1. EARACHE & REFERRED OTALGIA Col Shoaib Ahmed MBBS (Honours) FCPS FRCS (Glasgow) Classified ENT Specialist & Head & Neck Surgeon CMH Rawalpindi *

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

3. Details of nerves 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

4. Nerve Supply Greater auricular nerve Lesser occipital nerve

5. Nerve supply of pinna

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

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

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

9. 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

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

11. When to label as referred otalgia ? CLINICALLY NORMAL Pinna External auditory meatus Tympanic membrane Mastoid process

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

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

14. Pharyngeal causes Acute tonsillitis Peritonsillar abscess Malignant tumours – Most important Pharynx Larynx Oral cavity

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

16. Commonest Causes Teeth TM joint Tongue (base) Tonsils Pharynx Larynx

17. DEPARTMENT OF ENT HEAD & NECK SURGERY COMBINED MILITARY HOSPITAL RAWALPINDI

18. Any Questions ?