Otalgia, or ear pain, is a common symptom that can arise from pathologies within the ear (primary otalgia) or as referred pain from distant structures (referred otalgia). Understanding the sensory innervation of the ear and the potential sources of referred pain is crucial for accurate diagnosis and management.
Primary Otalgia
Primary otalgia results from direct stimulation of sensory nerves supplying the ear. The ear receives sensory innervation from:
- Greater auricular nerve (C2, C3).
- Lesser occipital nerve (C2, C3).
- Auriculotemporal nerve (V3).
- Facial nerve (VII).
- Jacobson’s nerve (branch of glossopharyngeal nerve, IX).
- Arnold’s nerve (auricular branch of the vagus nerve, X).
Causes of Primary Otalgia
- Pinna: Trauma, cellulitis, herpes zoster oticus, malignancy, chronic relapsing perichondritis, chondrodermatitis nodularis helicis.
- External Auditory Canal (EAC): Otitis externa (acute, chronic, malignant), furuncle, keratosis obturans, herpes zoster oticus, malignancy, bullous myringitis.
- Middle Ear: Otitis media, malignancy.
- Inner Ear: Noise-induced injury.
Referred Otalgia
Referred otalgia occurs when pain from distant structures is perceived in the ear due to shared neural pathways. The nerves involved include:
- Trigeminal Nerve (V): Supplies the anterior two-thirds of the tongue, floor of the mouth, palate, lower teeth, salivary glands, temporomandibular joint (TMJ), and mandible.
- Site of Perception: Pinna, tragus, anterior wall of EAC.
- Causes: Dental caries, impacted molars, tongue malignancy, TMJ osteoarthritis, ill-fitting dentures, parotid infections.
- Glossopharyngeal Nerve (IX): Supplies the posterior third of the tongue, tonsils, nasopharynx, hypopharynx, and parapharyngeal space.
- Site of Perception: Deep ear pain, middle ear, Eustachian tube.
- Causes: Acute tonsillitis, peritonsillar abscess, base of tongue or tonsillar malignancy, Eagle syndrome, parapharyngeal abscess.
- Vagus Nerve (X): Supplies the valleculae, supraglottis, thyroid gland, tracheobronchial tree, and esophagus.
- Site of Perception: Inferior and posterior EAC.
- Causes: Malignancy of supplied structures, thyroiditis.
- Upper Cervical Nerves (C2, C3): Supply the cervical spine muscles and facet joints.
- Site of Perception: Posterior pinna, skin over mastoid.
- Causes: Cervical spondylitis, spinal stenosis, osteoarthritis.
Temporomandibular Joint (TMJ) Dysfunction Syndrome
- Characteristics: Diffuse pain around the TMJ, crepitus, trismus.
- Predisposition: More common in females; bruxism is a key etiological factor (present in 50% of cases).
- Clinical Findings: Tenderness of lateral pterygoids (85% of cases), confirmed via intraoral palpation.
- Signs of Bruxism: Flattened molar occlusal surfaces, worn incisors, buccal mucosa scarring.
- Treatment: Soft diet, hot fomentation, muscle relaxants.
Costen Syndrome (TMJ Neuralgia)
- Symptoms: Ear pain, tinnitus, dizziness, aural congestion.
- Treatment:
- Rest, soft diet, anti-inflammatory drugs (e.g., ibuprofen, diclofenac).
- Benzodiazepines or low-dose tricyclic antidepressants for refractory cases.
- TMJ surgery (condylotomy) with occlusal splints as a last resort.
Glossopharyngeal Neuralgia
- Characteristics: Severe, transient pain in the ear, base of the tongue, tonsillar fossa, or below the jaw.
- Types:
- Tympanic type: Ear pain.
- Oropharyngeal type: Oropharyngeal pain.
- Triggers: Swallowing, coughing, yawning, talking.
- Cause: Often vascular compression by the posterior inferior cerebellar artery.
- Treatment:
- First-line: Carbamazepine.
- Surgical: Microvascular decompression or nerve section (posterior fossa, neck, or transtonsillar approach).
Eagle’s Syndrome (Styalgia)
- Cause: Elongated styloid process (>4 cm) or calcified stylohyoid ligament.
- Symptoms: Dull throat pain radiating to the ear, odynophagia, foreign body sensation.
- Diagnosis: Palpation in the tonsillar fossa, X-ray, orthopantomogram (OPG), or CT scan.
- Management:
- Conservative: Steroids, local anesthetics, carbamazepine.
- Surgical: Transoral or transcervical removal of the elongated styloid process.
Psychogenic Causes
When no organic cause is identified, otalgia may be psychogenic. Patients should be monitored and periodically re-evaluated to rule out underlying pathology.
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Otalgia Best Lecture Notes Dr Rahul Bagla ENT Textbook
Reference Textbooks.
- Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
- Glasscock-Shambaugh, Textbook of Surgery of the Ear.
- P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
- Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
- Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery
- Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
- Salah Mansour, Middle Ear Diseases – Advances in Diagnosis and Management.
- Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
- Rob and smith, Textbook of Operative surgery.
- Anirban Biswas, Textbook of Clinical Audio-vestibulometry.
- Arnold, U. Ganzer, Textbook of Otorhinolaryngology, Head and Neck Surgery.
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