Clinical Differences in Types of Otalgia

Referred otalgia in patients with thyroid cancer: Case series from Saudi Arabia

INTRODUCTION AND IMPORTANCE

Referred Otalgia is very unlikely to be the first presentation of thyroid carcinoma, however, it is important to examine thyroid in cases of otalgia lacking any evidence of primary origin.

CASE PRESENTATION

We report five cases of thyroid carcinoma, variant types, presented by secondary otalgia in Al-Baha region, KSA followed by proper surgery and patient relief during the last eight years. Patients' ages ranged from 25 to 65 years old.

CLINICAL DISCUSSION

Thyroid inflammation, including acute and subacute thyroiditis, was reported as a possible cause of the pain referred to the ear and the angle of the mandible, however otalgia caused by thyroid cancer is an extremely rare presentation.

CONCLUSION

Otolaryngologists should be aware that thyroid cancer may be associated with otalgia in any age group, however extremely rare. With very limited sources for this clinical entity, we recommend further studies on the different varieties of thyroid cancer presentations and the possibilities of the unexplained otalgia.

Differential screen and treatment of sternocleidomastoid syndrome versus eagle syndrome: a case report

BACKGROUND/PURPOSE

Differential screening is a complex process in chronic pain conditions. There is significant uncertainty that surrounds the pathophysiology of many chronic pain syndromes that may lead to misdiagnosis and treatment failures. Such differential screening is even more challenging where there is regional overlapping from surrounding tissues. This case report chronicles the differential screening and treatment of a patient with sternocleidomastoid syndrome (SCMS) originally diagnosed as Eagle's syndrome (ES).

CASE DESCRIPTION

A 55-year-old woman, referred to a physical therapist (PT) by an ear, nose and throat (ENT) physician with the diagnosis of ES. The patient complained of yearlong left-sided otalgia, blurred vision, excessive lacrimation, dysphagia, hyperesthesia on the left side of the face, unilateral temporal headaches, and both left mandibular and anterior neck pain.

OUTCOMES

The PT examination revealed the patient did not exhibit hallmark findings for clinical confirmation of ES and instead demonstrated multiple signs consistent with SCMS.

DISCUSSION

Manual therapy techniques and therapeutic exercises resolved the patient's year-long chronic symptoms within 6 sessions.

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.

Migraine-Associated Otalgia: An Underappreciated Entity

Background and Objectives

Otalgia can be primary/otogenic or secondary as a referred pain from another site, which can be difficult to establish owing to various causes and the complex innervation of the ear. In our center, we observed a large group of patients with unexplained otalgia that had a higher prevalence of migraine. We hypothesized that migraine may cause secondary otalgia. This study then aimed to determine the prevalence of migraine-associated otalgia and evaluate the efficacy of migraine treatment.

Subjects and Methods

This 2-year retrospective study was conducted at a busy otology clinic. Patients were identified using diagnostic codes corresponding to otalgia. The prevalence of migraine-associated otalgia was determined, and the efficacy of migraine treatment was evaluated in these patients. The interventions included prophylactic and abortive migraine treatments. Statistical analysis was conducted to compare between the pre- and post-treatment symptoms.

Results

A total of 208 patients with otalgia were identified. Sixty-four out of ninety patients with unexplained otalgia met the criteria for migraine; of them, 30 patients had an adequate follow-up and were thus included in the evaluation of treatment efficacy. Otalgia improved in 87% of the patients who received migraine treatment. After treatment, the mean pain score and headache frequency significantly decreased from 7 to 2 and from 27 to 9 days per month, respectively (p<0.001).

Conclusions

Migraine should be considered as a source of secondary otalgia, and patients should receive treatment as they often respond to migraine treatment.

Is there an association between otologic symptoms and temporomandibular disorders?: An evidence-based review

BACKGROUND

The aim of this article is to discuss the scientific evidence available on the the pathophysiology and management of otologic complaints in patients with temporomandibular disorders (TMDs).

TYPES OF STUDIES REVIEWED

The authors conducted an electronic search in MEDLINE, Web of Science and ScienceDirect and retrieved all the relevant peer-reviewed journal articles available in English on the topic. No time restriction was applied.

RESULTS

No consensus exists on the management of otologic symptoms in patients with concomitant TMD. The scientific evidence suggests that conservative or reversible TMD therapy might provide relief. However, this evidence is scarce and low, thus further studies with larger sample sizes and better designed methodological frameworks are needed. Until such evidence is available, dentists and orofacial pain specialists should treat TMD patients using current guidelines and refer those with otologic symptoms to an otolaryngologist.

PRACTICAL IMPLICATIONS

Given the wide range of potential pathophysiologies and treatments for each otologic symptom described in the TMD patient, close collaboration with otolaryngologists is essential to achieve the best patient care.

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.

Secondary Otalgia: Referred Pain Pathways and Pathologies

Otalgia is very common, and when the cause of ear pain is not identified on otoscopy and physical examination, cross-sectional imaging is routinely used to evaluate for potential sources of referred ear pain (secondary otalgia). Innervation of the ear structures is complex, involving multiple upper cervical, lower cranial, and peripheral nerves, which transit and innervate a large anatomic territory involving the brain, spine, skull base, aerodigestive tract, salivary glands, paranasal sinuses, face, orbits, deep spaces of the neck, skin, and viscera. Interpreting radiologists must be familiar with these neural pathways and potential sources of secondary otalgia. The purposes of this review are to detail the currently proposed mechanisms of referred ear pain, review the salient neuroanatomy of the complex pathways responsible for secondary otalgia, highlight important benign and malignant etiologies of referred ear pain, and provide a structured search pattern for approaching these challenging cases on cross-sectional imaging.

The frequency of involvement of head & neck sites in referred otalgia - An experience at a tertiary care hospital

Objective:

To determine the frequency of involvement of distant head & neck sites which share sensory innervations with the ear in referred otalgia.

Methods:

This prospective study was conducted in the Department of ENT at Hayatabad Medical Complex, Peshawar, during the period from July 1, 2017 to December 31, 2017.*Non probability convenience sampling technique was used to include patients in the study. Patients with true ‘otogenic pain’ as determined on clinical examination or imaging studies were excluded from analysis. Only those who presented with referred ear ache were included in the study to determine the frequency of involvement of distant head & neck sites in ‘referred otalgia’. Otalgia was designated as “Unknown Origin” when the ear and distant sites too were found normal.

Results:

Out of a total of 150 patients, there were 81(54%) males and 69(46%) females. The ages ranged from 5 to 66 years with a mean age of 29.15 years. The commonest age groups involved were 21-35 years and 36-55 years. Referred otalgia of tonsillar origin was found in 47(31.3%) of patients followed by that of dental origin in 35(23.3%). Otalgia due to pharyngitis, rhinosinusitis and cervical origin was 24(16%), 8(5.3%) and 6(4%) respectively. Otalgia due to temporomandibular joint was noted in 12(8%) of females and 3(2%) of males & that of “unknown origin” affected 5(3.33%) of females and 2(1.3%) of males.

Conclusions:

The ear should be examined in detail in patients presenting with earache to look for indigenous pathology. In the presence of a ‘Normal Ear’, it is important to examine the tonsils, teeth, pharynx and the nose & paranasal sinuses as the possible sites of origin of earache.

An Unusual Cause of Ear Pain. A Life Threatening Disease Revealed by a Common Symptom

A 40-year-old woman presented to the emergency department (ED) for bilateral otalgia as her sole complaint. The physician's otoscopic examination was normal and the rest of the examination was unremarkable except for previously unknown high blood pressure. The patient had no chest pain or dyspnea. She was discharged from the ED with antihypertensive therapy, pain-relief medications, and an appointment with a cardiologist. Twelve days later, transthoracic echocardiography revealed pericardial effusion and dilated ascending aorta. Computed tomography scan finally diagnosed an aortic dissection (AD) type A (Stanford classification) which necessitated emergency surgery.

A Case of Bruxism-Induced Otalgia

Here, the author presents a case of bruxism-induced otalgia in a 29-year-old female patient. The pain was sharp and penetrating in character. It was usually worse in the morning and frequently radiated to the right temporal area. She had received unsuccessful medical treatments for migraine headache. The otoendoscopic examination revealed a normal tympanic membrane. A thorough inspection of her teeth revealed excessive wear on the incisal edges, and the cause of her otalgia was identified as bruxism-related temporomandibular joint disorder. After the use of an occlusal splint and repeated botulinum toxin injections in the masseter and anterior temporalis muscles, along with good sleep hygiene, she experienced significant relief of pain and symptoms. The author suggests that multidisciplinary cooperation between ENT clinicians and dentists is necessary for the quick and accurate diagnosis and treatment of bruxism and the consequential referred otalgia.