Otalgia

1. Physiology
   1. Ear shares sensory fibers from head, neck and chest
      1. Trigeminal Nerve (CN 5)
      2. Facial Nerve (CN 7)
      3. Glossopharyngeal Nerve (CN 9)
      4. Vagus Nerve (CN 10)
      5. Cervical nerves (C2 and C3)
2. History: Red Flags to suggest secondary cause
   1. Age over 50 years (malignancy, Temporal Arteritis)
   2. Excessive Tobacco use (malignancy, vascular disease)
   3. Cardiac Risk Factors (Coronary Artery Disease, thoracic aneurysm)
3. Causes: Primary Ear Conditions (50-60% of Otalgia cases)
   1. Common
      1. Cerumen Impaction
      2. Ear Canal Foreign Body
      3. Otitis Externa
      4. Suppurative Otitis Media
      5. Serous Otitis Media
      6. Eustachian tube dysfunction (often with Upper Respiratory Infection)
      7. Ear Barotrauma
   2. Uncommon: Urgent
      1. Malignant Otitis Externa
      2. Cholesteatoma
      3. Mastoiditis
      4. Cellulitis
   3. Uncommon: Other
      1. Ramsay Hunt Syndrome (Herpes Zoster Oticus)
      2. Relapsing Polychondritis
      3. Wegener's Granulomatosis
4. Causes: Secondary, Referred Pain (40-50% of Otalgia cases)
   1. Common
      1. Dental causes (38%) such as Dental Caries, Periodontal Abscess
      2. Temporomandibular Joint Disorders (35%)
      3. Cervical spine disorders (8%)
      4. Parotitis
      5. Pharyngitis
   2. Uncommon: Urgent
      1. Head and Neck tumors
      2. Temporal Arteritis
      3. Carotidynia
      4. Angina Pectoris or Acute Coronary Syndrome
      5. Thoracic aneurysym
   3. Uncommon: Other
      1. Bell's Palsy
      2. Eagle's Syndrome (styloid process elongation)
      3. Gastroesophageal Reflux
      4. Oral Aphthous Ulcers
      5. Periauricular or cervical adenitis
      6. Sialolithiasis
      7. Sinusitis
      8. Thyroiditis
      9. Trigeminal Neuralgia and other regional Neuropathy (5%)
5. Management
   1. Treat underlying cause
   2. Systemic Analgesics (e.g. Acetaminophen, Ibuprofen)
   3. Topical anesthetics (if no TM Rupture)
      1. Auralgan (Benzocaine and Antipyrine) 2-4 drops three to four times daily
         1. Avoid "new" Auralgan containing U-polycosanol 410 (uproven benefit)
            1. Costs $150 instead of old generic version price of $2
            2. Write to allow pharmacist to substitute with Generic Drug
         2. Reference
            1. (2008) Prescriber's Letter 15(5):26
      2. Some naturopathic ear drops found safe and effective
         1. Sarrell (2001) Arch Pediatr Adolesc Med 155:796-9
6. References
   1. Ely (2008) Am Fam Physician 77:621-8
   2. Kuttila (2004) J Orofac Pain 18:226-34
   3. Shah (2003) Otolaryngol Clin North Am 36: 1137-51