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.

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.

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.

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.

Otogenic Lateral Sinovenous Thrombosis in Children: A Case Series from a Single Centre and Narrative Review.

AIM: We aimed to describe otogenic lateral sinovenous thrombosis (OLST), a rare, potentially life-threatening complication of otomastoiditis. METHODS: Children diagnosed with OLST in a tertiary-care Hospital from 2014 to 2019 was retrospectively selected. Clinical and radiological features, timing of diagnosis, treatment and outcome are reported. RESULTS: Seven children (5 males) were studied. Fever and neurological symptoms (headache, lethargy, diplopia, dizziness and papilledema) were always present. Otalgia and/or otorrhea were found in 6 children; none had signs of mastoiditis. Diagnosis was reached after 7 days (median) from clinical onset. Brain CT-scan was performed in 5 children being diagnostic for 3. Venography-MRI detected OLST and mastoiditis in all cases without parenchymal lesions. Treatment was based on intravenous rehydration, antibiotic and low-molecular weight heparin; acetazolamide was added in 3 children. Mastoidectomy and ventriculoperitoneal-shunting were selectively performed. Patients were discharged after 26 days (median). Follow-up neuroimaging showed sinus recanalization after a median time of 6 months. CONCLUSION: A multidisciplinary approach is needed to optimize diagnostic-therapeutic protocols of pediatric OLST.

Ear Pain: Diagnosing Common and Uncommon Causes.

Otalgia (ear pain) is a common presentation in the primary care setting with many diverse causes. Pain that originates from the ear is called primary otalgia, and the most common causes are otitis media and otitis externa. Examination of the ear usually reveals abnormal findings in patients with primary otalgia. Pain that originates outside the ear is called secondary otalgia, and the etiology can be difficult to establish because of the complex innervation of the ear. The most common causes of secondary otalgia include temporomandibular joint syndrome and dental infections. Primary otalgia is more common in children, whereas secondary otalgia is more common in adults. History and physical examination usually lead to the underlying cause; however, if the diagnosis is not immediately clear, a trial of symptomatic treatment, imaging studies, and consultation may be reasonable options. Otalgia may be the only presenting symptom in several serious conditions, such as temporal arteritis and malignant neoplasms. When risk factors for malignancy are present (e.g., smoking, alcohol use, diabetes mellitus, age 50 years or older), computed tomography, magnetic resonance imaging, or otolaryngology consultation may be warranted.

Luc abscess: an extraordinary complication of acute otitis media.

Luc abscess is an uncommon suppurative complication of otitis media. Unfamiliarity of this complication leads to delayed diagnosis and treatment. This abscess is usually benign. Infection in the middle ear spreads via anatomic preexisting pathways, and this process results with subperiosteal pus collection. Conservative treatment with drainage under empirical wide spectrum antibiotic is efficient. Here,we present a 9-year-old boy who had left facial swelling after a period of otalgia, diagnosed as Luc abscess without mastoiditis.

Otalgia.

BACKGROUND: Otalgia is frequently seen in general practice. It can be broadly divided into primary otalgia, which includes the diseases occurring largely within the ear, or secondary otalgia, which is pain referred to the ear by travelling along cranial nerves that supply both the ear and referred region. The causes of secondary otalgia may require more extensive examination and investigation to define the aetiology. OBJECTIVE: The aims of this article are to outline the most common causes of otalgia seen in general practice, and provide a pragmatic approach to initial assessment and deciding when to refer for specialist review. DISCUSSION: The most common cause of primary otalgia is infection. Other causes require a greater index of suspicion. Specialist referral could be made if there are complications of primary otalgia or if a secondary cause needs to be excluded in a patient with a normal otology examination.

The Otalgia Point: A Novel Clinical Gesture in Otolaryngology.

INTRODUCTION: In cases of otalgia without any accompanying findings, some patients locate their otalgia below the attachment of the lobule, at the apex of the jugulodigastric region. PURPOSE: To present a series of these patients for whom nasal steroids or myringotomy usually ameliorated their pain. MATERIALS AND METHODS: Thirty-two patients with normal physical examinations, tympanograms, and age-appropriate audiograms spontaneously indicated otalgia at "the otalgia point." Inspection of the oropharynx and nasal airway, palpation of the neck and temporal mandibular joints, and nasopharyngoscopy/laryngoscopy ruled out referred causes of otalgia. Patients were offered either nasal steroid spray or trial myringotomy followed by tympanostomy tube. RESULTS: Otalgia improved in all 10 (100%) patients who selected nasal steroids. Otalgia resolved in 17 of 20 (85%) myringotomy participants. Three patients declined intervention. In all, symptoms improved in 27/29 treated patients (93%). CONCLUSION: This description of "the otalgia point" introduces a new otolaryngologic gesture in physical examination that can aid in the therapeutic management of some patients with otalgia and normal examinations. This is an uncontrolled case series that serves as a pilot study for further exploration of this gesture.

A case of nasal septal deviation-induced rhinogenic contact point otalgia.

Recently, the author experienced a case of intractable right-sided otalgia in a 17-year-old male patient. The pain was intermittent and frequently radiated to the right forehead and periorbital region. He had received unsuccessful medical treatments for migraine headache. The otoendoscopic examination revealed a normal tympanic membrane. Nasal endoscopy showed only an intranasal mucosal contact point between the septal crest and the right inferior turbinate, without other signs of sinus inflammation. Topical application of an anesthetic and vasoconstrictive solution-soaked cotton pledget at the intranasal contact area made the patient experience a significant improvement of symptoms. After surgical removal of the mucosal contact point by conventional septoplasty and turbinoplasty, he experienced significant relief of symptoms and complete recovery. Here, the author report a case of intractable otalgia induced by nasal septal deviation with review of literatures, and suggestion for new disease entity of rhinogenic contact point otalgia induced by nasal septal deviation is carefully made.

Endonasal dilatation of the Eustachian tube (EET) in children: feasibility and the role of tubomanometry (Estève) in outcomes measurement.

Studies on endonasal dilatation of the Eustachian tube (EET) utilizing a balloon catheter have shown encouraging results over the last years. This retrospective analysis presents our outcomes with EET in children with chronic obstructive dysfunction of the Eustachian tube, as well as the role of tubomanometry (TMM, Estève) as a diagnostic tool in the pre- and postoperative assessment of the Eustachian tube (ET) dysfunction. The data of 33 children, having undergone EET between September 2010 and March 2014, were retrospectively evaluated. They were assessed using tubomanometry before and after the EET. The R-data as the rate of Eustachian tube function in tubomanometry (TMM) were pre- and postoperatively matched with the clinical outcomes. Moreover, the patients' complaints before and after the procedure were analyzed. We did not see any EET-related complications in children. Most patients noticed a relief of their complaints. In the same time, tubomanometry was not able to show improved tube function or favorable postoperative changes in the R-data. Ear-related symptoms (e.g. otorrhea, otalgia, hearing loss) have been improved. EET is a feasible method in adults as well as in children to treat chronic tube dysfunction. However, tubomanometry does not seem to be the adequate tool to evaluate the tube function and thus the success rate of EET in children with chronic dysfunction of the Eustachian tube.

OTOLOGIC FOREIGN BODY: AN UNDECLARED AND UNUSUAL IMPACTION.

BACKGROUND: This study reports two cases of undeclared and unusual foreign body (FB) impaction in the ears of Nigerian adult patients that were accidentally discovered and successfully managed. AIM: The report aims to create awareness, and encourage Otorhinolaryngologist to have proper otoscopy done for all patients with suspected ear FB and double check again following FBs removal. CONCLUSION It has recommended a need for an increased public enlightenment to raise awareness about the danger of cleaning the ears with cotton swab or other sharp materials.

Managing emergency department patients with otalgia.

Though the vast majority of conditions associated with otalgia are not life-threatening, there are nuances and controversies in the diagnosis and management of even the most common diseases, such as acute otitis media and otitis externa. For more severe disease processes, such as necrotizing otitis externa, acute mastoiditis, and perichondritis, early recognition and timely management are paramount in reducing morbidity and mortality. A systematic approach to the evaluation of these patients is key to establishing an accurate diagnosis, identifying patients who are at high risk for dangerous etiologies or complications, and providing optimal patient care. This issue summarizes the most recent guidelines and presents a systematic, evidence-based approach to the emergency department evaluation and management of patients with otalgia.

A 9-year-old boy with atypical retroauricular pain: a case report.

Idiopathic causes of retroauricular pain are rarely seen in clinical practice. We present a 9-year-old child who suffered from atypical retroauricular pain resistant to conventional treatment. After excluding any other cause of retroauricular pain, a nerve block was performed with a 0.3 ml lidocaine 1% injection into the trigger point. We believe that this case report is important because in the literature there are no similar cases described in children.

Evaluation and Management of Otalgia.

Otalgia can be broadly categorized into primary otologic causes and secondary nonotologic causes. Isolated otalgia in the absence of hearing loss, otorrhea, or abnormal otoscopic findings is typically secondary to referred pain from nonotologic causes, as the sensory nerve supply to the ear arises from 4 cranial nerves and the cervical plexus. The most common causes of primary otalgia are acute otitis media and otitis externa, whereas the most common causes of secondary otalgia are temporomandibular joint disorders and dental pathology. Persistent unilateral ear pain and other alarm symptoms warrant further evaluation for possible neoplasm.

A case report of refractory otalgia after Ramsay Hunt syndrome successfully treated by applying pulsed radiofrequency to the great auricular nerve: A CARE-compliant article.

RATIONALE: Ramsay Hunt syndrome is a type of herpes zoster infection involving geniculate ganglion and facial nerve. Unilateral facial palsy, otalgia, and painful vesicular rash on the auricle and external auditory canal are the typical symptoms. Although postherpetic neuralgia (PHN) is a devastating complication of herpes zoster infection, PHN following Ramsay Hunt syndrome has rarely been reported. PATIENT CONCERNS: A 55-year-old immunocompetent female patient visited our pain clinic, for left-sided refractory otalgia (PHN) that persisted for 3 months after she was diagnosed with Ramsay Hunt syndrome. Although facial palsy and tinnitus had recovered within 2 to 4 weeks after symptom onset, the patient had been experiencing a persistent and severe otalgia radiating to mandibular angle, temporal and upper cervical area of neuropathic nature. DIAGNOSES: The patient's pain persisted despite conservative medication and administration of ultrasound-guided stellate ganglion block, facial nerve block, and great auricular nerve block several times. INTERVENTIONS: The patient was treated with the application of ultrasound-guided pulsed radiofrequency (PRF) to the great auricular nerve. OUTCOMES: The patient experienced significant pain reduction more than 50% on a numeric rating scale after 2 weeks of PRF treatment. LESSONS: Chronic otalgia might be a type of PHN after Ramsay Hunt syndrome with cervical nerve involvement. PRF treatment to the great auricular nerve can be a therapeutic option for refractory otalgia following Ramsay Hunt syndrome.

Management of myofascial pain: low-level laser therapy versus occlusal splints.

The present study was designed to compare the effects of low-level laser with occlusal splints in patients with signs and symptoms of myofascial pain (MP) dysfunction syndrome. A total of 40 (34 women and 6 men, with a mean age of 32.84 [SD, 10.70] years) were selected after the diagnosis of MP according to the Research Diagnostic Criteria for Temporomandibular Disorder. The patients were randomly divided into 2 groups: study group (n = 20) and control group (n = 20). Low-level laser was applied to patients in the study group 2 times per week, for a total of 10 sessions. Patients in the control group were instructed to wear occlusal splints 24 h/d for 3 months. The functional examination was based on Research Diagnostic Criteria for Temporomandibular Disorder and pressure pain threshold values were obtained with the aid of an algometer in both groups. Patients' self-report of pain was evaluated with visual analog scale. Comparisons were made within and between the groups before and after treatment. Vertical movements showed statistically significant improvements after the treatments in both groups (P < 0.01), but when the groups were compared with each other, there were no significant difference between the groups. In both groups, tenderness to palpation of the muscles decreased significantly. Pressure pain threshold evaluations and visual analog scale scores revealed similar results, too. This particular type of low-level laser therapy (820 nm, 3 J/cm2, 300-mW output power) is as effective as occlusal splint in pain release and mandibular movement improvement in MP.

12 minute consultation: an evidence-based management of referred otalgia.

BACKGROUND: Otalgia is a common presenting symptom to the ENT clinic. The aetiology of otalgia can be divided into otological and referred depending on its underlying pathology. This article aims to provide a systematic and evidence-based method of managing a patient with referred otalgia. METHODS: The data in this article are based on a literature review performed on MEDLINE and EMBASE in January 2010. The keywords used included otalgia in combination with diagnosis, management, investigations and treatment. Articles in the English language were selected and reviewed. Suitable references from these articles were also reviewed. RESULTS: The majority of published literature on the management of diseases causing referred otalgia is level III/IV evidence. CONCLUSIONS: An understanding of the different causes of referred otalgia is essential as it can be multifactorial in origin. The main concern in a patient with referred otalgia is overlooking a malignant lesion in the upper aerodigestive tract or base of skull/infratemporal fossae. A thorough history followed by a systematic examination usually helps to arrive at a diagnosis. Treatment should be directed towards the underlying pathology.