Ear Pain (Otalgia) - Differential Diagnosis Framework Primary Otalgia - Pain that originates from the ear - Pain that is continuous and progressively worsens is more likely to be associated with infection and primary otalgia Most Common Causes of Primary Otalgia: • Otitis media • Otitis externa Mechanical Causes of Primary Otalgia: • Barotrauma • Eustachian tube dysfunction • Foreign object • Cerumen impaction Infectious Causes of Primary Otalgia: • Otitis externa - Caused by bacterial infections (90%), Fungal infections (10%) • Otitis media: - Streptococcus pneumoniae - Moraxella catarrhalis - Haemophilus influenzae • Bullous myringitis • Malignant otitis externa • Cellulitis of auricle • Mastoiditis • Viral myringitis • Cranial nerve VII: - Ramsay Hunt syndrome - Herpes zoster Neoplastic Causes of Primary Otalgia: • Cholesteatoma • Basal/squamous cell CA • Melanoma Inflammatory Causes of Primary Otalgia: • Granulomatosis with polyangiitis • Relapsing polychondritis - Relapsing, bilateral, erythematous or violaceous opacification on the external ear, sparing the ear lobes Secondary Otalgia: - Pain that originates outside the ear - Intermittent pain is likely to be associated with secondary otalgia Most Common Causes of Primary Otalgia: • Temporomandibular joint syndrome • Dental infections Cranial Nerve V: • TMJ syndrome • Dental infections (caries, abscess, pulpitis) • Trigeminal neuralgia • Sinusitis • Mandibular osteomyelitis • Tumor Cranial nerve IX can refer pain: • Tonsillitis • Pharyngitis • Pharyngeal tumor • Glossopharyngeal neuromas Vagus nerve (irritation): • Myocardial ischemia causing otalgia C2 and C3 cervical nerve roots—cervical spine degeneration: • Tumor • Infection • Inflammatory process Temporal arteritis should be considered in patients 50 years or older who have normal ear examination findings and any of the following symptoms: headache, malaise, weight loss, fever, or anorexia Other Causes of Secondary Otalgia: • Carotidynia • Cervical adenopathy • Cervical spine arthritis • Cricoarytenoid arthritis • Gastroesophageal reflux • Head and neck tumors • Musculoskeletal: myofascial pain, torticollis, cervical disc degeneration, cervical radiculopathy • Oral aphthous ulcers • Thyroiditis (rarely causes isolated otalgia), thyroid carcinoma • Thoracic aneurysms • Other rare causes (subdural hematoma, lung cancer, central line placement, carotid artery aneurysm, Pott puffy tumor) • Lymph node: lymphadenopathy, lymph node malignancies • Gastrointestinal disease: gastroesophageal reflux disease (GERD), esophageal carcinoma • Sialadenitis (infection of salivary gland duct), sialolithiasis (salivary duct stones), salivary gland tumor Clues In History To Narrow Down Ddx: • Pain location • Duration • Aggravating factors • Alleviating factors • Associated symptoms • Previous episodes • Medical history • Smoking status • Alcohol abuse Red Flags: • Dysphagia • Odynophagia • Dysphonia • Hemoptysis • Loss of vision or black spots • Unintended weight loss Physical Exam: • Traction on the auricle • Palpation of the tragus to differentiate disease processes affecting the external ear and ear canal • Otoscopic examination • Oral exam • TMJ • Head, neck, nasal, cervical spine #Earpain #Otalgia #Ear #Pain #Otology #Otolaryngology #differential #diagnosis
