Δευτέρα 26 Οκτωβρίου 2020

Secondary Otalgia: Referred Pain Pathways and Pathologies.

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Etiology of Secondary Otalgia
ETIOLOGY HISTORY PHYSICAL EXAMINATION ADDITIONAL INFORMATION
Subacute etiologies

Bell palsy

Retroauricular pain that is less severe than with Ramsay Hunt syndrome

Facial weakness that involves the forehead with otherwise unremarkable examination

Pain may occur in only 50% of patients

Carotidynia

May have dysphagia or throat or neck tenderness radiating to the ear

Tender carotid artery

More common in women and often self-limited

Cervical adenopathy

Recent upper respiratory tract infection

Tender cervical lymph nodes

Consider biopsy or imaging for lymph nodes > 1.5 cm and lasting longer than two months

Cervical spine arthritis

Pain with neck movement

Reduced range of motion; tense paraspinal muscles

Referred pain from C2 and C3 cervical nerve roots

Cricoarytenoid arthritis

Pain is worse with talking, swallowing, or coughing

Inflammatory arthritis

Likely caused by rheumatoid arthritis or systemic lupus erythematosus

Dental causes (caries, abscess, pulpitis)

Dental symptoms

Caries; abscess; gingivitis; facial swelling

Caries and abscess are the most common causes

Gastroesophageal reflux

Acid reflux

Unremarkable

Pain from irritation of cranial nerves IX and X

Head and neck tumors

Increased risk: smoking, alcohol use, age ≥ 50 years, radiation exposure, weight loss

Possible painless neck mass, or no unusual findings; consider fiberoptic nasolaryngoscopy

Consider early referral; imaging should be coordinated with the otolaryngologist; pain is worse with swallowing, especially acidic or spicy foods

Idiopathic

Variable

Unremarkable

Often diagnosed as neuropathic pain, TMJ syndrome, or eustachian tube dysfunction

Myofascial pain

Cervical pain may be aggravated by chewing or neck movement

Likely to have trigger point in the neck or mastoid tip at attachment of sternocleidomastoid muscle

Consider TMJ, cervical spine, or dental disorders

Neuralgias (trigeminal, glossopharyngeal, geniculate, sphenopalatine)

Pain usually lasts seconds and is episodic, possibly with a trigger

May have trigger point, but typically the examination is unremarkable

Trigeminal is most common

Oral aphthous ulcers

Localized pain in mouth but may refer to ear

Shallow ulcers inside mouth, usually gray

Recurrent etiology not well understood

Pharyngitis or tonsillitis

Sore throat

Pharyngeal erythema; tonsillar exudate

Ear may not be directly involved

Psychogenic

History of depression or anxiety

Variable affect

May be previously diagnosed as idiopathic

Salivary gland disorders

Pain in preauricular area

Prominent parotid glands

Recent mumps outbreaks in United States; more commonly purulent parotitis associated with dehydration or stone obstruction

Sinusitis

Recent upper respiratory infection

Nasal congestion, purulent nasal discharge, anosmia

Otalgia from sinusitis is unusual

Thyroiditis (rarely causes isolated otalgia)

May have tender thyroid

Enlarged or tender thyroid

Pain is referred from the vagus nerve

TMJ syndrome

Pain/clicking with opening jaw

Tender TMJ; crepitus on motion of mandible

Leading cause of secondary otalgia in adults; risk factors include clenching and biting lips/mouth, gum chewing

Acute etiologies requiring immediate identification

Myocardial infarction

Risk factors for coronary artery disease

Unstable vital signs

If suspected, start immediate acute coronary syndrome workup

Temporal arteritis

Age ≥ 50 years; jaw claudication; diplopia

May be tender along temporal artery; may see prominent artery

Erythrocyte sedimentation rate ≥ 50 mm per hour
Biopsy and immediate treatment to prevent blindness
Consider early referral

Thoracic aneurysms

Older men; hypertension; risk factors for coronary artery disease

May have unstable vital signs

Computed tomography or magnetic resonance angiography

Other rare causes (subdural hematoma, lung cancer, central line placement, carotid artery aneurysm, Pott puffy tumor)

Variable

Variable

Pott puffy tumor is typically a complication of prolonged sinusitis with no treatment8

TMJ = temporomandibular joint.

Adapted with permission from Ely JW, Hansen MR, Clark EC. Diagnosis of ear pain. Am Fam Physician. 2008;77(5):624, 626, with additional information from reference 8.


Sensory distribution of the nerves innervating the ear. (A) Trigeminal nerve (V): face, sinuses, teeth. (B) Facial nerve (VII): anterior two-thirds of the tongue, soft palate. (C) Glossopharyngeal nerve (IX): posterior one-third of the tongue, tonsils, pharynx, middle ears. (D) Vagus nerve (X): heart, lungs, trachea, bronchi, larynx, pharynx, gastrointestinal tract, middle ears. (E) Cervical nerves 2 and 3 (C2 and C3): external ears, ear canals, anterior region of the neck, posterior region of the neck.

Etiology of Primary Otalgia
ETIOLOGY HISTORY PHYSICAL EXAMINATION ADDITIONAL INFORMATION
Common causes

Barotrauma

Pain starts while scuba diving or while flying in an airplane; patient may have experienced a recent blast injury

Tympanic membrane can show middle ear hemorrhage

Prevent with use of topical nasal decongestants or autoinflation

Eustachian tube dysfunction

Symptoms of pressure dysregulation

Tympanic membrane retraction or positive tympanographic findings

Also associated with aural fullness and intermittent symptoms7

Foreign object

Commonly insects, small toys, peanuts; most common in children

Foreign object visible in ear canal

May require general anesthesia to remove

Otitis externa

Recent swimming with history of discharge

Pain with pulling on external ear; discharge may be present

More common in summer

Otitis media

Recent upper respiratory tract infection; children may pull on ears

Red, inflamed, cloudy tympanic membrane

Most common cause of ear pain

Uncommon causes

Cellulitis of auricle

Preceding insect bite, scratch, or piercing; rapid progression

Earlobe usually involved

Must treat aggressively; parenteral antibiotics may be required

Cholesteatoma

Sense of fullness

A pearly mass may be visible through the tympanic membrane; often infected with visible squamous material

May be asymptomatic early, but generally associated with hearing loss and otorrhea

Granulomatosis with polyangiitis (Wegener granulomatosis)

Arthralgia, hearing loss, myalgias, oral ulcers, otorrhea, and rhinorrhea

Often with chronic otitis media or serous otitis

Consider testing for antineutrophil cytoplasmic autoantibodies

Malignant otitis externa

Retroauricular pain; often associated with diabetes mellitus and immunocompromised state; consider in persons with no improvement in otitis externa

Granulation tissue may be present in the external auditory canal
Lower cranial neuropathies (VII, X, XI, XII)

Easy to miss with subtle findings; technetium bone scan can be used to determine the extent of disease

Mastoiditis

Recent otitis media that is typically chronic but may be acute

Tender edematous mastoids

Uncommon, but prevalence is increased in children with decreased access to health care

Ramsay Hunt syndrome (herpes zoster oticus)

Pain can be present before lesions develop; may be associated with hearing loss, vertigo, or tinnitus

Vesicular rash on auricle or ear canal with possible palsy of cranial nerve VII

Can also involve cranial nerves V, IX, and X; pain can occur without eruption

Relapsing polychondritis

Recurrent swelling of the auricle; hearing loss

Earlobe is typically not involved because it has no cartilage

Noninfectious; other cartilaginous sites (trachea, nose, bronchi) can be affected

Trauma

Blunt trauma, frostbite, burns

Evidence of the trauma

Most common is laceration of the auricle

Tumors or infected cysts

Pain usually well localized to auricle or ear canal

Similar presentation to chronic otitis media or externa but nonresponsive to therapy

May be confused with chronic inflammation; if nonresponsive to therapy, timely otolaryngology referral is advised

Viral myringitis

Similar presentation to acute otitis media

Tympanic membrane red but not bulging; hemorrhagic bullae of tympanic membrane and ear canals are typical

Bullous myringitis is not pathognomonic of viral meningitis, but commonly presents in that fashion

Adapted with permission from Ely JW, Hansen MR, Clark EC. Diagnosis of ear pain. Am Fam Physician. 2008;77(5):623, 625, with additional information from reference 7.

Secondary Otalgia: Referred Pain Pathways and Pathologies.

AJNR Am J Neuroradiol. 2020 Oct 22;:

Authors: Norris CD, Koontz NA

Abstract
Otalgia is very common, and when the cause of ear pain is not identified on otoscopy and physical examination, cross-sectional imaging is routinely used to evaluate for potential sources of referred ear pain (secondary otalgia). Innervation of the ear structures is complex, involving multiple upper cervical, lower cranial, and peripheral nerves, which transit and innervate a large anatomic territory involving the brain, spine, skull base, aerodigestive tract, salivary glands, paranasal sinuses, face, orbits, deep spaces of the neck, skin, and viscera. Interpreting radiologists must be familiar with these neural pathways and potential sources of secondary otalgia. The purposes of this review are to detail the currently proposed mechanisms of referred ear pain, review the salient neuroanatomy of the complex pathways responsible for secondary otalgia, highlight important benign and malignant etiologies of referred ear pain, and provide a structured search pattern for approaching these challenging cases on cross-sectional imaging.

PMID: 33093134 [PubMed - as supplied by publisher]

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