OTALGIA

Otalgia is ear pain or an earache. Primary otalgia is from pain that originates inside the ear. Referred otalgia is from pain that originates from outside the ear. Otalgia is not always associated with ear disease.

 
TYPES OF OTALGIA

Primary otalgia: Ear pain can be caused by disease in the external, middle or inner ear, but the three are indistinguishable in terms of the pain experienced.

External ear pain may be:

Mechanical: Trauma, foreign bodies such as hairs, insects or cotton buds
Ineffective (otitis externa): Staphylococcus, Pseudomonas,  Candida, herpes zoster, or viral myringitis

 

Middle ear pain may be:

Mechanical: Barotrauma, Eustachian tube obstruction leading to acute otitis media
Inflammatory/Infective: acute otitis media, mastoiditis

 

Secondary Otalgia: Ear pain can be referred pain to the ears in five main ways:

Via Trigeminal nerve (Cranial Nerve V). Rarely, trigeminal neuralgia can cause otalgia
Via Facial nerve (Cranial Nerve VII). This can come from the teeth (most commonly the upper molars, when it will be worse when drinking cold fluids), the temporomandibular joint (due to its close relation to the ear canal), or the parotid gland.
Via Glossopharyngeal nerve (Cranial Nerve IX). This comes from the oropharnyx, and can be due to pharyngitis or tonsillitis, or to carcinoma of the posterior third of the tongue.
Via Vagus nerve (Cranial Nerve X).  This comes from the larynopharynx in carcinoma of the pyriform fossa or from the esophagus in GERD.
Via the second and third cervical vertebrae, C2 and C3. This ear pain is therefore postural.

Psychogenic otalgia is when no cause to the pain in ears can be found, suggesting a functional origin. The patient in such cases should be kept under observation with periodic re-evaluation.


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 nerv, the Arnold branch of the vagus nerve, and the Ramsey Hunt branch of the facial nerve.  Neuroanatomically, the sensation of otalgia is thought to center in the spinal tract nucleus of CN V. not surprisingly, fibers from CNs V, VII, VIV and 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.

Diagnostic Evaluations

• Complete blood cell count
• Thyroid function and erythrocyte sedimentation rate(ESR) studies
  
• Dental radiography
  
• CT scanning and MRI
  
• PET scanning
  
• Audiography
  
• Vestibulocochlear testing
  
• Nasal endoscopy
  
• Upper aerodigestive tract endoscopy, laryngoscopy
  

Assessment

• Obtain history of the pain, paying special attention to a recent history of any of the following: Travel by airplane, upper RTI, exposure to very loud noise, trauma to the head and distress that led to teeth grinding or dental work.
• Determine the presence of pain with swallowing, neck rotation, palpation of the face and head, palpation of mastoid process and manipulation of the pinna.
  
• Assess the temporomandibular joint (TM) by asking the client to poen and close the mouth.
  

Medical Management

                Otalgia is managed by treating the primary problem. Identification of a causative etiology is often necessary to successfully treat referred otalgia. Once determined, most causes of referred otalgia can be readily treated.

• Use antibiotics such as Amoxicillin and clavulanate (Augmentin), Amoxicillin, Clarithromycin and Ciprofloxacin in treating various types of infections( e.g., tonsililitis, pharyngitis, and sinusitis).
• Use antivirals such as Acyclovir (Zovirax), Famiciclovir (Famvir) and Valacyclovir (Valtrex) if the causative agent is suspected to be viral such as in cases associated with herpes zoster or shingles.
  
• Antifungals such as Fluconazole (Diflucan) and Nystatin (Mycostatin) are indicated if the source is caused by a fungus (e.g., oral thrush/candidiasis).
  
• Antiulcer/antacid medications such as Famotidine (Pepcid), Ranitide (Zantac) and Esomeprazole magnesium (Nexium) can be used for esophagitis and gastroesophageal reflux disease.
  
• Administer analgesics such as Ibuprofen (Motrin, Advil) and Oxycodone and acetaminophen (Percocet), pydrocodone and acetaminophen (Lortab, Vicodin). Drug combination indicated  for the relief of moderate to severe pain. Pain control is essential to quality patient care.
  
• Use NSAIDs when myalgias and neuralgias are suspected. Re-examine the patient after a 2-week trial of NSAIDs. Strong narcotic analgesics are not indicated and should not be used to treat referred otalgia. Narcotics may mask symptoms, making the correct diagnosis difficult to reach.
  
• Application of heat by warm compress, eating a soft diet, providing a quite environment and positioning the client with affected ear down provide comfort.
  
• The client with TMJ should avoid chewing and hyperextension of jaw. He or she should also try to stop grinding the teeth. A specially fitted mouth guard to be worn while sleeping can be helpful in preventing teeth grinding at night.
  

Otalgia - Types, Pathophysiology, Diagnostic Evaluation,  Assessment and Medical Management