Otalgia_Causes_ConcernsPGME0519SlideshareScribd.pptx

Differential diagnoses of otalgia both primary and secondary, and when to be concerned

1. Otalgia - C auses and Concerns Mr Chee Toh BSc FRCS (ORL-HNS) Consultant ENT Surgeon

2. Primary and Secondary Primary otalgia is ear pain that stems in an ear pathology Secondary otalgia is pain referred to the ear from a remote site

3. Causes of Primary Otalgia Acute Otitis Externa Furunculosis Wax impaction Foreign body Trauma Acute Otitis Media ET dysfunction Neoplasm Other inflammatory conditions

4. Causes of Secondary Otalgia DENTAL PROBLEMS TMJ DISORDERS Throat problems Sinus problems Neck problems Neuralgia Temporal arteritis CPA problems Herpes zoster

5. Nerve Supply of Ear Richly innervated Multiple cranial & spinal nerves Shared nerve supply with other head & neck sites Inner ear has no sensory supply

6. Trigeminal Nerve and C2/3

7. Facial Nerve

8. Glossopharyngeal and Vagus

9. Innervation of External Ear

10. Summary of innervation Most of the external ear Great auricular nerve (cervical plexus C 2,3) Auriculo temporal nerve (branch of Vc) Small contributions from Auricular branch of X nerve Somatosensory branch of VII nerve Middle ear supply Tympanic branch of IX nerve

11. Primary Otalgia

12. Acute Otitis Externa 1

13. Acute Otitis Externa 2 Predisposition Dermatological Aggravation Interference Wetting Pseud, Gram pos, Gram neg Can be very painful Antibiotic-steroid combination drops Refer if necessary

14. Malignant or Necrotizing OE Osteomyelitis of skull base High mortality Diabetics and immunosuppressed IV antibiotics and surgical debridement Long-term ciprofloxacin

15. Furunculosis Infection of skin gland or hair follicle Very tender and may be very painful Usually Staphylococcal Usually resolves spontaneously May need flucloxacillin or topical antibacterial Rarely needs I&D

16. Wax impaction Due to cotton bud use Or ear plugs or wandering fingers Or narrow ear canals Treat by oil drops or keratolytics Then syringing or microsuction if necessary

17. Foreign Body Common in children Safest to remove under GA In adults usually the cotton end of a cotton bud! May impact and cause trauma or infection

18. Trauma Physical Usually a cotton bud or ear wax remover or pen Barotrauma (TM) Aircraft Diving Slap to ear If kept dry, most mild trauma will resolve without treatment Occasionally, ear drops are indicated

19. Acute Otitis Media

20. Acute Mastoiditis 1

21. Acute Mastoiditis 2

22. Acute Mastoiditis 3

23. Acute Mastoiditis 4

24. Acute Mastoiditis 5 Recent URTI or ASOM Hearing loss Otorrhoea Central point of inflammation Loss of postauricular sulcus Either bulging red or dull red ear drum (if inadequate antibiotics ear signs may be subtle or absent) Unwell/fever These differentiate from postauricular lymphadenitis

25. Eustachian Tube Dysfunction Popping and/or autophony Clicking and/or pain on swallowing Look for associated nasal symptoms/signs Exclude nasopharyngeal lesion May be sequelum of resolving ME effusion If in isolation usually self-limiting If does not settle may need intervention Nasal sprays, Otovent Endoscopic balloon Eustachian tuboplasty Grommets, other ET cushion surgery neuromodulators, muscle relaxants, CBT

26. Neoplasm and other inflammatory Thankfully rare Usually obvious destructive non-healing ulcer or exophytic growth Malignancy: extensive resection and radiotherapy

27. Secondary or Referred Otalgia

28. Dental Problems Dental sources Impacted tooth (last molar, upper) Dental caries Dental abscess Periodontal infection Ill fitting dentures

29. TMJ Dysfunction Clicking, grinding and clenching Well developed masseters Tender and clicking TMJ, assymmetric movement 1-2 weeks extra soft diet with anti-inflammatories Softer diet for life Bite guard Neuromodulators, muscle relaxants Surgery under OMFS

30. Throat Problems Acute tonsillitis Peritonsillar abscess Malignant tumours – Most important Pharynx tongue base Changing demographics (young, non-smoker, HPV) Larynx Oral cavity

31. Neck Problems Occult malignancy or other inflammatory process Cervical osteoarthritis Sinus Problems

32. Neuralgia Clinical examination must be normal Trigeminal neuralgia unilateral facial pain Glossopharyngeal neuralgia (Eagle’s syndrome if stylohyoid) unilateral pharyngeal pain

33. CerebelloPontine Angle Lesions Acoustic neuroma Meningioma

34. Herpes Zoster Herpetic infection of geniculate ganglion Painful facial palsy Vesicles may or may not be seen High dose antiviral and corticosteroids

35. Summary of Referred Otalgia 1 Nerves C 2,3 V VII IX X

36. Summary of Referred Otalgia 2

37. When to worry? Destructive pathology evident Systemically unwell OE with diabetes or immunocompromise Associated upper aerodigestive tract symptoms No obvious diagnosis especially in an older smoker

38. That’s all folks! Thank you for listening