News Author: Laurie Barclay, MD
CME Author: Laurie Barclay, MD
Otitis media and otitis externa are the most common causes of ear pain, according to the results of a review of diagnostic methods and causes published in the March 1 issue of American Family Physician.
“Ear pain (otalgia) is a common symptom in primary care with many possible causes,” write John W. Ely, MD, MSPH, and colleagues from the University of Iowa Carver College of Medicine in Iowa City. “When the cause arises from the ear (primary otalgia), the ear examination is usually abnormal and the diagnosis is typically apparent. In secondary or referred otalgia, the ear examination is usually normal, and the pain may be referred from a variety of sites.”
The ear examination typically reveals the cause of primary otalgia, with the most common causes being otitis media and otitis externa. In contrast, secondary otalgia is often more difficult to diagnose because of the complex innervation of the ear and the many potential sources of referred pain. The most common causes of secondary otalgia are temporomandibular joint (TMJ) syndrome, pharyngitis, dental disease, and cervical spine arthritis.
Sensory innervation of the ear includes fibers from cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and X (vagus), and cervical nerves C2 and C3. Because these nerves have long courses in the head, neck, and chest, many diseases affecting these nerves can cause ear pain.
The cochlea and semicircular canals in the inner ear are innervated by cranial nerve VIII (vestibulocochlear), which lacks pain fibers. Although most pathologic processes of the inner ear are therefore not associated with pain, inner ear diseases such as Meniere’s disease can produce feelings of ear pressure, fullness, or other sensations.
When the history and physical examination do not allow definitive diagnosis, options for further evaluation include a trial of symptomatic treatment, imaging studies, and otolaryngologic referral.
Patients at higher risk for a cause of ear pain who need further evaluation include those who smoke, drink alcohol, are older than 50 years, or have diabetes. These patients, as well as those with history or physical examination suggesting a serious occult cause of ear pain, or those whose symptoms persist despite symptomatic treatment, should be considered for further evaluation with magnetic resonance imaging (MRI), fiberoptic nasolaryngoscopy, or measurement of erythrocyte sedimentation rate (ESR).
Specific clinical recommendations for evaluation of ear pain, all with C level supporting evidence, are as follows:
Consider MRI and referral for nasolaryngoscopy for patients with ear pain and normal ear examination who have signs, symptoms, or risk factors for tumor (eg, tobacco or alcohol use, age older than 50 years).
Symptomatic treatment is appropriate for adults with otalgia who are younger than 40 years, who are otherwise healthy, and who have a normal ear examination. If symptoms persist, these patients should be referred.
ESR should be measured to help rule out temporal arteritis in patients older than 50 years with unexplained ear pain and who receive a normal ear examination.
Common causes of otalgia associated with abnormal ear examination include otitis media, otitis externa, foreign body, and barotraumas.
In otitis media, which is more common in winter, there may be a history of recent upper respiratory infection or night restlessness in children. Examination typically reveals a red or cloudy tympanic membrane that is immobile on pneumatic otoscopy.
Patients with otitis externa may have a history of recent swimming, and this disorder is therefore more common in summer. Examination may show a white discharge, pain triggered by traction on the auricle or pressure on the tragus, and swelling and erythema of the external auditory canal, which may contain white debris.
Because the findings of otitis externa may be subtle, however, empiric therapy may be indicated. Malignant (necrotizing) otitis externa should be considered in immunocompromised or diabetic patients.
A foreign body in the ear, which may be an insect or small object, typically occurs in children, in whom the foreign body is visible in the ear canal. Sedation may be needed for removal.
With barotrauma, ear pain begins during descent in an airplane or while scuba diving. Examination may reveal hemorrhage of the tympanic membrane, and/or serous or hemorrhagic middle ear fluid. After an airplane flight, 10% of adults and 22% of children have otoscopic signs of barotrauma.
Common causes of otalgia associated with normal ear examination include TMJ syndrome, dental causes, pharyngitis or tonsillitis, cervical spine syndrome, or an idiopathic cause.
With TMJ syndrome, patients report pain or crepitus with talking or chewing. Risk factors include a habit of clenching the teeth and biting the inside of the lips and mouth. Examination shows tenderness of the TMJ, crepitus or clicking on mandible motion, and possibly restricted jaw movement.
Dental causes of ear pain may include caries, periodontal abscess, impacted third molars, or pulpitis. Caries and abscess are the most common dental causes. These patients may have dental complaints or a history of dental disorders. Examination of the oral cavity may demonstrate caries, abscess, gingivitis, facial swelling, and teeth tender to percussion.
Pharyngitis or tonsillitis is often accompanied by sore throat, and findings on examination are usually positive for pharyngeal or tonsillar redness and indicate swelling and exudate. Even if the ear is not involved, otalgia can be the primary symptom of throat inflammation.
In cervical spine arthritis, pain may be referred from the C2, C3 cervical nerve roots. The patient may complain of crepitus or pain with neck movement, and cervical range of motion may be decreased. Neck examination may also show tender spinous processes or paraspinal muscles.
Idiopathic causes of ear pain with normal examination are often labeled TMJ syndrome, neuropathic pain, or eustachian tube dysfunction.
“As with any symptom, a ‘rule out worst-case scenario’ strategy (in which certain diagnoses must be ruled out immediately) may help avoid serious diagnostic errors,” the authors conclude. “In patients with otalgia, physicians should rule out several potential causes that can have serious consequences if the diagnosis is delayed; these are malignant (necrotizing) otitis externa, cholesteatoma, myocardial infarction, temporal arteritis, and malignant tumor. However, these diseases can often be ruled out on the basis of a nonworrisome history and physical examination rather than extensive testing.”
The authors have disclosed no relevant financial relationships.
Am Fam Physician. 2008;77:621-628.
Clinical Context
Ear pain (otalgia) is a common presentation in the primary setting. Primary otalgia, or pain originating in the ear itself, typically is associated with abnormal ear examination and is easier to diagnose than secondary or referred otalgia, in which ear examination is usually normal and pain may be referred from several different sites.
This review describes practical diagnostic strategies for primary care clinicians evaluating patients with primary and secondary ear pain, risk factors that warrant additional evaluation, and common causes of otalgia.
Study Highlights
Specific clinical recommendations for evaluation of ear pain are as follows:
For patients with ear pain, normal ear examination, and signs, symptoms, or risk factors for tumor (eg, tobacco or alcohol use, age >50 years), consider MRI and referral for nasolaryngoscopy.
For adults who are younger than 40 years with otalgia, in otherwise good health, and with a normal ear examination, symptomatic treatment is appropriate, but if symptoms persist, these patients should be referred.
Patients older than 50 years with unexplained ear pain and normal ear examination should undergo measurement of ESR to help rule out temporal arteritis.
Common causes of otalgia linked with abnormal ear examination include otitis media, otitis externa, foreign bodies, and barotraumas.
Otitis media is more common in winter. History may be positive for recent upper respiratory infection or night restlessness in children. Examination usually shows a red or cloudy tympanic membrane that is immobile on pneumatic otoscopy.
Otitis externa is more common in summer and is often linked with a history of recent swimming. Physical findings may include a white discharge, pain triggered by traction on the auricle or pressure on the tragus, and swelling and erythema of the external auditory canal, which may contain white debris.
Empiric therapy may be indicated because the findings of otitis externa may be subtle. Malignant (necrotizing) otitis externa should be considered in immunocompromised or diabetic patients.
A foreign body in the ear, eg, insect or small object, typically occurs in children. The foreign body is usually visible in the ear canal. Sedation may be needed for removal.
With barotrauma, ear pain begins during descent in an airplane or while scuba diving. Examination may show tympanic membrane hemorrhage and/or serous or hemorrhagic middle ear fluid.
Common causes of otalgia associated with normal ear examination include TMJ syndrome, dental causes, pharyngitis or tonsillitis, cervical spine syndrome, or idiopathic causes.
With TMJ syndrome, patients report pain or crepitus with talking or chewing and a habit of clenching the teeth and biting the inside of the lips and mouth. Examination shows tenderness of the TMJ, crepitus or clicking on mandible motion, and possibly restricted jaw movement.
Dental causes of ear pain may include caries or periodontal abscess (the most common dental causes), impacted third molars, or pulpitis. Mouth examination of the oral cavity may show caries, abscess, gingivitis, facial swelling, and teeth tender to percussion.
Pharyngitis or tonsillitis is often accompanied by sore throat, with pharyngeal or tonsillar redness, and sometimes swelling and exudates on examination.
Ear pain may be referred from the C2, C3 cervical nerve roots in cervical spine arthritis. There may be crepitus or pain with neck movement, decreased cervical range of motion, and/or tender spinous processes or paraspinal muscles.
Idiopathic causes of ear pain with normal examination are often labeled TMJ syndrome, neuropathic pain, or eustachian tube dysfunction.
Potentially serious diagnoses must be ruled out immediately, including malignant (necrotizing) otitis externa, cholesteatoma, myocardial infarction, temporal arteritis, and malignant tumor, but these can often be ruled out from history and physical examination rather than by extensive testing.
Pearls for Practice
Specific clinical recommendations for evaluation of ear pain are to consider MRI and referral for nasolaryngoscopy for patients with ear pain and normal ear examination who have signs, symptoms, or risk factors for tumor. Symptomatic treatment is appropriate for adults younger than 40 years who are in otherwise good health with normal ear examination, unless symptoms persist. Patients older than 50 years with unexplained otalgia and normal ear examination should have ESR measured to help rule out temporal arteritis.
Common causes of otalgia associated with abnormal ear examination include otitis media, otitis externa, foreign body, and barotraumas. Common causes of otalgia associated with normal ear examination include TMJ syndrome, dental causes, pharyngitis or tonsillitis, or cervical spine syndrome or idiopathic causes.
Experts Weigh in on US Government’s Vaccine Injury Ruling
Caroline Cassels
The US government’s recent decision to compensate the family of a 9-year-old girl because it ruled her underlying mitochondrial disorder was exacerbated by vaccines and resulted in autismlike symptoms has raised concerns the judgment will send an unintended message that population-based immunization is harmful.
On the other hand, some believe the decision may open the door to more research into potentially vulnerable subpopulations that could be at increased risk of sequelae from vaccines.
On March 6, the parents of Hannah Poling announced that federal health officials ruled a series of 9 simultaneous vaccines administered to their daughter when she was 19 months old worsened an underlying mitochondrial condition that ultimately led to a diagnosis that included “features of autism spectrum disorder.” As a result, the family is being compensated from the National Vaccine Injury Compensation Program.
A news release from the US Health Resources and Services Administration (HRSA) states that while the government cannot publicly disclose details of a specific case without the consent of the individuals involved, it “has reviewed the scientific information concerning the allegation that vaccines cause autism and has found no credible evidence to support the claim.
“HRSA has maintained and continues to maintain the position that vaccines do not cause autism and has never concluded in any case that autism was caused by vaccination.”
Open to Misinterpretation?
Despite this reassurance, experts are concerned that the ruling, which they say is based on a rare case with rare circumstances and a rare outcome, will be misinterpreted as an acknowledgment that vaccines cause autism.
According to Joel Bregman, MD, chair of the committee on developmental disabilities of the American Psychiatric Association (APA), it is known that this child has a rare underlying mitochondrial condition and received a number of vaccines at once, which is also atypical, and subsequently developed autismlike symptoms.
“This is a unique set of circumstances that should not be extrapolated to the rest of the population,” Dr. Bregman told Medscape Neurology & Neurosurgery. “Even though there is a great deal of research — not just in the United States, but in other countries as well — there is no evidence linking childhood vaccines to autism. We are very concerned the public may misinterpret this decision,” he added.
Decline in Immunization Rates
Wendy Roberts, MD, codirector of the autism research unit at Toronto’s Hospital for Sick Children, in Ontario, agreed.
“The confusion here is there may be an occasional child who has a very bad reaction to immunization — statistically it is about 1 in a population of 100,000. But as soon as parents hear of 1 case, not understanding the 1-in-100,000 statistic, they immediately think all immunization is bad,” Dr. Roberts said in an interview.
The consequence of this is a potential decline in immunization rates, which poses a serious public health threat. According to Dr. Roberts, prospective research undertaken by her team indicates this is already happening.
“We know that our vaccination uptake has gone down at least 3% to 4%. But in some sectors where individuals have a family history of autism, it has dropped by 30% to 40%,” she said.
Dr. Roberts added that she is concerned the US government ruling will contribute to a further decline in immunization rates.
The McCain Factor
She noted in particular that she was very concerned by media reports quoting US Republican presidential candidate Sen. John McCain that thimerosal, the mercury-based preservative used in vaccines, was strongly linked to autism.
“When someone in his [McCain’s] position makes those kinds of strong statements, it is such a misuse of power. Canada has led the way in removing preservatives from vaccines, and our rates of autism are just as high as anywhere else,” she said.
Both Drs. Bregman and Roberts made the point that there are a whole generation of people who have no experience with outbreaks of infectious diseases such as measles and their potentially devastating consequences.
“We’re not just talking about a rash or a fever. Many of these diseases are associated with significant mortality and adverse consequences, including brain damage,” said Dr. Bregman.
More Research Warranted?
Robert Hendren, president of the American Academy of Child and Adolescent Psychiatry (AACAP), said his organization is also concerned that the public may interpret the decision as a blanket attack on or condemnation of population-based immunization.
“This is a complex issue, and we are expecting the lay public to sort it all out, and so there is a possibility that it will be simplified and seen as a message that vaccines are associated with autism,” he told Medscape Neurology & Neurosurgery.
While there is no doubt about the immense benefits of population-based immunization, Dr. Hendren added, the ruling may provide the impetus to conduct more research into specific subpopulations of individuals who, for whatever reason, may be at greater risk of an adverse reaction to vaccination.
If such subpopulations do exist, said Dr. Hendren, these individuals would be unlikely to show up in large, population-based studies.
For its part, the American Academy of Pediatrics released a position statement about the Poling case stating that the academy is seeking access to “official documents in the case, so medical experts can examine the science and consider whether it raises implications for other children.”
In its statement, the HRSA says it will present its views “on the allegation that vaccines cause autism in an omnibus autism proceeding in May.”
Medscape Neurology & Neurosurgery contacted the Autism Society of America (ASA) for comment on the ruling but, despite repeated calls, did not receive a response. However, in a statement about the Poling case posted on its Web site, the society states that the “ASA believes that the science of autism causes and treatments needs to be more vigorously researched. We hope that primary decisions will be reached through thoughtful dialogue by parents and professionals on medical research and comprehensive treatment and services, not court rulings.”
Reviewed by Dr. Ramaz Mitaishvili
