Earache (Otalgia)

Earache may be due to ear disease, or may be referred from disease elsewhere. It is referred earache that so often causes difficulty in diagnosis. Aural causes Earache may be caused by any disease of the external ear or middle-ear cleft and the diagnosis is obvious on examination of the ear.The most common causes are acute otitis media, acute otitis externa, furunculosis and, very rarely, acute mastoiditis. Malignant disease of the ear will cause intractable earache. If the ear is not convincingly abnormal, look for a source of referred otalgia; you will nearly always find it. Referred earache Pain may be referred to the ear via the following nerves: 1 the auriculo-temporal branch of the trigeminal nerve from, for example, carious teeth, impacted molar teeth, the temporomandibular joint or the tongue; 2 tympanic branch of the glossopharyngeal nerve from, for example, tonsillectomy, tonsillitis/quinsy, carcinoma of base of tongue or tonsil or glosso-pharyngeal neuralgia; 3 sensory branch of the facial nerve from, for example, herpes zoster; 4 auricular branch of the vagus nerve from, for example, carcinoma of larynx, carcinoma of piriform fossa or postcricoid carcinoma; 5 great auricular nerve (C2–3) and lesser occipital nerve (C2) from, for example, cervical spondylosis. Some causes of referred otalgia merit special mention on account of their frequency or diagnostic importance. POST-TONSILLECTOMY EARACHE Post-tonsillectomy earache is usual, but do not forget to examine the ear. Otitis media may be present. TEMPOROMANDIBULAR JOINT DYSFUNCTION Temporomandibular joint dysfunction or pain dysfunction syndrome is common and often not diagnosed. There may be severe earache, trismus and a feeling of fullness in the ear. It is sometimes associated with faulty dental occlusion but is often simply due to grinding or clenching the teeth. There is tenderness and clicking of the temporomandibular joint and tenderness of the medial pterygoid muscle intraorally. Advice: a bite-raising splint, soft diet and correction of malocclusion are usually curative. MALIGNANT DISEASE Malignant disease of the posterior tongue, vallecula, tonsil, larynx or pharynx often produces earache, which may be an early symptom.The combination of earache with dysphagia, especially if there is an enlarged cervical node, means cancer until proved otherwise. NB. The problem of referred earache is often misdiagnosed through lack of thought. If the earache has no obvious aural cause, look for a source of referred pain.

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