Secondary Otalgia: Referred Pain Pathways and Pathologies.

gnorimies20.15 shared this article with you from Inoreader Message: https://www.aafp.org/afp/2018/0101/p20.html#:~:text=Pain%20that%20originates%20outside%20the,joint%20syndrome%20and%20dental%20infections., Etiology of Secondary Otalgia ETIOLOGY HISTORY PHYSICAL EXAMINATION ADDITIONAL INFORMATION Subacute etiologies Bell palsy Retroauricular pain that is less severe than with Ramsay Hunt syndrome Facial weakness that involves the forehead with otherwise unremarkable examination Pain may occur in only 50% of patients Carotidynia May have dysphagia or throat or neck tenderness radiating to the ear Tender carotid artery More common in women and often self-limited Cervical adenopathy Recent upper respiratory tract infection Tender cervical lymph nodes Consider biopsy or imaging for lymph nodes > 1.5 cm and lasting longer than two months Cervical spine arthritis Pain with neck movement Reduced range of motion; tense paraspinal muscles Referred pain from C2 and C3 cervical nerve roots Cricoarytenoid arthritis Pain is worse with talking, swallowing, or coughing Inflammatory arthritis Likely caused by rheumatoid arthritis or systemic lupus erythematosus Dental causes (caries, abscess, pulpitis) Dental symptoms Caries; abscess; gingivitis; facial swelling Caries and abscess are the most common causes Gastroesophageal reflux Acid reflux Unremarkable Pain from irritation of cranial nerves IX and X Head and neck tumors Increased risk: smoking, alcohol use, age ≥ 50 years, radiation exposure, weight loss Possible painless neck mass, or no unusual findings; consider fiberoptic nasolaryngoscopy Consider early referral; imaging should be coordinated with the otolaryngologist; pain is worse with swallowing, especially acidic or spicy foods Idiopathic Variable Unremarkable Often diagnosed as neuropathic pain, TMJ syndrome, or eustachian tube dysfunction Myofascial pain Cervical pain may be aggravated by chewing or neck movement Likely to have trigger point in the neck or mastoid tip at attachment of sternocleidomastoid muscle Consider TMJ, cervical spine, or dental disorders Neuralgias (trigeminal, glossopharyngeal, geniculate, sphenopalatine) Pain usually lasts seconds and is episodic, possibly with a trigger May have trigger point, but typically the examination is unremarkable Trigeminal is most common Oral aphthous ulcers Localized pain in mouth but may refer to ear Shallow ulcers inside mouth, usually gray Recurrent etiology not well understood Pharyngitis or tonsillitis Sore throat Pharyngeal erythema; tonsillar exudate Ear may not be directly involved Psychogenic History of depression or anxiety Variable affect May be previously diagnosed as idiopathic Salivary gland disorders Pain in preauricular area Prominent parotid glands Recent mumps outbreaks in United States; more commonly purulent parotitis associated with dehydration or stone obstruction Sinusitis Recent upper respiratory infection Nasal congestion, purulent nasal discharge, anosmia Otalgia from sinusitis is unusual Thyroiditis (rarely causes isolated otalgia) May have tender thyroid Enlarged or tender thyroid Pain is referred from the vagus nerve TMJ syndrome Pain/clicking with opening jaw Tender TMJ; crepitus on motion of mandible Leading cause of secondary otalgia in adults; risk factors include clenching and biting lips/mouth, gum chewing Acute etiologies requiring immediate identification Myocardial infarction Risk factors for coronary artery disease Unstable vital signs If suspected, start immediate acute coronary syndrome workup Temporal arteritis Age ≥ 50 years; jaw claudication; diplopia May be tender along temporal artery; may see prominent artery Erythrocyte sedimentation rate ≥ 50 mm per hour Biopsy and immediate treatment to prevent blindness Consider early referral Thoracic aneurysms Older men; hypertension; risk factors for coronary artery disease May have unstable vital signs Computed tomography or magnetic resonance angiography Other rare causes (subdural hematoma, lung cancer, central line placement, carotid artery aneurysm, Pott puffy tumor) Variable Variable Pott puffy tumor is typically a complication of prolonged sinusitis with no treatment8 TMJ = temporomandibular joint. Adapted with permission from Ely JW, Hansen MR, Clark EC. Diagnosis of ear pain. Am Fam Physician. 2008;77(5):624, 626, with additional information from reference 8. Sensory distribution of the nerves innervating the ear. (A) Trigeminal nerve (V): face, sinuses, teeth. (B) Facial nerve (VII): anterior two-thirds of the tongue, soft palate. (C) Glossopharyngeal nerve (IX): posterior one-third of the tongue, tonsils, pharynx, middle ears. (D) Vagus nerve (X): heart, lungs, trachea, bronchi, larynx, pharynx, gastrointestinal tract, middle ears. (E) Cervical nerves 2 and 3 (C2 and C3): external ears, ear canals, anterior region of the neck, posterior region of the neck. Etiology of Primary Otalgia ETIOLOGY HISTORY PHYSICAL EXAMINATION ADDITIONAL INFORMATION Common causes Barotrauma Pain starts while scuba diving or while flying in an airplane; patient may have experienced a recent blast injury Tympanic membrane can show middle ear hemorrhage Prevent with use of topical nasal decongestants or autoinflation Eustachian tube dysfunction Symptoms of pressure dysregulation Tympanic membrane retraction or positive tympanographic findings Also associated with aural fullness and intermittent symptoms7 Foreign object Commonly insects, small toys, peanuts; most common in children Foreign object visible in ear canal May require general anesthesia to remove Otitis externa Recent swimming with history of discharge Pain with pulling on external ear; discharge may be present More common in summer Otitis media Recent upper respiratory tract infection; children may pull on ears Red, inflamed, cloudy tympanic membrane Most common cause of ear pain Uncommon causes Cellulitis of auricle Preceding insect bite, scratch, or piercing; rapid progression Earlobe usually involved Must treat aggressively; parenteral antibiotics may be required Cholesteatoma Sense of fullness A pearly mass may be visible through the tympanic membrane; often infected with visible squamous material May be asymptomatic early, but generally associated with hearing loss and otorrhea Granulomatosis with polyangiitis (Wegener granulomatosis) Arthralgia, hearing loss, myalgias, oral ulcers, otorrhea, and rhinorrhea Often with chronic otitis media or serous otitis Consider testing for antineutrophil cytoplasmic autoantibodies Malignant otitis externa Retroauricular pain; often associated with diabetes mellitus and immunocompromised state; consider in persons with no improvement in otitis externa Granulation tissue may be present in the external auditory canal Lower cranial neuropathies (VII, X, XI, XII) Easy to miss with subtle findings; technetium bone scan can be used to determine the extent of disease Mastoiditis Recent otitis media that is typically chronic but may be acute Tender edematous mastoids Uncommon, but prevalence is increased in children with decreased access to health care Ramsay Hunt syndrome (herpes zoster oticus) Pain can be present before lesions develop; may be associated with hearing loss, vertigo, or tinnitus Vesicular rash on auricle or ear canal with possible palsy of cranial nerve VII Can also involve cranial nerves V, IX, and X; pain can occur without eruption Relapsing polychondritis Recurrent swelling of the auricle; hearing loss Earlobe is typically not involved because it has no cartilage Noninfectious; other cartilaginous sites (trachea, nose, bronchi) can be affected Trauma Blunt trauma, frostbite, burns Evidence of the trauma Most common is laceration of the auricle Tumors or infected cysts Pain usually well localized to auricle or ear canal Similar presentation to chronic otitis media or externa but nonresponsive to therapy May be confused with chronic inflammation; if nonresponsive to therapy, timely otolaryngology referral is advised Viral myringitis Similar presentation to acute otitis media Tympanic membrane red but not bulging; hemorrhagic bullae of tympanic membrane and ear canals are typical Bullous myringitis is not pathognomonic of viral meningitis, but commonly presents in that fashion Adapted with permission from Ely JW, Hansen MR, Clark EC. Diagnosis of ear pain. Am Fam Physician. 2008;77(5):623, 625, with additional information from reference 7. Secondary Otalgia: Referred Pain Pathways and Pathologies. Via Skull Base Secondary Otalgia: Referred Pain Pathways and Pathologies. AJNR Am J Neuroradiol. 2020 Oct 22;: Authors: Norris CD, Koontz NA Abstract Otalgia is very common, and when the cause of ear pain is not identified on otoscopy and physical examination, cross-sectional imaging is routinely used to evaluate for potential sources of referred ear pain (secondary otalgia). Innervation of the ear structures is complex, involving multiple upper cervical, lower cranial, and peripheral nerves, which transit and innervate a large anatomic territory involving the brain, spine, skull base, aerodigestive tract, salivary glands, paranasal sinuses, face, orbits, deep spaces of the neck, skin, and viscera. Interpreting radiologists must be familiar with these neural pathways and potential sources of secondary otalgia. The purposes of this review are to detail the currently proposed mechanisms of referred ear pain, review the salient neuroanatomy of the complex pathways responsible for secondary otalgia, highlight important benign and malignant etiologies of referred ear pain, and provide a structured search pattern for approaching these challenging cases on cross-sectional imaging. PMID: 33093134 [PubMed - as supplied by publisher] View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.