Department of Otorhinolaryngology

Ossama Mahmoud Professor of otorhinolaryngology Ain Shams University EAR PAIN (OTALGIA) Ossama Mahmoud Professor of otorhinolaryngology Ain Shams University

Nerve Supply of the Ear Richly innervated Multiple cranial & spinal nerves Shared nerve supply with other head & neck sites Inner ear has no sensory supply

Nerve Supply of the Ear Great auricular nerve (cervical plexus C 2,3) Most of the external ear Great auricular nerve (cervical plexus C 2,3) Auriculo temporal nerve (branch of Vc) Small contributions from Auricular branch of X nerve Somatosensory branch of VII nerve Middle ear supply Tympanic branch of IX nerve

Nerve Supply Lesser occipital nerve Greater auricular nerve

Nerve supply of pinna

Nerve supply of external auditory canal Great auricular nerve Auriculo temporal nerve Arnold nerve

Otalgia 2 types Primary otalgia Pain that arises from a pathology within the ear (external , middle) Referred otalgia Pain that originates from outside the ear

Otalgia: Differential Diagnosis Primary Otitis media Otitis externa Mastoiditis TM perforation Foreign body Referred Dental TMJ Dental abscess Poorly-fitting denture Oral cavity Tongue Sinuses Throat Tonsillitis/pharyngitis Eustachian dysfunction Neck Musculoskeletal Other Neuralgias Tumors Angina Temporal arteritis Zoster

Otalgia (clinical exam.) Ear normal? No Yes Thorough head and neck exam Done

Primary otalgia Common causes: Infections of pinna external auditory canal (boil) middle ear / mastoid (otitis media, mastoiditis) Neoplasms of external & middle ear

Referred Pain Pain felt at a site different from the location of the injured or diseased part of the body Nerve signals from several areas of the body may "feed" the same nerve pathway leading to the spinal cord and brain EXAMPLES Pain of coronary artery insufficiency Gall bladder pain Appendix Liver

Why referred otalgia occurs ? Irritation of the large array of nerves their distant branches ↓ Cause perception of pain within the ear

When to label as referred otalgia ? CLINICALLY (& radiologically) NORMAL Pinna External auditory meatus Tympanic membrane Mastoid process

Causes of Referred Otalgia Nerves C 2,3 V VII IX X

Common Causes of Referred Otalgia Dental sources Impacted tooth (last molar, upper) Dental caries Periodontal infection Ill fitting dentures TMJ disorders

Pharyngeal causes Acute tonsillitis Peritonsillar abscess Malignant tumours – Most important Pharynx (pyriform fossa ) Larynx Oral cavity

Clinical examination (ENT & neurological) must be normal Neuralgias Clinical examination (ENT & neurological) must be normal Trigeminal neuralgia – unilateral facial pain Glossopharyngeal neuralgia unilateral pharyngeal pain