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Causes of Otalgia
Local Causes
Causes of Referred Pain

Acute otitis externa

Acute otitis media



Ramsay Hunt Syndrome







Cervical nerves, trigeminal, glossopharyngeal and vagal nerves are involved in referred pain to the ear. Mechanism of referred otalgia;
  • C-spine                                                             -> cervical nerves 2 & 3
  • Nose and sinuses                                             -> CN V
  • Teeth                                                                 -> CN V
  • Temporomandibular joint                                  -> CN V
  • Oropharynx                                                       -> CN IX
  • Larynx                                                               -> CN X
  • Oesophagus                                                      -> CN X

Acute otitis externa

  • Common associations with eczema
  • Common after use of cotton buds
  • Common in anything that increases humidity in the ear à ear phone use, swimming etc.
  • 4 main causative agents; streptococcus, staphylococcus, pseudomonas and fungus (secondary fungal infection is common after initial overuse of antibiotics)
  • Sx; itching and pain
  • O/E;                                                                    
    • Red and tender ear canal                                                           
    •   Watery discharge                                                          
    •   Accumulation of debris + oedema à hearing loss
  • Rx;                                                             
    • Topical antibiotic OR                                                           
    • Topical steroid drop OR                                                         
    • Antibiotic dressing (if canal severely swollen)                                                          
    • 1% hydrocortisone (for itching)

Acute otitis media

  • Causes severe otalgia
  • Upper respiratory tract infection
    • ascends via and blocks Eustachian tube
    • negative pressure in middle ear
    • exudates
    • otitis media with effusion (OME)
  • N.B Mastoiditis is a severe possible complication
  • Sx;                                                              
    • Pain (due to pressure in middle ear)
    • Hearing loss
    •   Disharge (if tympanic membrane ruptures) à reduced pain
    •   Imbalance (especially in adults)
  • O/E;
    • Injected, congested and bulging ear drum
    • Hearing loss
    • Large tonsils ( + adenoids NB cannot see on normal examination of buccal cavity and pharynx)
    • Tympanometry shows no ear movement and produces a flat trace. (Tympanometry measures how the tympanic membrane moves in relation to an applied pressure and thus pressures in the middle ear can be calculated)
  • Rx;
    • NSAIDs and analgesics
    • Systemic broad spectrum antibiotics
    • Decongenstants
    • Myringotomy and grommet insertion (if recurrent)
    • Adenoidectomy (if recurrent)

Ramsay Hunt Syndrome

  • Infection of the facial nerve ganglion by herpes zoster (shingles)
  • NB can cause permanent damage to facial nerve if not treated promptly
  • Sx;
    • Otalgia
    • Facial palsy
    • Hearing loss
    • Imbalanced.      O/E;
    • Vesicles in ear canal and around pinnae.      Rx;
    • Systemic acyclovir


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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University, and is studying for a Masters of Sports Medicine at the University of Queensland. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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