What are the causes of ear pain and discharge. How can otalgia and otorrhea be diagnosed and treated. What are the underlying mechanisms of referred ear pain. How do environmental factors contribute to ear conditions.

The Fundamentals of Otalgia: Ear Pain Explained

Otalgia, commonly known as ear pain, is a condition that can originate from various sources, both within and outside the ear. Understanding this complex symptom is crucial for proper diagnosis and treatment. Otalgia may manifest as a deep ache, sharp discomfort, or a feeling of fullness in the ear.

What causes otalgia? Ear pain can stem from multiple factors:

• Direct ear infections (otitis externa or media)
• Dental problems
• Sinus infections
• Temporomandibular joint (TMJ) disorders
• Throat infections
• Neurological conditions

Is otalgia always related to ear problems? No, surprisingly, about 50% of ear pain cases are actually referred pain from dental issues. This highlights the importance of a thorough examination beyond just the ear itself.

Decoding Otorrhea: When Your Ears Start Draining

Otorrhea refers to the discharge from the ear, which can vary in consistency and color. This symptom often indicates inflammation in the external or middle ear, or both. The nature of the discharge can provide valuable clues about the underlying condition.

What are the different types of ear discharge?

• Clear: Often associated with cerebrospinal fluid leak
• Sanguinous (bloody): May indicate trauma or severe infection
• Mucoid: Typically seen in middle ear infections
• Purulent: Suggests bacterial infection

How can the cause of otorrhea be determined? A detailed patient history and careful examination of the ear canal and eardrum are essential. In some cases, additional tests such as mastoid x-rays or impedance audiometry may be necessary to rule out middle ear or mastoid disease.

The Intricate Mechanisms of Referred Ear Pain

Referred pain is a fascinating phenomenon where pain originating from one area is perceived in another. In the case of ear pain, this can lead to misdiagnosis if not properly understood.

How does referred pain work in relation to ear discomfort? The mechanism involves nerve impulses from a distant or deeper structure being interpreted by the brain as originating from a more superficial area. This often follows dermatomal patterns, which are areas of skin supplied by specific spinal nerves.

Can previous injuries or surgeries affect pain referral? Yes, interestingly, pain may be referred not to its usual point but to a site of previous trauma or surgery. This suggests that pain referral can be influenced by learned experiences and past events.

Diagnostic Approaches for Otalgia and Otorrhea

Accurate diagnosis of ear pain and discharge requires a systematic approach. Healthcare providers must consider a wide range of potential causes and use various diagnostic tools to pinpoint the issue.

What steps are involved in diagnosing ear-related symptoms?

1. Detailed patient history
2. Physical examination of the ear, including otoscopy
3. Assessment of surrounding structures (teeth, jaw, sinuses)
4. Audiological tests when necessary
5. Imaging studies in some cases

Why is a multidisciplinary approach often necessary? Given the complex nature of ear pain and its potential sources, collaboration between otolaryngologists, dentists, and other specialists may be required for accurate diagnosis and effective treatment.

Environmental and Lifestyle Factors Influencing Ear Health

Various external factors can contribute to the development of ear pain and discharge. Understanding these can help in prevention and management of ear-related issues.

What environmental factors can affect ear health?

• Excessive water exposure (swimmer’s ear)
• Changes in air pressure (barotrauma)
• Exposure to loud noises
• Climate conditions (humidity, temperature)

How can lifestyle choices impact ear conditions? Habits such as frequent use of earbuds, improper ear cleaning techniques, and smoking can all contribute to ear problems. Maintaining good overall hygiene and avoiding known irritants can help prevent many ear-related issues.

Treatment Modalities for Otalgia and Otorrhea

The treatment of ear pain and discharge varies depending on the underlying cause. A tailored approach is necessary to address the specific condition effectively.

What are common treatments for ear pain and discharge?

• Antibiotics for bacterial infections
• Antifungal medications for fungal infections
• Pain relievers for symptom management
• Ear drops for external ear conditions
• Surgical intervention in severe cases

When should someone seek medical attention for ear symptoms? Persistent pain, fever, hearing loss, or unusual discharge warrant prompt medical evaluation. Early intervention can prevent complications and lead to faster recovery.

Special Considerations in Pediatric Ear Conditions

Children are particularly prone to ear infections and related issues. The anatomy of a child’s ear, coupled with their developing immune system, makes them more susceptible to these problems.

Why are children more likely to experience ear infections? The Eustachian tubes in children are shorter, more horizontal, and less developed, making it easier for bacteria to travel from the nose and throat to the middle ear. Additionally, children’s immune systems are still developing, making them more vulnerable to infections.

What signs should parents watch for in children with potential ear issues?

• Tugging or pulling at the ear
• Irritability and crying
• Difficulty sleeping
• Balance problems
• Fever
• Fluid draining from the ear

How are ear conditions in children typically managed? Treatment often involves a combination of pain management, antibiotics when necessary, and close monitoring. In recurrent cases, surgical options like tympanostomy tubes may be considered.

Emerging Research and Future Directions in Ear Health

The field of otolaryngology is constantly evolving, with new research shedding light on the complexities of ear disorders and potential treatments.

What are some recent advancements in ear-related research? Studies are exploring new antibiotics to combat resistant bacteria, investigating the role of biofilms in chronic ear infections, and developing novel drug delivery methods for more effective treatments.

How might future technologies impact ear health care? Innovations in telemedicine and AI-assisted diagnostics could revolutionize how ear conditions are diagnosed and monitored, especially in remote or underserved areas. Additionally, advancements in regenerative medicine may offer new hope for treating hearing loss and other chronic ear conditions.

The Role of Genetics in Ear Disorders

Genetic factors play a significant role in many ear-related conditions, influencing both susceptibility to infections and the development of structural abnormalities.

What genetic conditions are associated with ear problems? Several genetic syndromes, such as Waardenburg syndrome, Treacher Collins syndrome, and Alport syndrome, can affect ear structure and function. Understanding these genetic links helps in early diagnosis and management of associated ear issues.

How does genetic research contribute to ear health care? Genetic studies are providing insights into the hereditary aspects of hearing loss and other ear disorders. This knowledge can lead to more personalized treatment approaches and potentially gene therapies in the future.

The Impact of Chronic Ear Conditions on Quality of Life

Persistent ear problems can significantly affect an individual’s daily life, impacting everything from communication to emotional well-being.

What are the long-term effects of chronic ear conditions? Chronic otitis media, for instance, can lead to hearing loss, balance problems, and even cognitive issues in severe cases. These conditions can affect academic performance in children and work productivity in adults.

How can the psychosocial impact of ear disorders be addressed? A holistic approach to treatment that includes psychological support, education, and rehabilitation can help patients cope with the challenges of chronic ear conditions. Support groups and counseling may also play a crucial role in managing the emotional aspects of these disorders.

Preventive Measures and Ear Health Education

Prevention plays a crucial role in maintaining ear health and reducing the incidence of ear-related problems.

What are effective strategies for preventing ear infections and other disorders?

• Practicing good hygiene, especially hand washing
• Avoiding exposure to secondhand smoke
• Breastfeeding infants (which can boost immunity)
• Staying up-to-date with vaccinations
• Proper ear protection in noisy environments

How can public health initiatives improve ear health awareness? Educational programs in schools and communities can help raise awareness about ear health, proper ear care techniques, and the importance of early intervention. These initiatives can also focus on dispelling myths and promoting evidence-based practices in ear care.

The Interplay Between Ear Health and Overall Wellness

Ear health is intricately connected to overall physical and mental well-being, often serving as an indicator of broader health issues.

How do systemic health conditions affect ear health? Conditions such as diabetes, cardiovascular diseases, and autoimmune disorders can impact ear health. For example, diabetes can increase the risk of ear infections and hearing loss. Understanding these connections is crucial for comprehensive patient care.

What role does nutrition play in ear health? Proper nutrition, particularly adequate intake of vitamins A, C, and E, as well as zinc and omega-3 fatty acids, can support ear health. These nutrients play roles in maintaining the immune system and the health of ear tissues.

Technological Advancements in Ear Diagnostics and Treatment

The field of otolaryngology is benefiting from rapid technological advancements, enhancing both diagnostic capabilities and treatment options.

What cutting-edge technologies are being used in ear health care? Advanced imaging techniques like high-resolution CT scans and MRI provide detailed views of ear structures. Endoscopic ear surgery offers minimally invasive options for treating various ear conditions. Additionally, 3D-printed prosthetics are revolutionizing reconstructive procedures for ear abnormalities.

How is telemedicine changing ear health care delivery? Telemedicine platforms are making it possible to conduct initial consultations and follow-up appointments remotely. This is particularly beneficial for patients in rural areas or those with mobility issues. However, it’s important to note that physical examinations are still crucial for accurate diagnosis in many cases.

The Economic Burden of Ear Disorders

Ear-related health issues can have significant economic implications, both for individuals and healthcare systems.

What are the direct and indirect costs associated with ear disorders? Direct costs include medical treatments, surgeries, and medications. Indirect costs encompass lost productivity, educational challenges for children, and long-term care needs for chronic conditions. In many countries, ear infections are one of the leading causes of healthcare visits for children, contributing substantially to healthcare expenditures.

How can healthcare policies address the economic impact of ear disorders? Implementing cost-effective screening programs, promoting preventive measures, and ensuring access to timely treatment can help reduce the overall economic burden. Additionally, investing in research for more effective treatments and potential cures can lead to long-term cost savings.

Cultural Perspectives on Ear Health and Treatment

Cultural beliefs and practices can significantly influence how ear health is perceived and managed across different communities.

How do cultural factors impact ear health care? In some cultures, traditional remedies for ear pain may be preferred over modern medical treatments. Understanding and respecting these cultural perspectives while providing evidence-based care is crucial for effective healthcare delivery.

What challenges arise from cultural differences in ear health management? Language barriers, differing health beliefs, and varying healthcare-seeking behaviors can all impact the diagnosis and treatment of ear conditions. Healthcare providers need to be culturally competent to address these challenges effectively.

By exploring these multifaceted aspects of ear health, we gain a deeper understanding of the complexities involved in managing otalgia and otorrhea. From the intricate mechanisms of referred pain to the latest technological advancements in treatment, the field of ear health continues to evolve, offering hope for improved outcomes and quality of life for those affected by ear disorders.

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

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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

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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.