Dental_Pain_. Referred. _to_. Ear.pptx

Referred otalgia

1. By: Dr.Abdullah Ibrahimi

2. Introduction Sometimes , the ear is normal but pain comes from nearby structures. This is called Referred Pain . is an unpleasant sensation localized to an area separate from the site of the causative injury or other noxious stimulus Often, referred pain is caused by nerve compression or irritation Pain felt in the ear although the source lies outside the ear, such as in teeth, TMJ, throat, or neck.

3. When to label as referred otalgia ? CLINICALLY NORMAL Pinna External auditory meatus Tympanic membrane Mastoid process

4. Referred otalgia Common causes : Dental causes(caries ,abscess ,impacted teeth) TMJ dysfunction Tonsillitis and pharyngitis Cervical spine arthritis

5. Referred otalgia Uncommon cause : Tumors (hypopharynx ,larynx ,base of the tongue ,nassopharynx ,parotid ,esophagus ) Neuralgias (trigeminal ,glossopharyngeal ) Temporal arteritis Oral ulcers Sinusitis /Nasal polyps Thyroiditis Parotid gland disorders(mumps ,stone ) Myocardial ischemia Psychogenic otalgia

6. Neural Basis Shared nerve supply between teeth and ear. Mainly via Trigeminal nerve (CN V). Also: Vagus (CN X), Great auricular, Glossopharyngeal (CN IX).

7. Mechanism Sensory fibers from teeth and ear converge in brainstem. Brain cannot localize exact source → Pain felt in ear.

8. Common Dental Causes 1. Pulpitis 2. Periapical abscess 3. Periodontal infections 4. Impacted wisdom tooth 5. Cracked tooth or trauma

9. Teeth Commonly Involved - Lower molars (especially 3rd molar) - Premolars - Occasionally upper molars (sinus involvement)

10. Clinical Features - Ear pain with normal ear exam. - Pain worsens by chewing. - Sensitivity to temperature. - Pain radiates to temple or jaw.

11. ENT Findings - Normal external/middle ear. - No discharge or redness. - Pain persists despite ear drops → Suspect dental cause.

12. Differential Diagnosis Dental origin: tooth sensitivity, swelling TMJ disorder: clicking, limited opening Throat infection: sore throat, dysphagia True ear disease: discharge, hearing loss, fever

13. Diagnostic Approach - Take dental & medical history. - Oral exam & percussion. - Radiography (OPG). - Refer to dentist if ENT normal.

14. Treatment - Treat underlying dental problem: - Root canal (pulpitis) - Extraction/drainage (abscess) - Analgesics for pain. - ENT + Dentist collaboration.

15. Complications Unnecessary antibiotics. Delayed dental care. Spread of infection to neck spaces.

16. Prevention Consider dental origin in unexplained ear pain. Promote ENT-Dental cooperation.

17. A Rare Case Report Summary

18. Patient Information 20-year-old male Pain in right lower second molar for 1 month Facial swelling and limited mouth opening for 6 days Pus discharge intraorally and from right ear for 2 days Difficulty swallowing and mild hearing loss

19. Clinical Findings Right mandibular second molar grossly carious and tender Yellowish pus discharge from right ear with foul odor Right submandibular lymph nodes tender Mouth opening reduced to 11 mm Fever (100°F) and mild systemic symptoms

20. Radiographic and ENT Findings Periapical radiolucency around mandibular right second molar Mild radiolucency near right condylar region Tympanic membrane congested, pus from middle ear Mild hearing loss on right side

21. Treatment Hospital admission and IV antibiotics (3rd gen cephalosporin + sulbactam) NSAIDs administered Extraoral incision and drainage under antibiotic cover Extraction of right lower second molar under local anesthesia Rapid recovery – ear discharge stopped within 24 hours

22. Possible Route of Infection Infection spread from mandibular second molar to pterygomandibular space From there, reached temporomandibular joint (TMJ) Extended via discomallear and Pinto’s ligaments to middle ear Resulted in pus drainage through the ear canal

23. Outcome and Discussion Swelling and limited mouth opening resolved within 5 days Hearing improved considerably First reported case of odontogenic infection discharging through ear

24. Summary - Referred otalgia = ear pain from non-ear source. - Common dental causes: pulpitis, abscess, impacted tooth. - Careful history & dental exam essential.

25. References 1. Zakrzewska JM. Referred Otalgia: A Dental Perspective. 2. Scully C. Oral and Maxillofacial Medicine. 3. Bhatia K. Referred Ear Pain: Clinical Review.