What are the main causes of ear pain and discharge. How can otalgia and otorrhea be diagnosed and treated effectively. What are the common symptoms associated with ear conditions that patients should be aware of. When should someone seek medical attention for ear problems.

Understanding Otalgia: Causes and Characteristics of Ear Pain

Otalgia, commonly known as ear pain, can originate from various sources, both within and outside the ear. This discomfort may manifest in different ways, ranging from a deep ache to a sharp, stabbing sensation. In some cases, patients might experience a feeling of fullness or blockage in the ear.

The causes of otalgia are diverse and can be categorized into two main types:

• Primary otalgia: Pain originating from the ear itself
• Secondary otalgia: Pain referred from other areas of the head and neck

Primary otalgia often results from conditions directly affecting the ear structures, such as infections, trauma, or inflammation. Secondary otalgia, on the other hand, can be caused by issues in nearby areas like the jaw, sinuses, or teeth.

Common Causes of Otalgia

Understanding the potential causes of ear pain is crucial for accurate diagnosis and treatment. Some frequent sources of otalgia include:

1. Ear infections (otitis media or externa)
2. Temporomandibular joint (TMJ) disorders
3. Dental problems (e.g., tooth decay, abscesses)
4. Sinus infections
5. Throat infections or tonsillitis
6. Neuralgias (e.g., trigeminal neuralgia)
7. Cervical spine issues

It’s important to note that approximately 50% of otalgia cases stem from dental sources, highlighting the need for comprehensive evaluation and potential dental referrals.

Otorrhea: Identifying and Addressing Ear Discharge

Otorrhea refers to the presence of discharge from the ear canal. This symptom can indicate inflammation or infection of the external or middle ear, or both. The characteristics of the discharge can provide valuable clues about the underlying condition.

Ear discharge may vary in appearance and consistency, including:

• Clear fluid
• Bloody discharge
• Mucoid secretions
• Purulent (pus-like) drainage

The onset, duration, amount, and quality of otorrhea are essential factors to consider when evaluating this condition. Environmental factors, trauma, and familial disorders can all contribute to the development of ear discharge.

Diagnostic Approach for Otorrhea

Proper diagnosis of otorrhea requires a thorough examination and may involve several steps:

1. Detailed patient history, including previous ear conditions, surgeries, and environmental exposures
2. Careful cleaning and inspection of the ear canal using suction tips or wire applicators
3. Evaluation of the eardrum and middle ear
4. Possible imaging studies, such as mastoid x-rays
5. Impedance audiometry to assess middle ear function
6. Diabetes screening, especially in chronic or recurrent cases
7. Biopsy of any granular tissue present

The Science Behind Referred Ear Pain

Referred pain is a fascinating phenomenon that can complicate the diagnosis of otalgia. In this process, nerve impulses from a distant or deeper structure are perceived as originating from a more superficial area of the body. This mechanism explains why conditions affecting organs or tissues near the ear can manifest as ear pain.

The concept of referred pain is based on several key principles:

• Dermatomal distribution: Pain often follows patterns related to specific nerve pathways
• Common central origin: Nerve branches from different areas may share connections in the spinal cord
• Deep pain projection: Visceral and muscular pain can be misinterpreted as surface pain
• Learning and habituation: Previous experiences can influence pain perception and localization

Understanding the mechanisms of referred pain is crucial for healthcare providers when diagnosing and treating otalgia, as it emphasizes the need to consider sources beyond the ear itself.

Diagnostic Challenges in Otalgia and Otorrhea

Accurately diagnosing the causes of ear pain and discharge can be challenging due to the complex anatomy and interconnected nature of the head and neck region. Healthcare providers must employ a systematic approach to evaluation and diagnosis.

Key Steps in Diagnosing Ear Conditions

1. Comprehensive patient history
2. Thorough physical examination of the ear, head, and neck
3. Consideration of referred pain sources
4. Appropriate use of diagnostic tools and imaging
5. Collaboration with dental and other specialists when necessary

In cases where the cause of ear pain is not immediately apparent, follow-up visits and continued monitoring may be necessary to identify the underlying issue.

Treatment Approaches for Otalgia and Otorrhea

The treatment of ear pain and discharge depends on the underlying cause. A tailored approach is essential for effective management of these conditions.

General Treatment Strategies

• Pain management with over-the-counter or prescription analgesics
• Antibiotic therapy for bacterial infections
• Antifungal medications for fungal infections
• Ear cleaning and debridement when necessary
• Treatment of underlying conditions (e.g., dental issues, sinus infections)
• Management of chronic conditions like TMJ disorders

In some cases, surgical intervention may be required, particularly for chronic middle ear infections or complications of otitis media.

Preventive Measures and Self-Care for Ear Health

While not all ear conditions can be prevented, there are several steps individuals can take to maintain ear health and reduce the risk of developing otalgia or otorrhea.

Tips for Promoting Ear Health

1. Practice good hygiene, including regular hand washing
2. Avoid inserting objects into the ear canal
3. Protect ears from excessive noise exposure
4. Use earplugs or swim caps when swimming
5. Manage allergies and upper respiratory infections promptly
6. Maintain good oral hygiene and regular dental check-ups
7. Avoid smoking and limit alcohol consumption

By following these preventive measures, individuals can reduce their risk of developing ear-related issues and promote overall ear health.

When to Seek Medical Attention for Ear Problems

While minor ear discomfort can often be managed at home, certain symptoms warrant prompt medical evaluation. Recognizing these signs is crucial for timely intervention and prevention of potential complications.

Red Flags for Ear Conditions

Individuals should seek medical attention if they experience any of the following:

• Severe or persistent ear pain
• Sudden hearing loss or significant changes in hearing
• Dizziness or vertigo associated with ear symptoms
• Facial weakness or paralysis
• Fever accompanying ear pain or discharge
• Blood or pus draining from the ear
• Ear pain following head trauma
• Symptoms persisting for more than a few days despite home care

Early intervention can prevent the progression of ear conditions and reduce the risk of long-term complications.

Advances in Ear Care: New Diagnostic and Treatment Options

The field of otolaryngology continues to evolve, with new technologies and techniques emerging to improve the diagnosis and treatment of ear conditions. These advancements offer promising options for patients suffering from otalgia and otorrhea.

Innovative Approaches in Ear Care

1. High-resolution imaging techniques for better visualization of ear structures
2. Genetic testing for hereditary ear disorders
3. Minimally invasive surgical procedures for middle ear issues
4. Advanced hearing aid technologies for managing hearing loss
5. Targeted drug delivery systems for treating ear infections
6. Bioengineered tissues for eardrum repair
7. Virtual reality applications for vestibular rehabilitation

These innovations offer new possibilities for diagnosing and treating ear conditions, potentially improving outcomes and quality of life for patients with otalgia and otorrhea.

Understanding the complexities of ear pain and discharge is crucial for both healthcare providers and patients. By recognizing the diverse causes, employing appropriate diagnostic techniques, and utilizing effective treatment strategies, many ear conditions can be successfully managed. Additionally, staying informed about preventive measures and emerging technologies in ear care can contribute to better overall ear health and improved patient outcomes.

As research in otolaryngology continues to advance, it is likely that new insights into the mechanisms of ear pain and innovative treatment approaches will emerge. This ongoing progress holds the promise of more effective and personalized care for individuals suffering from otalgia and otorrhea, ultimately enhancing their quality of life and auditory health.

Otalgia and Otorrhea – Clinical Methods

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.

Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition.

Show details

• Contents

Search term

John S. Turner, JR.

Definition

Otalgia, or ear pain, in or about the external ear and temporal bone may occur from multiple causes, many of which are remote from the ear itself. Otorrhea, or ear drainage, indicates inflammation of the external or middle ear or both. The Otorrhea may be clear, sanguinous, mucoid, or purulent.

Technique

Otalgia

To ascertain the etiology of otalgia accurately, a detailed history relating to ear, dental, sinus, jaw, neck, tongue, mouth, and neurologic disorders in the head and neck region must be taken. Symptoms referable to one of these sites will usually point to the most likely etiology as listed in .

Table 122.1

Intrinsic Cause of Ear Pain.

Acute, chronic, or recurrent pain may be present. The sensation may vary from a deep aching to a sharp, quick lancing discomfort. Only a vague fullness may be present, or there may be a blocked feeling to the ear. Acute, sudden pain may be accompanied by fever, nasal congestion, nasal or ear drainage, or headache. Chronic pain usually exists by itself, and fewer associated complaints are noted. Tinnitus, dizziness, or hearing impairment are commonly seen with recurrent ear pain. The pain may seem deep and penetrating within the canal, or it may be more diffuse and extend either anterior or posterior to the pinna. The patient may volunteer that neck motion, chewing, swallowing, coughing, nose blowing, Valsalva maneuver, or flying aggravate or precipitate the discomfort.

Ear pain without obvious physical findings must be followed at periodic intervals until the source is located. Since 50% of patients have pain from dental sources, dental referral is often needed. Insidious dental infection or decay may be very difficult to identify, and this, as well as more remote causes, must often be pursued on more than one visit.

Otorrhea

A careful history is needed to determine environmental or factitious causes and familial disorders. The patient should be asked to describe the onset, duration, amount, and quality of the otorrhea. Questions should be asked as to the presence of childhood ear disease, trauma, possible foreign bodies, or assorted upper respiratory symptoms. Previous surgery to the ear, sinus, or pharynx should be noted. Questions about dermatitis in other areas of the body should be asked. Drug intake must be documented, and associated treatment with chemotherapy or radiation therapy must be noted. Excessive water exposure may be found.

The ear must be cleaned meticulously with small suction tips or wire applicators in order to permit adequate inspection and evaluation of the eardrum and middle ear. Mastoid x-rays may be needed to rule out associated middle ear or mastoid disease. Impedance audiometry may help in this determination also.

Studies for diabetes are needed in all chronic cases and in recurrent Candida infections. All granular tissue should be biopsied.

Basic Science

Otalgia

Referred pain is an incompletely understood phenomenon wherein nerve impulses emanating from a distant or deeper structure are localized to a more superficial structure of the body. The site of pain referral generally follows the dermatomal rule. Well-known examples of this phenomenon are shoulder pain caused by diaphragmatic pleurisy and pain down the inner side of the arm and little finger of cardiac origin. In each situation, the pain spreads from one area to another through nerve branches that have a common central origin within the same segments of the gray matter of the spinal cord.

Referred pain generally comes from viscera and muscles and is often described as deep pain. The faulty projection of deep pain to the surface is thought to be the result of infrequency of deep pain and inability to use vision to verity the source of stimulation; thus, learning appears to be an important factor in referred pain.

Evidence that reference of sensation is a learned phenomenon can be found in the clinical observation that a pain may be referred not to its usual point of reference but to a site of previous surgical operation, trauma, or localized pathologic process. Some individuals suffer severe pain localized to the teeth during high-altitude flying. Upon exclusion of every possible dental cause for pain, it was discovered that the pain stimulus was expansion of air trapped in the maxillary sinus. The group referring pain to the teeth had a high incidence of traumatic denial work on the side of reference, suggesting habit reference of pain. Under experimental conditions, it can be shown that a projection of pain is learned and that pain impulses conducted in overlapping pathways are simply given the previously learned reference for impulses in that path. Neither habit reference nor any other theory of referred pain can fully explain the phenomena that occur.

When pain is referred to the ear from a painful lesion elsewhere, it is likely that both the ear and the area containing the lesion receive sensory innervations from the same cranial nerve and that spread occurs by way of central connections within the gray matter of the brainstem.

The nerve supply to the external auditory canal and the middle ear comes from three cranial nerves; the trigeminal, glossopharyngeal, and vagus, and from the cervical plexus via the lesser occipital nerve (c2) and the great auricular nerve (c2–3). A small portion of the auricle, the superior and anterior walls of the external canal, and the anterior part of the tympanic membrane are supplied by the third branch of the auriculotemporal branch of the third division of the trigeminal nerve. Practically the whole surface of the auricle receives its sensory innervations from the great auricular and lesser occipital nerves. The inferior and posterior walls of the external canal and the posterior portion of the tympanic membrane are supplied with sensory fibers from the auricular branch of the vagus nerve. It is generally correct to state that the ganglionic representation of the sensation of the auricle and external canal can be divided into the gasserian ganglion in front, the second and third cervical ganglia behind, and jugular ganglion in between.

The tympanic plexus that lies on the promontory is formed mainly by nerves derived from the tympanic branch of the glossopharyngeal nerve but also receives branches from the geniculate ganglion of the facial nerve. Sympathetic branches from the carotid plexus join the tympanic plexus, although sensory function is doubtful. The skin overlying the mastoid is innervated by the mastoid branches of the great auricular and lesser occipital nerves, while cells in the mastoid receive their sensory supply through a mastoid branch of the tympanic plexus. Sensory branches from the trigeminal to structures within the middle ear are very questionable.

Referred pain pathways responsible for most cases of otalgia involve the same three cranial nerves that innervate the external auditory canal and middle ear. Painful impulses originating in the region of a diseased lower molar tooth or temporomandibular joint would be traced by way of the gasserian ganglion to the spinal nucleus of the trigeminal (fifth cranial) nerve in the brainstem. This nucleus also connects with ear structures by way of other sensory branches of the third division that innervate the wall of the external canal and tympanum.

Irritative impulses from the tongue or tonsil travel through the glossopharyngeal (ninth cranial) nerve and its ganglia to enter the somatic sensory nucleus of that nerve within the medulla. This nucleus also receives the sensory branches of the ninth cranial nerve from the middle ear and adjacent structures. It is clear again, as in referred pain by the fifth nerve, that the pathway must pass through the sensory nucleus in the medulla.

In the same manner, the somatic afferent pathways of the vagus (tenth cranial) nerve from the larynx ascend through the peripheral ganglia to the spinal nucleus in the medulla and here connect with afferents from the concha and deeper structures of the ear.

The fifth, ninth, and tenth cranial nerves are closely related in their central connection in the brainstem; however, there must be a fair degree of separation within each of the three nerve systems centrally. Otherwise, the localized reference of pain observed clinically would not occur. Beyond a certain level of sensory irritation, there seems to be an overflow into the adjacent centers with more diffuse and poorly localized pain.

The onset, intensity, and duration of ear pain depend on the particular etiology. The cause of all persistent pain must he pursued intensely.

Otorrhea

Both infection and trauma produce ear drainage. The various causes are listed in , and the reader is referred to the reference list for a detailed discussion of each specific cause.

Table 122.2

Causes of Otorrhea.

Clinical Significance

Otalgia

Pain in the ear may be divided into intrinsic and extrinsic causes denoting the site of origin. Intrinsic causes (Table 122.1) can usually be documented by direct examination of the ear.

Extrinsic causes produce pain in the ear reflex by lesions remote from the ear itself. This is often referred to as reflex or referred otalgia. In order to interpret the significance of referred pain in the ear, it is necessary to know the nerve supply of the ear and to know to what other organs the same or related nerves are distributed (see Basic Science). Lesions in the ear rarely produce pain in more distant areas, but many remote areas refer pain to the ear. When the patient complains of earache though having a normal external canal and drum, a number of sources of pain should come to mind. In about one-half of cases the cause will be of dental origin either occurring from the teeth themselves or from the temporomandibular joint. The joint is the most common site of pain, followed by the lower molar teeth.

Lesions of the anterior two-thirds of the tongue and inflammatory conditions of the parotid gland refer pain along the auricular branch of the auriculotemporal nerve. Referred pain from the submaxillary and lingual salivary glands via the lingual nerve may cause pain in front of the ear. An inflammation on the anterior one-third of the tongue may cause pain in front of the ear, whereas an ulceration of the posterior one-third of the tongue, such as a beginning carcinoma, may cause pain within the ear itself. This is explained by referral through two different nerve sources.

Patients with acute and chronic infections of the tonsils frequently complain of otalgia. Lesions of the palate, pharynx, or nasopharynx, especially in the region of the eustachian tube, often produce pain deep in the ear, and occasionally growths of the tonsil give rise to earache as the first and only symptom. Otalgia is often the earliest sign of a beginning malignancy in the nasopharynx. The ninth cranial nerve is involved in this referred pain pattern.

Ulcerative lesions of the entrance of the larynx such as tuberculosis or malignancy may cause reflex otalgia, secondary to irritation of the superior laryngeal branch of the vagus nerve.

The ear should be examined carefully. If no cause for pain can be found in that area, then the examiner should think of the nerve supply of the ear and the mechanisms of referred pain. Think and check the letter “T”:

Acute and chronic forms of thyroiditis may present as throat and ear pain, but tenderness will be maximal over the thyroid lobe on that side. Inflammation of the carotid bulb (carotidynia) often presents in a similar manner.

An unsuspected source of otalgia is elongation of the styloid process with protrusion into the tonsillar fossa (Eagle’s syndrome). Ear pain combined with throat discomfort should alert the examiner to palpate the tonsillar fossa.

Otorrhea

The ear canal should be dry and clean in its natural state. Ear drainage except for liquid cerumen is always pathological.

References

Otalgia

1. Kern EB. Referred pain to the ear. Minn Med. 1972;55:896–98. [PubMed: 4342363]

2. Kreisberg MK, Turner JS. Referred otalgia. Ear, Nose, Throat J. 1987;66:398–407. [PubMed: 3315629]

3. Turner JS. Treatment of hearing loss, ear pain and tinnitus in older patients. Geriatrics. 1982;37:107–18. [PubMed: 7095424]

4. Weaver MD. Ear pain. In: Wood RP., Northern JS, eds. Manual of otolaryngology. Baltimore: Williams and Wilkins, 1979;33–39.

Otorrhea

1. Goodhill V. External ear diseases. In: Goodhill V, ed. Diseases, deafness and dizziness. Hagerstown, MD: Harper & Row, 1979;168–91.

2. Jackson RT, Per-Lee JH, Todd NW, Turner JS. Ear, nose and throat disease. In: Drug treatment. 3rd ed. Baltimore: Adis Press, 1987;369–373.

3. Turner JS, Staats E. et al. Use of gentamicin in preparing the chronically infected ear for tympanoplastic surgery. South Med J. 1966;59:94–97. [PubMed: 5902763]

Copyright © 1990, Butterworth Publishers, a division of Reed Publishing.

Bookshelf ID: NBK227PMID: 21250071

Contents

• PubReader
• Print View
• Cite this Page
• PDF version of this page (497K)

In this Page

• Definition
• Technique
• Basic Science
• Clinical Significance
• References

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• The effects of povidone-iodine preparation on the incidence of post-tympanostomy otorrhea. [Otolaryngol Head Neck Surg. 1990]
• [A case of middle ear tuberculosis; PCR of the otorrhea was useful for the diagnosis].[Kekkaku. 1999]
• Diagnosis and management of spontaneous cerebrospinal fluid-middle ear effusion and otorrhea.[Laryngoscope. 2004]
• Review Office management of the draining ear.[Otolaryngol Clin North Am. 1992]
• Review Diagnosis of ear pain.[Am Fam Physician. 2008]

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Otalgia and Otorrhea – Clinical Methods

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.

Clinical Methods: The History, Physical, and Laboratory Examinations.

3rd edition.

Show details

• Contents

Search term

John S. Turner, JR.

Definition

Otalgia, or ear pain, in or about the external ear and temporal bone may occur from multiple causes, many of which are remote from the ear itself. Otorrhea, or ear drainage, indicates inflammation of the external or middle ear or both. The Otorrhea may be clear, sanguinous, mucoid, or purulent.

Technique

Otalgia

To ascertain the etiology of otalgia accurately, a detailed history relating to ear, dental, sinus, jaw, neck, tongue, mouth, and neurologic disorders in the head and neck region must be taken. Symptoms referable to one of these sites will usually point to the most likely etiology as listed in .

Table 122.1

Intrinsic Cause of Ear Pain.

Acute, chronic, or recurrent pain may be present. The sensation may vary from a deep aching to a sharp, quick lancing discomfort. Only a vague fullness may be present, or there may be a blocked feeling to the ear. Acute, sudden pain may be accompanied by fever, nasal congestion, nasal or ear drainage, or headache. Chronic pain usually exists by itself, and fewer associated complaints are noted. Tinnitus, dizziness, or hearing impairment are commonly seen with recurrent ear pain. The pain may seem deep and penetrating within the canal, or it may be more diffuse and extend either anterior or posterior to the pinna. The patient may volunteer that neck motion, chewing, swallowing, coughing, nose blowing, Valsalva maneuver, or flying aggravate or precipitate the discomfort.

Ear pain without obvious physical findings must be followed at periodic intervals until the source is located. Since 50% of patients have pain from dental sources, dental referral is often needed. Insidious dental infection or decay may be very difficult to identify, and this, as well as more remote causes, must often be pursued on more than one visit.

Otorrhea

A careful history is needed to determine environmental or factitious causes and familial disorders. The patient should be asked to describe the onset, duration, amount, and quality of the otorrhea. Questions should be asked as to the presence of childhood ear disease, trauma, possible foreign bodies, or assorted upper respiratory symptoms. Previous surgery to the ear, sinus, or pharynx should be noted. Questions about dermatitis in other areas of the body should be asked. Drug intake must be documented, and associated treatment with chemotherapy or radiation therapy must be noted. Excessive water exposure may be found.

The ear must be cleaned meticulously with small suction tips or wire applicators in order to permit adequate inspection and evaluation of the eardrum and middle ear. Mastoid x-rays may be needed to rule out associated middle ear or mastoid disease. Impedance audiometry may help in this determination also.

Studies for diabetes are needed in all chronic cases and in recurrent Candida infections. All granular tissue should be biopsied.

Basic Science

Otalgia

Referred pain is an incompletely understood phenomenon wherein nerve impulses emanating from a distant or deeper structure are localized to a more superficial structure of the body. The site of pain referral generally follows the dermatomal rule. Well-known examples of this phenomenon are shoulder pain caused by diaphragmatic pleurisy and pain down the inner side of the arm and little finger of cardiac origin. In each situation, the pain spreads from one area to another through nerve branches that have a common central origin within the same segments of the gray matter of the spinal cord.

Referred pain generally comes from viscera and muscles and is often described as deep pain. The faulty projection of deep pain to the surface is thought to be the result of infrequency of deep pain and inability to use vision to verity the source of stimulation; thus, learning appears to be an important factor in referred pain.

Evidence that reference of sensation is a learned phenomenon can be found in the clinical observation that a pain may be referred not to its usual point of reference but to a site of previous surgical operation, trauma, or localized pathologic process. Some individuals suffer severe pain localized to the teeth during high-altitude flying. Upon exclusion of every possible dental cause for pain, it was discovered that the pain stimulus was expansion of air trapped in the maxillary sinus. The group referring pain to the teeth had a high incidence of traumatic denial work on the side of reference, suggesting habit reference of pain. Under experimental conditions, it can be shown that a projection of pain is learned and that pain impulses conducted in overlapping pathways are simply given the previously learned reference for impulses in that path. Neither habit reference nor any other theory of referred pain can fully explain the phenomena that occur.

When pain is referred to the ear from a painful lesion elsewhere, it is likely that both the ear and the area containing the lesion receive sensory innervations from the same cranial nerve and that spread occurs by way of central connections within the gray matter of the brainstem.

The nerve supply to the external auditory canal and the middle ear comes from three cranial nerves; the trigeminal, glossopharyngeal, and vagus, and from the cervical plexus via the lesser occipital nerve (c2) and the great auricular nerve (c2–3). A small portion of the auricle, the superior and anterior walls of the external canal, and the anterior part of the tympanic membrane are supplied by the third branch of the auriculotemporal branch of the third division of the trigeminal nerve. Practically the whole surface of the auricle receives its sensory innervations from the great auricular and lesser occipital nerves. The inferior and posterior walls of the external canal and the posterior portion of the tympanic membrane are supplied with sensory fibers from the auricular branch of the vagus nerve. It is generally correct to state that the ganglionic representation of the sensation of the auricle and external canal can be divided into the gasserian ganglion in front, the second and third cervical ganglia behind, and jugular ganglion in between.

The tympanic plexus that lies on the promontory is formed mainly by nerves derived from the tympanic branch of the glossopharyngeal nerve but also receives branches from the geniculate ganglion of the facial nerve. Sympathetic branches from the carotid plexus join the tympanic plexus, although sensory function is doubtful. The skin overlying the mastoid is innervated by the mastoid branches of the great auricular and lesser occipital nerves, while cells in the mastoid receive their sensory supply through a mastoid branch of the tympanic plexus. Sensory branches from the trigeminal to structures within the middle ear are very questionable.

Referred pain pathways responsible for most cases of otalgia involve the same three cranial nerves that innervate the external auditory canal and middle ear. Painful impulses originating in the region of a diseased lower molar tooth or temporomandibular joint would be traced by way of the gasserian ganglion to the spinal nucleus of the trigeminal (fifth cranial) nerve in the brainstem. This nucleus also connects with ear structures by way of other sensory branches of the third division that innervate the wall of the external canal and tympanum.

Irritative impulses from the tongue or tonsil travel through the glossopharyngeal (ninth cranial) nerve and its ganglia to enter the somatic sensory nucleus of that nerve within the medulla. This nucleus also receives the sensory branches of the ninth cranial nerve from the middle ear and adjacent structures. It is clear again, as in referred pain by the fifth nerve, that the pathway must pass through the sensory nucleus in the medulla.

In the same manner, the somatic afferent pathways of the vagus (tenth cranial) nerve from the larynx ascend through the peripheral ganglia to the spinal nucleus in the medulla and here connect with afferents from the concha and deeper structures of the ear.

The fifth, ninth, and tenth cranial nerves are closely related in their central connection in the brainstem; however, there must be a fair degree of separation within each of the three nerve systems centrally. Otherwise, the localized reference of pain observed clinically would not occur. Beyond a certain level of sensory irritation, there seems to be an overflow into the adjacent centers with more diffuse and poorly localized pain.

The onset, intensity, and duration of ear pain depend on the particular etiology. The cause of all persistent pain must he pursued intensely.

Otorrhea

Both infection and trauma produce ear drainage. The various causes are listed in , and the reader is referred to the reference list for a detailed discussion of each specific cause.

Table 122.2

Causes of Otorrhea.

Clinical Significance

Otalgia

Pain in the ear may be divided into intrinsic and extrinsic causes denoting the site of origin. Intrinsic causes (Table 122.1) can usually be documented by direct examination of the ear.

Extrinsic causes produce pain in the ear reflex by lesions remote from the ear itself. This is often referred to as reflex or referred otalgia. In order to interpret the significance of referred pain in the ear, it is necessary to know the nerve supply of the ear and to know to what other organs the same or related nerves are distributed (see Basic Science). Lesions in the ear rarely produce pain in more distant areas, but many remote areas refer pain to the ear. When the patient complains of earache though having a normal external canal and drum, a number of sources of pain should come to mind. In about one-half of cases the cause will be of dental origin either occurring from the teeth themselves or from the temporomandibular joint. The joint is the most common site of pain, followed by the lower molar teeth.

Lesions of the anterior two-thirds of the tongue and inflammatory conditions of the parotid gland refer pain along the auricular branch of the auriculotemporal nerve. Referred pain from the submaxillary and lingual salivary glands via the lingual nerve may cause pain in front of the ear. An inflammation on the anterior one-third of the tongue may cause pain in front of the ear, whereas an ulceration of the posterior one-third of the tongue, such as a beginning carcinoma, may cause pain within the ear itself. This is explained by referral through two different nerve sources.

Patients with acute and chronic infections of the tonsils frequently complain of otalgia. Lesions of the palate, pharynx, or nasopharynx, especially in the region of the eustachian tube, often produce pain deep in the ear, and occasionally growths of the tonsil give rise to earache as the first and only symptom. Otalgia is often the earliest sign of a beginning malignancy in the nasopharynx. The ninth cranial nerve is involved in this referred pain pattern.

Ulcerative lesions of the entrance of the larynx such as tuberculosis or malignancy may cause reflex otalgia, secondary to irritation of the superior laryngeal branch of the vagus nerve.

The ear should be examined carefully. If no cause for pain can be found in that area, then the examiner should think of the nerve supply of the ear and the mechanisms of referred pain. Think and check the letter “T”:

Acute and chronic forms of thyroiditis may present as throat and ear pain, but tenderness will be maximal over the thyroid lobe on that side. Inflammation of the carotid bulb (carotidynia) often presents in a similar manner.

An unsuspected source of otalgia is elongation of the styloid process with protrusion into the tonsillar fossa (Eagle’s syndrome). Ear pain combined with throat discomfort should alert the examiner to palpate the tonsillar fossa.

Otorrhea

The ear canal should be dry and clean in its natural state. Ear drainage except for liquid cerumen is always pathological.

References

Otalgia

1. Kern EB. Referred pain to the ear. Minn Med. 1972;55:896–98. [PubMed: 4342363]

2. Kreisberg MK, Turner JS. Referred otalgia. Ear, Nose, Throat J. 1987;66:398–407. [PubMed: 3315629]

3. Turner JS. Treatment of hearing loss, ear pain and tinnitus in older patients. Geriatrics. 1982;37:107–18. [PubMed: 7095424]

4. Weaver MD. Ear pain. In: Wood RP., Northern JS, eds. Manual of otolaryngology. Baltimore: Williams and Wilkins, 1979;33–39.

Otorrhea

1. Goodhill V. External ear diseases. In: Goodhill V, ed. Diseases, deafness and dizziness. Hagerstown, MD: Harper & Row, 1979;168–91.

2. Jackson RT, Per-Lee JH, Todd NW, Turner JS. Ear, nose and throat disease. In: Drug treatment. 3rd ed. Baltimore: Adis Press, 1987;369–373.

3. Turner JS, Staats E. et al. Use of gentamicin in preparing the chronically infected ear for tympanoplastic surgery. South Med J. 1966;59:94–97. [PubMed: 5902763]

Copyright © 1990, Butterworth Publishers, a division of Reed Publishing.

Bookshelf ID: NBK227PMID: 21250071

Contents

• PubReader
• Print View
• Cite this Page
• PDF version of this page (497K)

In this Page

• Definition
• Technique
• Basic Science
• Clinical Significance
• References

Related Items in Bookshelf

Related information

• PubMed

  Links to PubMed

Similar articles in PubMed

• The effects of povidone-iodine preparation on the incidence of post-tympanostomy otorrhea. [Otolaryngol Head Neck Surg. 1990]
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Ear injuries – symptoms and treatment

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Ear injuries are various injuries that affect the auricle, ear canal or inner parts of the ear. The human hearing organ consists of soft tissues and cartilaginous structures, has practically no bone tissue, therefore it is poorly protected from various kinds of damage.

Types of injuries

Causes

Complications

Due to its location, the outer part of the ear is most prone to injury, which is accompanied by damage to the cartilage tissue, tear or tear of the auricle, and the formation of extensive hemorrhage. In the latter case, the auricle turns into a dark red oval formation, and with the addition of an infection, necrosis of its tissues may occur.

Injury can damage or destroy the external auditory canal, rupture the eardrum, destroy cartilage or bone structures. The defeat of the middle ear may be accompanied by concussion of the tympanic cavity. Damage to the inner ear can lead to fractures of the auditory ossicles or labyrinth structures. The causes of injuries of the inner ear are penetrating wounds or contusions, craniocerebral trauma, as well as the effect of too loud sound. A sudden change in atmospheric pressure can cause barometric injury.

Damage to the ear, depending on the severity, is accompanied by severe pain, noise and ringing in the ears, bleeding, intense dizziness, nausea, complete or partial loss of hearing, impaired coordination of movements, paresis of the facial nerve and other symptoms. Against the background of traumatic damage to the parts of the ear, a purulent bacterial infection or sepsis may develop. Therefore, in case of any damage to the parts of the ear, you should immediately seek medical help.

• Blunt or stab wound
• Pathological effect of high or ultra-low temperatures or toxic substances
• Penetrating wound
• Strong blow with fist, blunt or sharp object
• Penetration into the ear cavity of a foreign body
• Sudden change in atmospheric pressure, etc.

Pathology may be accompanied by a concussion or contusion of the brain, fractures of the jaw bones, injuries of the upper spine.

The consequences of injuries can be very different. Starting from the repulsive appearance of the ear, ending with a complete or partial loss of the ability to hear.

After an injury to the outer ear with damage to the cartilaginous structures, the auricle turns into a shapeless pancake, which can often be observed in professional athletes involved in martial arts, but everyday ear injuries are far from uncommon. When an organ is damaged, bleeding often occurs, severe pain, congestion and ringing in the ears appear, hearing decreases or disappears.

Diagnosis of ear injuries

External injuries are detected during external examination and palpation. To determine damage to internal structures, special tools are used – an otoscope or a microotoscope, as well as diagnostic examinations of MRI or CT of the brain, X-ray of the skull, studies of the vestibular analyzer, etc. In case of internal injuries, neurological disorders often occur, so treatment by a neurologist may be necessary.

Treatment of ear injuries in the clinic “Gaide”

At the initial stage, the primary treatment of the wound, stopping the bleeding, thorough cleaning of the ear canal from pathological contents is carried out. In case of external damage, a daily toilet of the auricle and ear canal is necessary. When the internal structures of the middle ear are destroyed, the jaw is immobilized, as well as endoscopic restoration of the structures, followed by taponade with turundas for 2 days.

If the tympanic membrane or auditory ossicles are damaged, reconstructive surgery is performed to restore them. Treatment of internal injuries of the organ of hearing, accompanied by concussion and contusion of the brain, is carried out under the supervision of a neurologist to prevent possible complications.

In Gaide Medical Centers, you can get qualified first aid for any injuries at any convenient time without queues and long waiting times. We can undergo all the necessary diagnostic examinations: X-ray, CT, MRI, to exclude possible complications.

Anomalies in the development of the auricle. What are anomalies in the development of the auricle?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Anomalies in the development of the auricle is a group of congenital pathologies that are characterized by deformation, underdevelopment, or the absence of the entire shell or parts of it. Clinically, it can manifest itself as anotia, microtia, hypoplasia of the middle or upper third of the cartilage of the outer ear, including a folded or fused ear, protruding ears, splitting of the lobe and specific anomalies: “satire ear”, “macaque ear”, “Wildermuth ear”. Diagnosis is based on history, physical examination, sound perception assessment, audiometry, impedance or ABR test, and computed tomography. Surgical treatment.

ICD-10

Q16.0 Congenital absence of auricle

• Causes
• Pathogenesis
• Classification
• Symptoms
• Complications
• Diagnostics
• Treatment of ear anomalies
• Prognosis and prevention
• Prices for treatment

General

Anomalies in the development of the auricle is a relatively rare group of pathologies. According to statistics, their frequency in different parts of the world ranges from 0.5 to 5.4 per 10,000 newborns. Among Caucasians, the prevalence is 1 in 7,000 to 15,000 infants. In more than 80% of cases, violations are sporadic. U 75-9Only 1 ear is affected in 3% of patients, of which in 2/3 of cases it is the right ear. Approximately in a third of patients, malformations of the auricle are combined with bone defects of the facial skeleton. In boys, such anomalies occur 1.3-2.6 times more often than in girls.

Anomalies in the development of the auricle

Causes

Defects of the external ear are the result of violations of intrauterine development of the fetus. Hereditary defects are relatively rare and are part of the genetically determined syndromes: Nager, Treacher-Collins, Konigsmark, Goldenhar. A significant part of the anomalies in the formation of the ear shell is due to the influence of teratogenic factors. The disease is provoked:

• Intrauterine infections. They include infectious pathologies from the TORCH group, the pathogens of which are able to penetrate the hematoplacental barrier. This list includes cytomegalovirus, parvovirus, pale treponema, rubella, rubella virus, types 1, 2 and 3 of herpes virus, toxoplasma.
• Physical teratogens. Congenital anomalies of the auricle potentiate ionizing radiation during x-ray studies, prolonged exposure to high temperatures (hyperthermia). Less commonly, radiation therapy for cancer, radioactive iodine acts as an etiological factor.
• Mother’s bad habits. Relatively often, a violation of the intrauterine development of a child provokes chronic alcohol intoxication, narcotic substances, the use of cigarettes and other tobacco products. Among drugs, cocaine plays the most significant role.
• Medications. A side effect of some groups of pharmacological drugs is a violation of embryogenesis. These medications include tetracycline antibiotics, antihypertensives, iodine and lithium-based drugs, anticoagulants, and hormonal agents.
• Diseases of the mother. Anomalies in the formation of the auricle may be due to metabolic disorders and the work of the endocrine glands of the mother during pregnancy. The list includes the following pathologies: decompensated diabetes mellitus, phenylketonuria, thyroid lesions, hormone-producing tumors.

Pathogenesis

The formation of ear shell anomalies is based on a violation of the normal embryonic development of mesenchymal tissue located around the ectodermal pocket – I and II gill arches. Under normal conditions, the precursor tissues of the external ear are formed by the end of the 7th week of intrauterine development. At 28 obstetric weeks, the appearance of the external ear corresponds to that of a newborn child.

The influence of teratogenic factors during this time interval is the cause of congenital defects in the cartilage of the auricle. The earlier the negative impact was made, the more severe its consequences. Later damage does not affect the embryogenesis of the auditory system. Exposure to teratogens for up to 6 weeks is accompanied by severe malformations or complete absence of the shell and outer part of the ear canal.

Anomaly of the auricle

Classification

In clinical otolaryngology, classifications are used based on clinical, morphological changes in the auricle and adjacent structures. The main goals of dividing the pathology into groups are to simplify the assessment of the patient’s functional capabilities, the choice of treatment tactics, and the solution of the issue of the need and expediency of hearing aids. The classification of R. Tanzer is widely used, which includes 5 degrees of severity of anomalies of the auricle:

• I – annotia. It is a total absence of tissues of the shell of the outer ear. As a rule, it is accompanied by atresia of the auditory canal.
• II – microtia or complete hypoplasia. The auricle is present, but severely underdeveloped, deformed, or missing distinct parts. There are 2 main options:

• III – hypoplasia of the middle third of the auricle. It is characterized by underdevelopment of the anatomical structures located in the middle part of the cartilage of the ear.
• IV – underdevelopment of the upper part of the auricle. Morphologically represented by three subtypes:

Subtype B – ingrown ear. It is manifested by the fusion of the upper part of the back surface of the shell with the scalp.

• V – protruding ears. A variant of congenital deformity, in which there is a passion for the angle of attachment of the auricle to the bones of the cerebral part of the skull.

The classification does not include local defects in certain parts of the shell – the curl and the earlobe. These include Darwin’s tubercle, satyr’s ear, bifurcation or enlargement of the earlobe. Also, it does not include a disproportionate increase in the ear due to cartilage tissue – macrotia. The absence of these variants in the classification is due to the low prevalence of these defects compared to the above anomalies.

Symptoms

Pathological changes can be detected already at the time of the birth of the child in the delivery room. Depending on the clinical form, the symptoms have characteristic differences. Anotia is manifested by agenesis of the shell and opening of the auditory canal – in their place is a shapeless cartilaginous tubercle. This form is often combined with malformations of the bones of the facial skull, most often the lower jaw. In microtia, the shell is represented by a vertical ridge displaced forward and upward, at the lower end of which there is a lobe. In various subtypes, the ear canal may be preserved or closed.

Hypoplasia of the middle of the auricle is accompanied by defects or underdevelopment of the helical stalk, tragus, lower antihelix peduncle, cup. Anomalies in the development of the upper third are characterized by the “bending” of the upper edge of the cartilage outward, its fusion with the tissues of the parietal region located behind. More rarely, the upper part of the shell is completely absent. The auditory canal in these forms is usually preserved. With protruding ears, the outer ear is almost completely formed, however, the contours of the shell and antihelix are smoothed, and the angle between the bones of the skull and cartilage is more than 30 degrees, due to which the latter somewhat “bulges” outwards.

Morphological variants of earlobe defects include an abnormal increase in comparison with the entire shell, its complete absence. When split, two or more flaps are formed, between which there is a small groove ending at the level of the lower edge of the cartilage. Also, the lobe can grow to the skin located behind.

An anomaly in the development of the helix in the form of Darwin’s tubercle is clinically manifested by a small formation in the upper corner of the shell. With the “satire ear” there is a sharpening of the upper pole in combination with a smoothing of the curl. With the “ear of the macaque”, the outer edge is slightly enlarged, the middle part of the curl is smoothed or completely absent. “Wildermuth’s ear” is characterized by a pronounced protrusion of the antihelix above the level of the curl.

Complications

Complications of anomalies in the development of the auricle are associated with untimely correction of deformities of the auditory canal. Existing in such cases, severe conductive hearing loss in childhood leads to deaf-mutism or severe acquired disorders of the articulatory apparatus. Cosmetic defects negatively affect the social adaptation of the child, which in some cases causes depression or other mental disorders.

Stenosis of the lumen of the outer ear impairs the excretion of dead epithelial cells and earwax, which creates favorable conditions for the vital activity of pathogenic microorganisms. As a result, recurrent and chronic otitis externa and otitis media, myringitis, mastoiditis, and other bacterial or fungal lesions of regional structures are formed.

Diagnostics

The diagnosis of any pathology of this group is based on an external examination of the ear area. Regardless of the variant of the anomaly, the child is referred for a consultation with an otolaryngologist to exclude or confirm violations of the sound-conducting or sound-perceiving apparatus. The diagnostic program consists of the following studies:

• Auditory assessment. Basic diagnostic method. It is carried out with the help of sounding toys or speech, sharp sounds. During the test, the doctor evaluates the child’s reaction to sound stimuli of varying intensity in general and from each ear.
• Tone threshold audiometry. It is indicated for children older than 3-4 years, due to the need to understand the essence of the study. With isolated lesions of the outer ear or their combination with pathologies of the auditory ossicles, the audiogram shows a deterioration in sound conduction while maintaining bone conduction. With concomitant anomalies of the organ of Corti, both parameters decrease.
• Acoustic impedance and ABR test. These studies can be done at any age. The purpose of impedancemetry is to study the functionality of the tympanic membrane, auditory ossicles and to identify a malfunction of the sound-perceiving apparatus. In case of insufficient information content of the study, the ABR test is additionally used, the essence of which is to assess the reaction of the CNS structures to a sound stimulus.
• CT scan of the temporal bone. Its use is justified in case of suspicion of severe malformations of the temporal bone with pathological changes in the sound-conducting system, cholesteatoma. Computed tomography is performed in three planes. Also, based on the results of this study, the question of the feasibility and scope of the operation is being decided.

The results of the correction of anomalies of the auricle

Treatment of ear anomalies

The main method of treatment is surgical. Its goals are to eliminate cosmetic defects, compensate for conductive hearing loss and prevent complications. The selection of the technique and volume of the operation is based on the nature and severity of the defect, the presence of concomitant pathologies. The recommended age for intervention is 5-6 years. By this time, the formation of the auricle is completed, and social integration does not yet play such an important role. In pediatric otolaryngology, the following surgical techniques are used:

• Otoplasty. Restoration of the natural shape of the auricle is performed in two main ways – using synthetic implants or an autograft taken from the cartilage of the VI, VII or VIII ribs. The Tanzer-Brent operation is underway.
• Meatotympanoplasty. The essence of the intervention is the restoration of the patency of the auditory canal and the cosmetic correction of its inlet. The most common technique is according to Lapchenko.
• Hearing aid. It is advisable for severe hearing loss, bilateral lesions. Classic prostheses or cochlear implants are used. If it is impossible to compensate for conductive hearing loss with the help of meatotympanoplasty, devices with a bone vibrator are used.

Prognosis and prevention

The prognosis for health and the cosmetic result depend on the severity of the defect and the timeliness of the surgical treatment. In most cases, it is possible to achieve a satisfactory cosmetic effect, partially or completely eliminate conductive hearing loss.