Review article: Otalgia as presenting symptom of myocardial infarction.

OBJECTIVE: There are many etiologies for otalgia, most of which are benign conditions. However, it can also be the initial symptom for life threatening emergencies such as a myocardial infarction (MI). This case report and review of literature describes diagnosis of MI with the initial primary complaint of unilateral otalgia. PATIENT: A 77-year-old female with intermittent left-sided otalgia with exertion for many years that recently worsened. In the clinic, she had a normal otologic exam and denied any other associated symptoms. The following day, her symptoms progressed to otalgia radiating down her arm and dyspnea on exertion. After progression of symptoms, a nuclear stress test was performed revealing a large and severe apical infarct. INTERVENTIONS: Diagnosis of referred otalgia from a cardiac source. She had subsequent medical management of cardiac risk factors and treatment of angina. RESULTS: Resolution of otalgia with medical management for coronary artery disease (CAD) after treatment of unstable angina. CONCLUSIONS: Otologists should be aware of the atypical presentations of angina because a missed diagnosis is potentially fatal. Otalgia, either unilateral or bilateral, may be the only presenting symptom of underlying cardiac ischemia and a high index of suspicion is needed for early diagnosis. Patients with otalgia related to exertion, no abnormal findings on otoscopic examinations, and significant risk factors for cardiac disease should undergo systematic evaluation including a cardiac rule out.

Intracranial complications of acute mastoiditis: Surgery not always necessary.

INTRODUCTION: Acute mastoiditis (AM) can rapidly become life-threatening with various intracranial complications. The standard care includes antibiotics, mastoidectomy, and drainage. Reports show varying preferences for conservative and surgical treatments, with a more conservative approach gaining popularity. In this study we aim to evaluate the presenting symptoms, management and outcomes of patients presenting with intracranial complications secondary to acute mastoiditis. METHODS: Retrospective review for all children admitted for acute mastoiditis for 12 years period (January 2010-December 2021). Children who had mastoiditis associated with intracranial complications were included in the study. STROBE guidelines were followed in this study. RESULTS: 23 patients were diagnosed with acute mastoiditis with intracranial complications. The mean age was 2.1 years. The most common presenting sign was fever, followed by otalgia. The most common pathogens were Fusobacterium necrophorum and Streptococcus pneumoniae. The most common intracranial complication was sinus vein thrombosis (SVT) affecting 13 patients. Eventually, 10 patients underwent cortical mastoidectomy during 1-6 days upon admission, with an average of 3.2 days. During the follow-up period patients were monitored for clinical progression. Patients who did not show clinical improvement such as persistent fever, worsening symptoms, or the presence of neurological symptoms were treated surgically. The length of stay was an average of 15.5 days overall, with no significantly longer hospital stay in patients who were treated surgically compared to patients who were treated conservatively (17.1 days vs. 14.2 days, P = .26). CONCLUSION: Intracranial complications of acute mastoiditis remain a significant challenge. Selected patients with intracranial complications can be treated conservatively with close monitoring, without increasing the risk of immediate or long-term complications. Initial antimicrobial treatment should cover anaerobic bacteria, as it correlates with severe complications.

Efficacy of rehabilitative therapies on otologic symptoms in patients with temporomandibular disorders: A systematic review of randomised controlled trials.

BACKGROUND: The term temporomandibular disorder (TMD) indicates a set of musculoskeletal conditions involving temporomandibular joint (TMJ), masticatory musculature, and related anatomical structures. Pain is the most common clinical manifestation of TMD, and the auditory system might be involved and affected, through tinnitus, dizziness, otalgia and ear fullness sensation. OBJECTIVES: The aim of this systematic review of randomised controlled trails (RCTs) was to evaluate the efficacy of rehabilitative approaches on otologic symptoms in patients with TMD. METHODS: PubMed, Scopus and Web of Science were systematically searched from the inception until 8th October 2023 to identify RCTs presenting participants with a diagnosis of TMD associated with otologic signs and symptoms, rehabilitative approaches as interventions, and modification of the otological symptoms as outcome. RESULTS: Out of 931 papers suitable for title/abstract screening, 627 articles were assessed for eligibility. Five studies were included reporting the efficacy of occlusal splint therapy, low-level laser therapies, and physical therapy in patients diagnosed whit secondary otalgia or tinnitus associated with TMD. No RCTs evaluating other otologic symptoms, ear fullness, dizziness or vertigo were found. CONCLUSIONS: Results of this systematic review suggested that rehabilitative approaches might be effective in improving secondary otalgia and tinnitus in TMD patients. Thus, further RCTs with a higher level of evidence and more representative samples should be conducted to better understand the effects of TMD therapy on otologic complains.

A woman in her forties with ear pain. / En kvinne i 40-årene med smerter i øret.

Background: A woman in her forties developed intermittent pain in her ear and pharynx which worsened when talking and swallowing. Multidisciplinary approach confirmed a rare diagnosis. Case presentation: The patient reported left-sided ear fullness, followed by otalgia and burning pain in the palate. Numbness in the palate and nasal cavity, and soreness upon palpation of the external ear canal were noted upon examination. Magnetic resonance imaging (MRI) with contrast showed a vessel located in close proximity to the glossopharyngeal nerve on the left side. A diagnosis of glossopharyngeal neuralgia was made, and the patient was treated with antiepileptic medications without substantial effect. Microvascular decompression of the glossopharyngeal nerve was therefore performed. A large vein located along the glossopharyngeal nerve was separated and fixated away from the nerve. The patient reported pain alleviation after the operation, which has continued to improve on follow-ups. Interpretation: Glossopharyngeal neuralgia is a rare condition characterised by intermittent, unilateral pain in the base of the tongue, oropharynx, and/or angle of the mandible which radiates to the ipsilateral ear. The condition should be treated medically, but open surgical treatment should be considered in refractory cases. Early diagnosis and treatment are essential.

CSF cytology in a patient with vertigo and earache.

Large atypical cells in cerebrospinal fluid in a patient with earache and vertigo. In this Enigma Portal case, we described uncommon cerebrospinal fluid findings in a case of vertigo and earache in a 40-year-old man.

Audiological and vestibular symptoms following SARS-CoV-2 infection and COVID-19 vaccination in children aged 5-11 years.

PURPOSE: The present study assessed the prevalence of audio-vestibular symptoms following SARS-COV-2 infection or COVID-19 vaccination among children, comparing the two groups. A further aim was to evaluate whether children with pre-existing unilateral hearing loss were more prone to adverse events. MATERIALS AND METHODS: This retrospective study included children aged 5-11 years with normal hearing or a proven history of unilateral hearing loss who contracted SARS-CoV-2 or received two doses of COVID-19 vaccine. Tinnitus, hyperacusis, aural fullness, otalgia, otorrhea, new-onset hearing loss, vertigo and dizziness were investigated as possible complications of SARS-CoV-2 infection or the COVID-19 vaccine. RESULTS: This study included 272 children (143 boys, 129 girls), with a mean age of 7.8 ± 2.3 years. Among these, 120 were affected by pre-existing unilateral hearing loss. The most common audio-vestibular symptoms reported by children following SARS-CoV-2 infection and COVID-19 vaccination were aural fullness (33/132, 25 %) and dizziness (5/140, 3.6 %), respectively. All symptoms following COVID-19 vaccination resolved within 24 h. Compared to children who received the COVID-19 vaccine, those infected with SARS-CoV-2 had a higher prevalence of tinnitus (p = 0.009), hyperacusis (p = 0.003), aural fullness (p < 0.001), otalgia (p < 0.001), otorrhea (p < 0.001), and vertigo (p = 0.006). Two girls also experienced new-onset unilateral sensorineural hearing loss following SARS-CoV-2 infection. Children with a known history of unilateral hearing loss did not have a higher prevalence of audio-vestibular symptoms than children with normal hearing. CONCLUSIONS: Our results suggest that the COVID-19 vaccine is safe and can be recommended for children with unilateral hearing loss without fear of possible audio-vestibular sequelae.

Aetiology and management options for secondary referred otalgia: a systematic review and meta-analyses.

OBJECTIVES OF REVIEW: To review the literature for the evidence base for the aetiology and management of referred otalgia, looking particularly at non-malignant, neuralgic, structural and functional issues. TYPE OF REVIEW: Systematic review. SEARCH STRATEGY: A systematic literature search was undertaken from the databases of EMBASE, CINAHL, MEDLINE®, BNI, and Cochrane Library according to predefined inclusion and exclusion criteria. EVALUATION METHOD: All relevant titles, abstracts and full text articles were reviewed by three authors who resolved any differences by discussion and consultation with senior author. RESULTS: 44 articles were included in our review. The overall quality of evidence was low, with the vast majority of the studies being case-series with three cohort and four randomised-controlled trials included. The prime causes and management strategies were focussed on temporomandibular joint dysfunction (TMJD), Eagle syndrome and neuralgia. Our meta-analyses found no difference on the management strategies for the interventions found. CONCLUSIONS: Referred otalgia is common and treatment should be aimed at the underlying pathology. Potential aetiologies are vast given the extensive sensory innervation of the ear. An understanding of this and a structured approach to patient assessment is important for optimal patient management.

Glossopharyngeal Neuralgia Characterized by Otalgia: A Retrospective Study.

Glossopharyngeal neuralgia (GPN) is an uncommon facial pain syndrome and is characterized by paroxysms of excruciating pain in the distributions of the auricular and pharyngeal branches of cranial nerves IX and X. Glossopharyngeal neuralgia characterized by otalgia alone is rare. Herein, the authors analyzed 2 patients with GPN with otalgia as the main clinical manifestation. The clinical features and prognosis of this rare group of patients with GPN were discussed. They both presented with paroxysmal pain in the external auditory meatus and preoperative magnetic resonance imaging suggested the vertebral artery were closely related to the glossopharyngeal nerves. In both patients, compression of the glossopharyngeal nerve was confirmed during microvascular decompression, and the symptoms were relieved immediately after surgery. At 11 to 15 months follow-up, there was no recurrence of pain. A variety of reasons can cause otalgia. The possibility of GPN is a clinical concern in patients with otalgia as the main complaint. The authors think the involvement of the glossopharyngeal nerve fibers in the tympanic plexus via Jacobson nerve may provide an important anatomic basis for GPN with predominant otalgia. Surface anesthesia test of the pharynx and preoperative magnetic resonance imaging is helpful for diagnosis. Microvascular decompression is effective in the treatment of GPN with predominant otalgia.

Incidence of Otalgia After Orthognathic Surgery.

BACKGROUND: In orthognathic surgery, it is well known that maxillary osteotomies and displacements sometimes affect auditory function. Thus, this study examined the relationship between the direction of maxillary displacement and postoperative otalgia. METHODS: Twenty consecutive patients underwent Le Fort I maxillary osteotomy using advancement, impaction, setback, or a combination of these procedures. The direction of movement and incidence of otalgia were investigated. Patients provided informed consent preoperatively, and postoperative reassurance was prudent. RESULTS: Pure-tone average evaluation based on horizontal or vertical movements did not show significant differences, although vertical movements resulted in fewer changes in the hearing threshold. Specifically, no significant changes were observed in the hearing thresholds of patients after surgery. No significant difference was also observed between horizontal and vertical movements in the tympanometry results. Negative changes were found in the results of the Eustachian tube dysfunction test in vertical movements, which returned to preoperative values in the final test. CONCLUSIONS: The risk of minor changes in hearing function is probable during the first week after orthognathic surgery; however, these negative changes either completely disappear or remain negligible.

The Effect of Developmental Delay and Autism Spectrum Disorder on External Auditory Canal Foreign Body Extraction.

OBJECTIVES: To determine the effect of developmental delay (DD) and autism spectrum disorder (ASD) on pediatric external auditory canal foreign body (EAC FB) retrieval outcomes. METHODS: A retrospective chart review of children presenting with EAC FB at a tertiary children's hospital was performed between January 2018 and December 2019. Charts were reviewed for demographics, presence of otalgia, complications, number of EAC FB episodes, indications for operating room removal, DD, and ASD status. RESULTS: A total of 1467 patients underwent EAC FB removal. One hundred thirty-seven children (9.3%) had DD, and, of those with DD, 63 (46%) had ASD. Children with DD were 1.76 years older compared with children with non-DD (NDD) ( P < 0.0001) at the time of presentation, whereas children with ASD were 1.45 years older than children with NDD ( P = 0.0023). Children with DD and ASD were more likely to require removal of FB in the operating room (OR) compared with the NDD group (36.5% vs 16.7%, P = 0.0001). This was not true for children with DD without ASD. Patients with DD reported significantly less otalgia when compared with NDD patients (26.3% vs 37.4%, P = 0.0097). A similar trend, although not statistically significant, was observed when comparing children with ASD with NDD patients. The NDD patients (1.1) had fewer EAC FB episodes than patients with DD (1.6, P < 0.0001) and ASD (1.8, P < 0.0016). Hazard ratios for multiple episodes of FB were 4.5 (95% confidence interval, 2.9-6.8) for DD, and 5.6 for ASD (95% confidence interval, 3.2-9.9). The complication rate for all groups was low. CONCLUSIONS: Due to the different ways that children with DD and ASD present compared with NDD children, physicians should be vigilant when evaluating symptoms and conducting physical examinations for EAC FB in those patients. A lower threshold for referral to otolaryngologists may result in more favorable outcomes.

Fifteen-minute consultation: A structured approach to the assessment of a child with earache.

Earache, or otalgia, in children is common. Diagnosis can be challenging due to the range of causes. Assessment involves a thorough history and examination. Identification of associated otological symptoms, including discharge, hearing loss, vertigo and facial nerve weakness, is helpful and can aid diagnosis. Examination should involve looking at the external ear, otoscopy to assess the ear canal and tympanic membrane and documentation of facial nerve function. If otological examination is normal, further examination looking for non-otological causes may be guided by the history. Investigations are often unnecessary but may include blood tests, audiology and imaging. Most otalgia is caused by an acute infection, which is self-limiting and can be managed in the community. However, ear, nose and throat (ENT) advice and input may be required for systemically unwell children or those who fail to improve despite appropriate medical therapy.

Referred otalgia: Common causes and evidence-based strategies for assessment and management.

OBJECTIVE: To provide family physicians and general otolaryngologists with a practical, evidence-based, and comprehensive approach to the management of patients presenting with suspected referred otalgia. SOURCES OF INFORMATION: The approach described is a review based on the authors' clinical practices along with research and clinical review articles published between 2000 and 2020. MEDLINE and PubMed were searched using the terms otalgia, referred otalgia, and secondary otalgia. Current guidelines for the management of referred otalgia were also reviewed. MAIN MESSAGE: Otalgia is defined as pain localized to the ear. It is one of the most common head and neck presentations in primary care, otolaryngology, and emergency medicine. Secondary otalgia arises from nonotologic pathology and represents nearly 50% of otalgia cases. Otalgia in the absence of other otologic symptoms is highly indicative of a secondary cause. A thorough assessment of patients presenting with referred otalgia requires an understanding of the possible causes of this condition, including dental and oral mucosal pathologies, temporomandibular joint disorders, cervical spine pathology, sinusitis, upper airway infection, and reflux, as well as head and neck malignancy. This paper aims to highlight the most common causes of referred otalgia, their presentations, and initial options for assessment and management. CONCLUSION: The prevalence of referred otalgia makes this an important condition for family physicians to be able to assess, manage, and triage based on patient presentation and examination. Understanding the common causes of referred otalgia will help reduce wait times for specialist assessment and allow ease and speed of access to management options for patients in community clinics.

Temporomandibular treatments are significantly efficient in improving otologic symptoms.

Symptoms of temporomandibular disorders (TMD) could be present as otologic symptoms like earache and dizziness in some patients. In most cases, these symptoms are not recognized because otolaryngologists fail to diagnose TMD as a source of the problem. This investigation was conducted to evaluate the effect of TMD treatments on the otologic symptoms which after taking history and clinical examinations seemed to be related to TMD. In the present study, the patients who were complaining of otalgia, ear fullness, tinnitus, hearing loss, and dizziness were evaluated by an ear fellow. Forty patients who had no known otologic or other primary causes to explain their symptoms, were referred to the orofacial pain clinic with the possible diagnosis of TMD. If the diagnosis was confirmed by an orofacial pain specialist, a combination of TMD treatments was administered to each case and the patients were followed up. The results showed that following implementation of treatment protocols for TMD, more than 50% of the patients reported complete or partial recovery in the second follow-up (p < 0.05). The most common otologic symptom of the referred cases was earache, and the most common associated complaint was neck pain. All the patients had one or more parafunctional habits. This study showed that TMD treatments were significantly efficient in improving otologic symptoms partially or completely and the authors concluded that for the patients with otolaryngologic unexplained symptoms, an overhaul examination is needed to assess TMD as a possible cause of the patient complaint. It is recommended that in cases with unexplained otologic symptoms, otolaryngologists care more about the neck trigger points (TP) and ask about the patient's parafunctional habits. Otolaryngologists and dentists need to be aware of the risk of developing otologic symptoms caused by these habits or cervical TPs.

An unusual presentation of scrub typhus in a child: a case report.

BACKGROUND: Scrub Typhus (ST) is an acute, febrile zoonotic disease caused by the bacterium Orientia tsutsugamushi which is endemic to the Asia-Pacific region. Infected adults rarely present with sensorineural hearing loss and otalgia. Though few cases of pediatric cases are known to present with otalgia, no pediatric cases of sensorineural deafness complicating ST have been reported to date. CASE PRESENTATION: A 5-year-old, previously healthy girl presented with a one-week history of high-grade intermittent fever, Headache and right ear pain with a recent onset of reduced hearing. She had a fever up to 39 °C, cervical lymphadenopathy, bilateral pleural effusion with diffuse infiltrations, and mild hepatosplenomegaly with no evidence of rash. Her initial examination was normal except for mildly enlarged tonsils. Unilateral right ear hearing loss was noted using Weber's test. Evidence of progressive, mild anemia, and raised inflammatory markers was noted. Diagnosis of scrub typhus was confirmed by positive detection of Orentia tsutsugamushi IgM antibodies on rapid diagnostic test and the presence of chigger mite in the right external auditory canal on repeat examination. She responded dramatically to the empirical treatment of ceftriaxone and doxycycline. On follow-up, she did not have any residual hearing loss and her ear pain had resolved completely. CONCLUSION: Acute onset hearing loss or severe otalgia with or without findings should be an important diagnostic clue for suspecting scrub typhus in patients who present with a history of fever especially in endemic areas.

Thinking Beyond Giant Cell Arteritis in COVID-19 Times.

BACKGROUND: The coronavirus disease 2019 has displayed multi-system manifestations since its first presentation. This article highlights an unusual presentation of COVID-19 that was reviewed by our instituition's otolaryngology and ophthalmology team. METHODS: We present 2 cases of COVID-19 which presented with unilateral otalgia and ipsilateral pulsatile headaches involving the temporal area. They were referred to the otolaryngology team for assessment of otalgia and subsequently referred to the ophthalmology team for possible giant cell arteritis (GCA). Both patients had no jaw claudication, scalp pain, or tenderness. RESULTS: Serology testing showed raised C-reactive protein (CRP) but normal platelets and erythrocyte sedimentation rate. Case 1 was tested for COVID-19 as part of a preoperative workup which returned positive. With a marked similarity in presentation, Case 2 was tested for COVID-19 which also returned positive. CONCLUSIONS: These 2 cases highlight another set of symptoms that COVID-19 patients may present with. In the context of a COVID-19 pandemic, if a patient presents symptoms similar to GCA but with isolated CRP, it should prompt consideration for COVID testing.

Are Throat Pain and Otalgia Predictive of Perineural Invasion in Squamous Cell Carcinoma of the Oropharynx?

PURPOSE: Head and neck cancer is often associated with pain and perineural invasion (PNI). The purpose of this study was to determine the association of pain complaints and the microscopic identification of PNI in patients with oropharyngeal squamous cell carcinoma (OPSCC). PATIENTS AND METHODS: A retrospective cohort study was performed including patients diagnosed with OPSCC from 2010 to 2019. Patients diagnosed and operated on with curative intent at 2 institutions were included. The primary predictor variable was pain (measured as no pain, ear pain, throat pain, or simultaneous pain). Other variables were patient demographics, p16 status, and TNM staging. The primary outcome variable was the histologic presence of PNI. Chi-square analysis was performed to test for any significant associations between pain, T stage, overall stage, and p16 status in relation to PNI outcome. Multivariate logistic regression analysis was used to control for cancer staging variables when testing the association between pain and PNI. RESULTS: The final sample was composed of 157 subjects of whom 126 were men. The mean age was 59.7 years. Seventy-seven (49.0%) presented with no pain, while 35 (22.3%), 39 (24.8%), and 6 (3.8%) presented with both throat/ear pain, throat pain only, and ear pain only, respectively. Patients with simultaneous pain had 3.41 times higher odds of PNI compared to the no pain group (P = .02), although only pathologic T stage 4 and a diagnosis on the base of the tongue were independent postoperative predictors of PNI (P < .05). CONCLUSIONS: Our study demonstrates that otalgia is a preoperative predictor of PNI in OPSCC and also demonstrates a trend of increasing pain complaints with PNI.

Complications and prognosis associated with intra-tympanic steroid injection to treat sudden sensorineural hearing impairment.

PURPOSE: The purpose of this study was to measure the incidence of complications in sudden sensorineural hearing loss (SSNHL) patients treated with intra-tympanic steroid injection (ITSI) and compare hearing recovery rates. MATERIALS AND METHODS: 123 patients with unilateral SSNHL receiving ITSIs were included in this study. Post-ITSI complications were documented including otalgia, dysgeusia, vertigo (duration>1 h), and persistent eardrum perforation. The pain intensity was evaluated with visual analog scale (VAS). Hearing was measured before ITSI and at 1 month after the final ITSI. We compared our patients' hearing threshold between presence and absence of different complications. RESULTS: 47.2% patients experienced post-injection otalgia with the average VAS score 3.2 (range 2-6). Five (4.1%) and six (4.9%) patients exhibited vertigo and persistent eardrum perforations, respectively. The patients were divided into three groups based on the absence of complications and the presence of vertigo and eardrum perforation. The hearing threshold improvements did not differ significantly among the three groups (p = 0.366). Although the difference was not significant (p = 0.664), the proportion of patients experiencing post-ITSI vertigo who were on contemporaneous oral steroids was lower than the proportion of non-vertigo patients on such steroids. CONCLUSION: The incidences of otalgia, vertigo, and persistent eardrum perforation in SSNHL patients treated with ITSI were 47.2%, 4.1% and 4.9%, respectively. We found no association between concurrent oral steroid use and the incidence of post-ITSI eardrum perforation or vertigo. Although statistical significance was lacking, patients who did not take contemporaneous oral steroids may have a higher rate of prolonged post-ITSI vertigo.

The Outcome of Cerumen Removal in the Pediatric Emergency Department.

OBJECTIVE: Cerumen obstructs the visualization of the tympanic membrane (TM) in up to 40% of children, sometimes posing a challenge to rule out the diagnosis of acute otitis media (AOM) as the source of otalgia (for verbal children), irritability, fever, and febrile seizures. We aim to determine the rate at which removing the cerumen from blocking the view of the TM could change the management of these patients in the pediatric emergency department (PED). METHODS: We retrospectively investigated all medical records of patients who underwent cerumen removal in the PED at a tertiary children's hospital from 2018 to 2019. We analyzed the effect of the procedure on the subsequent workup during their PED visit. RESULTS: Of 482 children who presented to the PED with otalgia, irritability, fever, and/or febrile seizures and who were referred to an otolaryngologist for subsequent treatment after preliminary evaluation in the PED, 176 were included in the study group after having the cerumen removed from one or both ears. Seventy-three of them were given a diagnosis of AOM, 93 had a normal-appearing TM, and 10 had external otitis. Twenty-one percent of those with AOM and 46% of those with a normal TM ( P = 0.008) had blood drawn as part of their workup in their PED visit. The rate of chest x-rays was also significantly less for the AOM group (16% vs 30%, P = 0.03), and they also underwent fewer urine tests ( P = NS). CONCLUSION: Cerumen removal changes the management of children in the PED who present with a possible diagnosis of an ear infection. Cerumen removal could avoid unnecessary laboratory and imaging studies, which could save time, costs, and suffering.

A pain in the ear: Two case reports of nervus intermedius neuralgia and narrative review.

OBJECTIVE: Present two cases of nervus intermedius neuralgia (NIN) in which patients described unilateral deep ear pain as their primary complaint and present a summary of NIN cases reported in the literature. BACKGROUND: The nervus intermedius is a tiny branch of the facial nerve that, with neuralgia, can present as a deep ear pain (NIN). The International Classification of Headache Disorders, 3rd edition, (ICHD-3) criteria for an NIN diagnosis include a unilateral deep ear pain with possible radiation that occurs in paroxysms with sharp pain and a tactile trigger. METHODS: A PubMed search was conducted for NIN and geniculate neuralgia. Two patients recently diagnosed with NIN at a single clinic were selected for case reports to highlight the variability of symptom presentation. RESULTS: The two cases reported here and the 127 cases reported in the literature show a wider range of presentations than included in the ICHD-3 criteria, including variable pain radiation sometimes diagnosed as concurrent trigeminal, glossopharyngeal, or occipital neuralgia. Pain was reported as constant or paroxysmal, as well as dull, sharp, or neuralgiform with inconsistent presence of triggers. While ICHD-3 does mention reported taste change, lacrimation, and salivation, the literature reports a much wider range of potential features associated with NIN. Optimal medical treatment is unclear given the predominance of surgical reporting of positive response to microvascular decompression, nerve sectioning, or other procedures. The two cases described here were successfully managed medically. CONCLUSION: NIN can present as described in the ICHD-3, but a more variable presentation may be possible. More studies are needed to clarify presentation, optimal medical treatment, and surgical indications for patients with NIN, especially when patients have no clear neurovascular conflict on neuroimaging.

Evaluation of Clinical Graded Treatment of Acute Nonsuppurative Otitis Media in Children with Acute Upper Respiratory Tract Infection.

Objective: To treat children with acute nonsuppurative otitis media induced by acute upper respiratory tract infection of varying severity and evaluate its therapeutic effects. Materials and Methods: Patients from the emergency department with acute nonsuppurative otitis media were followed up between September 2015 and December 2018. A total of 420 patients were classified into grades I to III according to tympanic membrane intactness and systemic reactions and treated according to grading. Results: Grade I patients showed no significant difference in the recovery of acute symptoms whether antibiotics are used or not. Grade II patients, after 3 months of follow-up, showed no tympanic membrane perforation, and 9 cases of binaural B-type children did not improve but were cured by operation. In grade III patients, after treatment for 4 hours in the experimental group 3, the earache subsided, 1 case had tympanic membrane perforation, and the patients recovered after 2 weeks (64/92) and after 3 months (28/92) of drug treatment. After treatment for 4 h in the control group 3, the earache eased, and 3 patients developed tympanic membrane perforation and were treated for 3 months. 4 binaural B-type children did not improve but recovered after surgical treatment. Conclusion: Grade I patients could be closely followed up by clinical observation. For anti-inflammatory patients with grade II disease, treatment has therapeutic significance. For patients with grade III, some patients still have TMP, but the use of cephalosporin third-generation drugs plus an appropriate amount of hormone therapy is effective in reducing symptoms and tympanic local reactions.