrome results if accompanied by facial nerve paralysis. Temporal arteritis is an auto-immune vasculitis, which can lead to blindness if not treated promptly.
Otalgia has many different causes. It divides into primary (arising from the ear) and secondary or referred (stemming from an organ outside the ear) causes. Primary otalgia tends to be more frequent and is usually due to an ear infection, acute otitis media, especially in children. Secondary otalgia can arise from locations close to the ear, such as the nose, sinuses, and neck. It can rarely occur from areas in the body that are more distant from the ear, such as in heart disease or gastroesophageal reflux. Evaluation and treatment largely depend on the diagnosis. It is essential to seek medical attention for ear pain, especially if associated with other symptoms.
Primary otalgia is most commonly due to infection, which is routinely addressable in the primary care office. A referral is rarely needed, but a pharmacist can have involvement with antimicrobial therapy, checking for interactions, and verifying dosages. Secondary otalgia, however, will often require an inter-disciplinary care team. Temporomandibular joint disease may require coordination between the primary care physician, pain clinic, and a dentist. Dental pathology will require referral to a dentist. Chronic musculoskeletal conditions, such as cervical disc degeneration or trigger points, will require coordination of care with physical therapy and pain management. Malignancy will require consultation with an oncologist.
"The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, Department of the Air Force, Department of Defense, or the U.S. government."
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