Otalgia

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Overview
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. It may be caused by several other conditions, such as impacted teeth, sinus disease, inflamed tonsils and infections in the nose and pharynx. The most common causes of ear pain can be identified though the description of the character, onset, and location (coupled with a physical examination).

Ear pain is usually broken into two categories:


 * 1) Otitis media (infection/inflammation of the inner ear). In Otitis media, most cases are viral in origin.
 * 2) Otitis externa: Outer ear canal infection. In Otitis externa, movement of tragus causes pain.

Epidemiology
Otitis Media
 * Male>female
 * Peak incidence is 6-18 months

Risk Factors for Otitis Media

 * Anatomic abnormalities
 * Day care
 * Siblings with otitis media
 * Smoking in household
 * Supine bottles

Complete Differential Diagnosis of Otalgia
In alphabetical order.


 * Acoustic nerve tumor
 * Acute otitis externa (Swimmer's ear)
 * Acute otitis media
 * Arthritis of the temporomandibular joint
 * Auricular erysipelas
 * Auricular perichondritis
 * Cellulitis
 * Cerumen impaction
 * Cervical spine disease
 * Cholesteatoma
 * Chronic otitis externa
 * Ear canal foreign body
 * Eczema
 * Eustachion tube dysfunction
 * Eustachion tube syringitis
 * Furunculosis
 * Herpes Zoster Oticus
 * High altitude sickness
 * Malignant otitis externa
 * Mastoiditis
 * Mumps
 * Myringitis bullosa
 * Other acute barotrauma
 * Psoriasis
 * Reaction to topical agents
 * Ruptured or perforated eardrum
 * Sterile middle ear effusion
 * Trauma
 * Tumor
 * Tympanostomy tube obstruction
 * Varicella

Referred Pain

 * Acute Coronary Syndrome
 * Angina
 * Arthritis
 * Cervical adenitis
 * Cervical spine affection
 * Dental caries
 * Ear, nose, throat (ENT) deep-space infection
 * Esophagitis
 * Laryngitis
 * Lymphadenitis
 * Mastoiditis
 * Metastatic tumor
 * Mumps
 * Parotiditis
 * Pahryngitis
 * Post-tonsillectomy/adnoidectomy
 * Retropharyngeal abscess
 * Rhinitis
 * Sialoadenitis
 * Sinusitis
 * Syphilitic meningitis
 * Tooth infection
 * Temporomandibular Joint Dysfunction (TMJ)
 * Tonsilitis
 * Trigeminal Neuralgia

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.
 * Infective (otitis externa): Staphylococcus, Pseudomonas, Candida, herpes zoster, or viral myringitis. (See Otitis externa)

Middle ear pain may be:
 * Mechanical: barotrauma (often iatrogenic), 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 oropharynx, 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 laryngopharynx 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.

Diagnosis
It is normally possible to establish the cause of ear pain based on the history. It is important to exclude cancer where appropriate, particularly with unilateral otalgia in an adult who uses tobacco or alcohol.

Laboratory Findings

 * Complete blood count (CBC)
 * Culture of otorrhea

MRI and CT

 * Head CT scan

Other Diagnostic Studies

 * Tympanometry
 * Audiometry

Treatment

 * Warm compress
 * Physical therapy, dental bite adjustment (TMJ)
 * Remove foreign bodies with a curette

Acute Pharmacotherapies

 * Control pain with acetaminophen, nonsteriodal anti-inflammatory drugs (NSAIDs), and topical benzocaine solution
 * Antibiotics (otitis media, otitis externa, pharyngitis / tonsillitis)
 * NSAIDs for TMJ
 * Steroid drops, 8% aluminum acetate +/- 2% acetic acid (otitis externa)
 * Antistaphylococcal antibiotics, IV antipseudomonal (malignant otitis externa)
 * Decongestants (barotrauma)