42. Ear pain

Question 1

Index conditions.

a) Local causes (primary otalgia)
b) Referred pain to ear (secondary otalgia)

Answer 1

a) Otitis media, otitis externa

b) Tonsillitis, cervical arthritis, TMJ disorders, oropharyngeal neoplasms, toothache (dental problems)

Question 2

Ramsay Hunt syndrome.

a) Symptoms
b) Cause
c) Treatment

Answer 2

a) - Severe ear pain
- Hearing loss/ hyperacusis
- Vertigo (?stroke)
- Tinnitus
- Vesicles: on TM/pinna (tip of nose = Hutchinson’s sign)
- Facial nerve palsy (Bells palsy)

b) Herpes-zoster virus (shingles)

c) - Corticosteroids (if given within 72 hours - 1 week)
- +/-Aciclovir
- Eye protection (patching, artificial tears)

Question 3

Otitis externa.

a) What is it?
b) Risk factors (hence, AKA…?)
c) Causes (e.g. infective)
d) Presentation
e) Findings on otoscopy
f) Management (general advice, mild, moderate, severe - what defines severe?)
g) Prevention

Answer 3

a) Inflammation of the outer ear: pinna, EAM +/- outer surface of the TM
b) Swimming (i.e. Swimmer’s ear), hot/humid climates, elderly, immunocompromised, diabetic, excess/ deficient earwax, dermatological (eg. eczema, dermatitis)

c) - Infective: bacterial (90% - staph, pseudomonas), fungal (eg. candida, aspergillus), Ramsay-Hunt (HZV)
- Derm: atopy, acne
- Irritants: topical medication, cotton buds, water, hearing aids, etc.

d) - Otalgia, itching and discharge +/- hearing loss (CHL)
- Pain with movement of the tragus or auricle.
- Pre-auricular lymphadenopathy

e) Erythematous canal, oedema, discharge, mobile TM

f) - Analgesia and warm compresses
- Avoid water contact and swimming until infection settles; avoid cotton buds and hearing aids
- Mild OE: topical acetic acid for 7 days
- Moderate OE: topical neomycin* + topical steroid (eg. betamethasone) for 7 - 14 days; may be inserted via an ear wick if practical
- Severe OE (cellulitis, systemically unwell, regional lymphadenopathy): oral flucloxacillin for 7 days

• Neomycin is ototoxic - do NOT use in TM perforation or patent grommet in situ
  g) Avoid moisture in ears: ear plugs when swimming/ showering, dry ears fully using towel/hairdryer, use olive oil drops to prevent wax build up, avoid cotton buds

Question 4

Mastoiditis.

a) What is it?
b) Cause, risk factors
c) Presentation: signs and symptoms
d) Management of suspected mastoiditis
e) Complications

Answer 4

a) Infection spreading from the middle ear (otitis media) to form an abscess in the mastoid air spaces of the temporal bone
b) Acute OM, immunocompromised, young age (6 - 12 months)

c) - Severe pain in/behind the ear*
- Systemically unwell (fever, malaise, poor feeding, etc.)
- Oedema behind the ear (over the mastoid bone)
- Pinna is pushed forwards and downwards (sticks out)
- Signs/symptoms of acute ear infection (red/bulging TM, discharge, etc.)
- Weber’s/Rinne’s: possible CHL
* note: tenderness over mastoid is not necessarily mastoiditis; can occur with any acute ear infection

d) - Urgent ENT review
- Bloods: FBC, CRP, cultures
- Imaging: CT head, LP (if risk of IC spread)
- Initial Rx: IV broad-spec ABx (eg. cephalosporin), then oral once settles
- Surgery indications: not settling on ABx, subperiosteal abscess present, intracranial spread

e) - Ear: hearing loss, labyrinthitis
- Intracranial: abscess (extradural, intracranial), meningitis, venous sinus thrombosis, CN palsies

Question 5

Otalgia: history

a) HPC
b) Ass sx
c) PMHx
d) DHx
e) FHx
f) SHx

Answer 5

a) Site, onset, character, radiation, associated symptoms, timing (constant more likely primary, intermittent more likely secondary)
- Exacerbated by chewing (more likely secondary otalgia), pain on moving pinna (more likely primary)

b) - Discharge, redness, recent URTI (?ear infection)
- Vertigo, hearing loss
- Scalp tenderness, jaw claudication (?GCA)
- Vesicles, facial droop (?Ramsay Hunt)
- Red flags: weight loss, anorexia, bleeding, night sweats, voice change, dysphagia

c) - Recurrent ear infections
- Dental history

d) ?
e) ?

f) - Barotrauma, eg. deep sea diving
- Swimmer (?otitis externa)

Question 6

Otalgia: examination

a) ENT
b) Other
c) Investigations

Answer 6

a) ENT.
- Pinna deviated (?mastoiditis)
- Pinna red, pinna movement painful (?otitis externa)
- Discharge in canal/ red canal
- Bulging/ red TM (?otitis media)

b) Other.
- Sinuses
- TMJ
- Neuro
- Lymph nodes

c) FBC, TFTs, ESR,
- ?CXR
- Audiology - tympanometry, audiometry

Question 7

Unilateral otalgia with weight loss and lymphadenopathy suggests…?

Answer 7

Head and neck cancer - 2/52 wait

- Referred pain from compression of CN IX (glossopharyngeal)

Question 8

How do children with ear pain present?

Answer 8

• Tugging at ear