Otalgia • is ear pain or an earache. Otalgia otogenic nonotogenic otalgia Otogenic or Primary otalgia is pain that originates inside the ear. otalgia Referred or secondary otalgia is pain that originates from outside the ear. otalgia The most common causes can be identified through the description of the character, onset, and location (coupled with a physical examination). otalgia Nerve supply The ear is unique in that no other structure in the body of comparable size is supplied by so many sensory nerves from so many neural segments otalgia 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 otalgia Children with ear infections are more likely to have acute otitis media, whereas adults with ear infections are more likely to have otitis externa External ear pain Mechanical: trauma, foreign bodies such as hairs, insects or cotton buds. Infective (otitis externa): Staphylococcus, Ps eudomonas, Candida, herpe s zoster, or viral myringitis. External ear pain Acute otitis externa (Swimmer's ear) Auricular perichondritis Cellulitis Cerumen impaction Chronic otitis externa Ear canal foreign body External ear pain Eczema Furunculosis Malignant otitis externa Myringitis bullosa Psoriasis Reaction to topical agents Acute Otitis Externa : This is a common cause of pain and discharge in the adult ear . An inflammatory process in the canal leads to pain and swelling of the external meatus itself, which may than become so narrowed as to become obstructed Wax The canal must be around 90% obstructed with wax to lead to a conductive hearing loss, however, wax pressed up against the drum itself may cause deafness and even tinnitus and vertigo (although this is rare) Chronic OE is less of an infection and more of a skin disease affecting the external ear canal. Pain is less prominent, and sufferers complain of itching and blockage of the ears. Other Causes of Otitis Externa Viral: Ramsay Hunt Syndrome is a Herpes Zoster infection of the facial nerve. This lead to severe otalgia, facial palsy and varicelliform rash over the pinna. Bullous Myringitis sporadically occurring viral disease of the canal and drum. vesicles appear on the surface of the drum and canal. There is extreme otalgia and occasionally a sensorineural hearing loss, probably because of a viral neuropathy of the VIIIth cranial nerve. Malignant otitis externa In diabetics, infection of the canal with pseudomonas aeruginosa can lead to an infiltrating infection, which starts in the ear canal, but invades bone and can spread across the skull base, affecting cranial nerves and become life threatening Middle ear pain Mechanical: barotrauma (often iatrogenic), Eustachi an tube obstruction leading to acute otitis media. Inflammatory / infective: acute otitis media, mastoiditis. Middle ear pain Acute otitis media Cholesteatoma Herpes Zoster Oticus Mastoiditis acute barotrauma Ruptured or perforated eardrum Sterile middle ear effusion Otitis media Acute otitis media Acute otitis media without effusion (myringitis) Recurrent otitis media Otitis Media with Effusion MICROBES AT FAULT!!! Streptococcus pneumoniae Haemophilus influenzae(non- typeable) Moraxella catarrhalis Group A Streptococcus Staph aureus Pseudomonas aeruginosa RSV assoc. with Acute Otitis Media SIGNS & SYMPTOMS Neonates/Infants: change in behavior, irritability, tugging at ears, decreased appetite, vomiting. Children(2-4): otalgia, fever, noises in ears, cannot hear properly, changes in personality Children (>4): complain of ear pain, changes in personality On Physical exam… The classic description for Otitis Media is an erythematic, opaque, bulging tympanic membrane with loss of anatomic landmarks including a dull/absent light reflex. Pneumatic Otoscopy: decreased tympanic membrane mobility Acute mastoiditis Definition: an infection of the mastoid characterized by diffuse osteitis followed by rarefaction and breakdown of the bony septae. Acute coalescent mastoiditis Haemorrhagic mastoiditis Masked mastoiditis Predisposition to pneumatic mastoid Predilection to kid Acute mastoiditis Symptoms Otalgia Aural discharge Conductive hearing loss fever Acute mastoiditis Physical findings Fever, Otorrhea Tympanic perforation Swelling of the superior TM and posterosuperior wall of EAC Postauricular area erythema and tenderness Pitting edema Obliteration of the postauricular crease Acute mastoiditis Radiographic evaluation Diffuse rarefaction of bone and breakdown of cellular septae Referred pain is an unpleasant sensation localized to an area separate from the site of the causative injury or other noxious stimulus Referred otalgia or pain is sensed by the ear but originates from a nonotologic source poses a difficult diagnostic challenge to even the most experienced otolaryngologist 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). Is there any Lesson ? Sympathy of one organ to other Nature compels us to ponder Referred otalgia or pain warning Referred earache may be a presenting syptom of head and neck cancer Secondary otalgia Ear pain can be referred to the ears in five main ways Secondary otalgia Via Trigeminal nerve Secondary otalgia Via Trigeminal nerve Dental Diseases Caries tooth Apical abscess Impacted molar Malocclusion Migraine Present with aura Throbbing unilateral headache May involve temporals and post auricular area’s Accompanied with tinnitus and auditory hallucinations Secondary otalgià facial nerve Secondary otalgia Secondary otalgia Via Glossopharyngeal nerve Secondary otalgia Via Glossopharyngeal nerve Post tonsillectomy pain More in adults than children Peritonsillar, paraphyrangeal and retropharyngeal abscess Oral Ulceration RAS is commonest oral ulcer Other causes include trauma ,Nutritional deficiency,Bechets syndrome and autoimmune disorders Secondary otalgia Via Vagus nerve Secondary otalgia Via Vagus nerve Secondary otalgia Via C2 and C3 Secondary otalgia Via C2 and C3 Cervical Spine C1 C2 C3 nerve roots are compressed Pain felt in the occiput, neck or mastoid area. Degenerative or infective lesions Cervical spondylosis Caries spine The Pinna and lower border of jaw is affected but not the meatus depending on the severity and extent of lesion 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. 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 usestobacco or alcohol. Laboratory Findings Complete blood count (CBC) Culture of otorrhea MRI and CT Head CT scan Other Diagnostic Studies Tympanometry Audiometry TAKE HOME MESSAGE 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.