Otalgia/earache

Otalgia/earache

1. OTALGIA DR. MAMOON AMEEN

2. OTALGIA Defined as  ear pain   or an  earache

3. Classified as : Otogenic or Primary otalgia: is the pain that originates by a disease within the ear. Referred or secondary otalgia: is the pain that originates by a disease outside the ear.

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

5. PRIMARY OTALGIA Pinna Trauma ( Laceration & bites ,tears ) Hematoma Perichondritis Infected pre-auricular sinus Frostbite, sunburn Neoplasm External auditory canal Impacted wax Foreign body Keratosis obturans Otitis externa Malignant otitis externa Herpes zoster oticus Exostoses Neoplasm

6. Middle Ear Bullous myringitis Acute otitis media Secretory otitis media Traumatic perforation Hemotympanum Otitic barotrauma Neoplasm Mastoid Mastoiditis Mastoid abscess Granulomas Neoplasm Inner ear Acoustic trauma Noise Meniere’s disease Vestibular schwannoma PRIMARY OTALGIA

7. IMPACTED WAX Normal secretion of cerumenous and sebaceous glands Excessive secretion, narrowing of EAC ,stiff hairs can lead to impaction Pain, deafness, tinnitus, Removal

8. FOREIGN BODY Insect or small objects Commonly occurs in children Foreign body visible on otoscopic examination Treated by removal Removal may need sedation

9. EAR FURUNCLE Staphylococcal Infection of hair follicle of Ext Meatus Clinical Features Painful swelling in outer 1/3 rd of ext auditory canal Discomfort aggravated on movement of jaw ,and pinna Deafness Treatment Ear pack of 10% ichthammol glycerin systemic antibiotics Analgesics If abscess formed ,incision and drainage should be done Blood Sugar Levels

10. ACUTE OTITIS EXTERNA Diffuse inflammation of meatal skin Etiology Hot humid climate Swimmers Trauma Unskilled instrumentation Scratching ear canal with hair pin Excessive cleaning of ear canal after swimming Existing CSOM Causative Organisms Pseudomonas aeruginosa Staph.aureus B.proteus

11. Clinical features Hot burning sensation Pain Serous or purulent discharge Meatal skin is red ,swollen and tender Cheesy debris in the deep meatus pain elicited by traction of auricle or pressure on tragus Treatment Aural toilet Medicated wicks Systemic and Topical antibiotics with steroids Analgesics ACUTE OTITIS EXTERNA

12. MALIGNANT OTITIS EXTERNA Progressive infection of meatus, surrounding soft tissue and skull base Causative Organism Pseudomonas auroginosa Predisposing Factors Elderly diabetics Immunocompromised

13. Clinical Features Excruciating Pain Granulations in the Ext ear canal XII nerve palsy Treatment High doses I/V Antibiotics for 6-8 weeks Diabetic control Debridement of devitalized tissue & bone MALIGNANT OTITIS EXTERNA

14. Viral Infection affecting geniculate ganglion of facial nerve Clinical Features Severe otalgia Vesicular rash on the in pinna or external auditory canal VII Nerve Palsy (Ramsay Hunt Synd.) Treatment Oral acyclovir HERPES ZOSTER OTICUS

15. HERPES ZOSTER OTICUS

16. Fungal Infection of ear canal Aspergilus niger, Aspergilus fumigatus, Candida albicans Predisposing Factors Hot & Humid climate Topical antibiotics drops for CSOM or otitis externa OTOMYCOSIS

17. Clinical Features Itching pain Discharge with musty color On otoscopic examination ,filamentous growth (black ,blue or green)or white creamy deposit . Treatment Aural Toilet Antifungal Agents OTOMYCOSIS

18. OTOMYCOSIS

19. Acute Infection of middle ear by pyogenic organisms. Common in infants and children Bacteriology Strep.Pneumonae,H INF, Moraxella Catarrhalis Predisposing factors Any thing interfering with normal function of eustachian tube Clinical Features Deafness , pain , Fever,Ear discharge Red Congested buldging TM Small Perforation with ear discharge ACUTE OTITIS MEDIA

20. Management Antibiotics Analgesics and Antipyretics Nasal Decongestants Systemic,Topical Ear Toilet Myringotomy Tm bulging and Pain Not responding to above treatment ACUTE OTITIS MEDIA

21. ACUTE OTITIS MEDIA

22. OTITIC BAROTRAUMA Pain onset during descent of airplane or while diving Non suppurative condition due to failure of Eustachian tube to maintain middle ear pressure at ambient atmospheric level Mechanism When atmospheric pressure is higher than middle ear pressure Eustachian tube gets locked.-  - ve pressure in middle ear - retraction of tympanic membrane- hyperaemia,transudation and haemorrhage in the middle ear.

23. Clinical features Severe earache ,hearing loss,tinnitus Tm retracted ,congested or ruptured Hemotympanum Treatment Nasal decongestants Antihistamines Myringotomy Prevention Swallow during descent Do not sleep during descent Auto inflation of tube by valsalva during descent. OTITIC BAROTRAUMA

24. MYRINGITIS BULLOSA Painful condition occurring spontaneously and resolving within several days . Vesicular eruption is seen on the tympanic membrane which maybe associated with bleeding or serous discharge . Probably caused by virus or mycoplasma pneumonia

25. Inflammation of mucosal lining of antrum and mastoid air cell system. Follow acute suppurative otitis media Clinical Features: Pain behind the ear Fever Ear Discharge Mastoid tenderness Sagging of posterosuperior meatal wall Swelling over the mastoid Deafness ACUTE MASTOIDITIS

26. Management : Hospitalization Antibiotics Myringotomy Pus under tension not resolving with medical therapy Cortical Mastoidectomy Subpreiosteal abscess Positive reservoir sign No change in symptoms after 48 hrs of medical management Complications Facial palsy, labrynthitis,intracranial complications. ACUTE MASTOIDITIS

27. REFERRED PAIN is an unpleasant sensation localized to an area separate from the site of the causative injury or other noxious stimulus

28. REFERRED PAIN Often, referred pain is caused by nerve compression or irritation. In this circumstance, the sensation of pain will generally be felt in the territory that the nerve serves ( ie,somatic dermatome) even though the damage originates elsewhere ( ie,visceral tissue).

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

30. WARNING Referred earache may be a presenting symptom of head and neck cancer

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

32. Referred otalgia Uncommon cause : Tumors (hypopharynx ,larynx ,base of the tongue ,nassopharynx ,parotid ,esophagus ) Neuralgias (trigeminal ,glossopharyngeal ,geniculate ) Temporal arteritis Oral ulcers Eagles syndrome

33. Referred otalgia Uncommon cause : Sinusitis /Nasal polyps Thyroiditis Parotid gland disorders(mumps ,stone ) GERD Myocardial ischemia Psychogenic otalgia

34. Referred otalgia Ear pain can be referred to the ears in five main ways.

35. TMJ dysfunction Caused by : (joint dislocation ,arthritis ) clinical features : pain around the TMJ Trismus Joint sound or crepitus Tenderness of the joint or associated muscle Management : Rest Soft diet Moist heat and massage NSAIDS Muscle relaxant Consultation with oral surgeon

36. Dental causes Caries tooth Apical abscess Impacted molar Malocclusion

37. Oral ulcers Recurrent aphthous ulcer is commonest oral ulcer Other causes include trauma ,nutritional deficiency ,Behcets syndrome and autoimmune disorders Painful locally ,earache

38. Throat infection Tonsillitis is one of the commonest cause of referred otalgia . Post-tonsillectomy referred pain less severe in children than adult . Peritonsiller ,retropharyngeal ,Parapharyngeal abscess will cause earache too Sore throat ,fever ,trismus ,odynophagia are associated symptoms with ear ache

39. Tumors Parotid ,hypopharynx ,nassophayrynx ,base of tongue ,larynx and cervical spine Risk factors include smoking ,alcohol use ,age older than 50 years,radiation exposure Associated symptom ( hoarsness, dysphagia,nasal blockage ,weight loss )

40. NEURALGIAS Trigeminal ,glossopharyngeal and geniculate (intermedius) neuralgia Pain usually brief (seconds) in their sensory distribution area Severe, lancing ,electric – shock- like pain May have trigger point

41. Eagles syndrome It is an elongation of the styloid process Cause deep ,unremitting pain exacerbated by swallowing ,yawning ,foreign body sensation in throat . Treated by surgical excision via trans-oral approach or lateral approach .

42. Cervical spine arthritis Cause crepitus or neck and ear pain with neck movements Decreased neck range of motion ,tender spinous processes or Para-spinal muscles Pain referred to ear from C2,C3 cervical nerve root

43. PSYCHOGENIC OTALGIA when no cause to the pain in ears can be found, it suggest a functional origin. The patient in such cases should be kept under observation with periodic re-evaluation.

44. EVALUATION OF OTALGIA History Ear symptoms Nasal symptoms swallowing disorders recent trauma General Symptoms Examination General physical examination Complete ENT examination Rhinoscopy , nasopharyngoscopy , and indirect laryngoscopy. Palpation of the neck is important to look for thyroid disease and 1lymphadenopathy

45. DIAGNOSTIC TEST CBC ,ESR PTA TYMPANOMETRY Pneumatic otoscopy X- ray FIBEROPTIC NASOPHARYNGOSCOP Barium swallow Indirect laryngoscopy CT scan MRI with gadolinium Biopsy Diagnostic anesthetic blocks and pharyngeal cocainization 

46. Thank you