Ear pain

Ear pain can present in one or both ears. It may or may not be accompanied by other symptoms such as fever, sensation of the world spinning, ear itchiness, or a sense of fullness in the ear. The pain may or may not worsen with chewing. The pain may also be continuous or intermittent. Ear pain due to an infection is the most common in children and can occur in babies. Adults may need further evaluation if they have hearing loss, dizziness or ringing in the ear. Additional red flags include diabetes, a weakened immune system, swelling seen on the outer ear, or swelling along the jaw. == Causes ==

Ear pain has a variety of causes, the majority of which are not life-threatening. Ear pain can originate from a part of the ear itself, known as primary ear pain, or from an anatomic structure outside the ear that is perceived as pain within the ear, known as secondary ear pain. Primary ear pain is most commonly caused by infection or injury to one of the parts of the ear.  Blunt trauma, such as a blow to the ear, can result in a hematoma, or collection of blood between the cartilage and perichondrium of the ear. This type of injury is particularly common in contact sports such as wrestling and boxing. Environmental injuries include sunburn, frostbite, or contact dermatitis. • Auricular Cellulitis: a superficial infection of the ear that may be precipitated by trauma, an insect bite, or ear piercing • Perichondritis: infection of the perichondrium, or fascia surrounding the ear cartilage, which can develop as a complication of untreated auricular cellulitis. It is important to identify and treat perichondritis with antibiotics to avoid permanent ear deformities. • Relapsing polychondritis: a systemic inflammatory condition involving cartilage in many parts of the body, but often including the cartilage of both ears. The severity and prognosis of the disease varies widely. Otitis externa Otitis externa, also known as "swimmer's ear", is a cellulitis of the external ear canal. In North America, 98% of cases are caused by bacteria, and the most common causative organisms are Pseudomonas and Staph aureus. Risk factors include exposure to excessive moisture (e.g. from swimming or a warm climate) and disruption of the protective cerumen barrier, which can result from aggressive ear cleaning or placing objects in the ear. Malignant otitis externa is a rare and potentially life-threatening complication of otitis externa in which the infection spreads from the ear canal into the surrounding skull base, hence becoming an osteomyelitis. It is very rare in children, though can be seen in immunocompromised children and adults. Cerumen impaction may cause ear pain, but it can also prevent thorough examination of the ear and identification of an alternate source of pain. • Foreign body: commonly include insects or small objects like beads • Tumors: the most common ear canal tumor is squamous cell carcinoma. Symptoms can resemble those of otitis externa, and cancer should be considered if the symptoms are not improving on appropriate treatment. Acute otitis media is also most common in these first 3 years of life, though older children may also experience it. • Mastoiditis: infection of the air cells in the mastoid process, the area of the skull located right behind the ear This has been thought to be caused by type II nerves responding to damage of the outer hair cells. Referred ear pain A variety of conditions can cause irritation of one of the nerves that provides sensation to the ear. Conditions causing irritation the trigeminal nerve (cranial nerve V): • Dental pain from cavities or an abscess • Oral cavity carcinoma Conditions causing irritation of the facial nerve (cranial nerve VII) or glossopharyngeal nerve (cranial nerve IX): • Tonsillitis: infection/inflammation of the tonsils • Post-tonsillectomy: pain following surgical removal of the tonsils • Pharyngitis: infection/inflammation of the throat • Sinusitis • Parotitis: inflammation of the parotid gland, the salivary gland right in front of the ear • Carcinoma of the oropharynx (base of tongue, soft palate, pharyngeal wall, tonsils) Conditions causing irritation of the vagus nerve (cranial nerve X): • GERD • Myocardial ischemia (inadequate oxygen supply to the heart muscle) Conditions causing irritation of cervical nerves C2-C3: • Cervical spine trauma, arthritis (joint inflammation), or tumor • Temporal arteritis: an autoimmune disorder leading to inflammation of the temporal artery, a large artery in the head. This condition tends to occur in adults older than 50. ==Pathophysiology==

Primary ear pain The ear can be anatomically divided into the external ear, the external auditory canal, the middle ear, and the inner ear. These three are indistinguishable in terms of the pain experienced. Secondary ear pain Many different nerves provide sensation to the various parts of the ear, including cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and X (vagus), and the great auricular nerve (cervical nerves C2-C3). These nerves also supply other parts of the body, from the mouth to the chest and abdomen. Irritation of these nerves in another part of the body has the potential to produce pain in the ear. This is called referred pain. Irritation of the trigeminal nerve (cranial nerve V) is the most common cause of referred ear pain. == Diagnostic ==

and/or ear trauma. If red flags are present it may be necessary to do additional workup such as a CT scan or biopsy to rule out a more dangerous diagnosis. Such diagnoses include malignant (or necrotizing) otitis externa, mastoiditis, temporal arteritis, and cancer. While the presence of a red flag does raise suspicion for one of these four disease, it does not guarantee a diagnosis as any one symptom can be seen in a variety of situations. For example, jaw claudication can be seen in temporal arteritis, but also in TMJ dysfunction. If there are no red flags, other sources of referred ear pain become more likely and are reasonable to pursue. • Indicates a "Can't Miss" diagnosis or a red flag. == Management ==

Management of ear pain depends on the underlying cause. Antibiotics While not all causes of ear pain are treated with antibiotics, those caused by bacterial infections of the ear are usually treated with antibiotics known to cover the common bacterial organisms for that type of infection. Many bacterial ear infections are treated with cleaning of the area, topical or systemic antibiotics, and oral analgesics for comfort. For symptoms that are not responsive to treatment within 10 days, a physician should evaluate for necrotizing external otitis. • Acute otitis media (AOM) self-resolves within 24–48 hours in 80% of cases. If it does not self-resolve, AOM thought to be caused by bacteria is treated with systemic antibiotics. If symptoms do not respond to a week of treatment, a physician should evaluate for mastoiditis. • Acute folliculitis. • Auricular cellulitis. • Suppurative otitis media. There is also a risk for tympanic membrane rupture. • Perichondritis. An otorhinolaryngologist should also evaluate it and if a foreign body is present in the cartilage, this foreign body should be removed. If there is cartilage involvement, then more advance care with hospitalization is needed. • Sinusitis can cause secondary ear pain. Treating the underlying sinusitis will treat the ear pain. (See sinusitis.) Some bacterial infections may require a more advanced treatment with evaluation by otorhinolaryngology, IV antibiotics, and hospital admission. • Necrotizing external otitis is potentially fatal and should be evaluated by an otorhinolaryngologist with admission to the hospital and IV antibiotics.(See otitis externa.) • Acute mastoiditis is treated with admission to the hospital, otorhinolaryngology consultation and empiric IV antibiotics. Cases with intracranial involvement are treated with a mastoidectomy with myringotomy. • Chondritis. Procedures Some causes of ear pain require procedural management alone, by a health professional, or in addition to antibiotic therapy. • Keratosis obturans is treated with removal of impacted desquamated keratin debris in the ear canal. • Chronic perichondritis and chondritis that continues to be symptomatic despite appropriate antibiotic management may require surgical debridement. Surgical drainage could be required. • Bullous myringitis leads to the development of bullae on the tympanic membrane that can be punctured to give pain relief. • Foreign body in the ear canal can cause pain and be treated with careful removal. • Infected sebaceous cyst is treated with incision and drainage of the cysts, oral antibiotics and otorhinolaryngology assessment. Other Given the variety of causes of ear pain, some causes require treatment other than antibiotics and procedures. • Relapsing polychondritis is an autoimmune disease treated with immunomodulating medications (medications that help modulate the immune system). • Temporomandibular joint dysfunction can lead to secondary ear pain and can be initially treated with a soft food diet, NSAIDs, application of a heat pack, massage of local area, and a referral to a dentist. • Myofascial pain syndromes are initially treated with NSAIDs and physical therapy. Local anesthetic injection into the muscle trigger point can be considered in severe cases. • Glossopharyngeal neuralgia is treated with carbamazepine. == Epidemiology ==

2/3 of people presenting with ear pain were diagnosed with some sort of primary otalgia and 1/3 were diagnosed with some sort secondary otalgia. A common cause of primary otalgia is ear infection called otitis media, meaning an infection behind the eardrum. The peak age for children to get acute otitis media is ages 6–24 months. One review paper wrote that 83% of children had at least one episode of acute otitis media by 3 years of age. Worldwide, there are 709 millions cases of acute otitis media every year. Hearing loss globally due to ear infection is estimated to be 30 people in every 10,000. Around the world there is around 21,000 to 28,000 deaths due to complications from ear infections. These complications include brain abscesses and meningitis. Otitis externae peaks at age 7–12 years of age and around 10% of people has had it at least once in their lives. Cerumen impaction occurs in 1 out of every 10 children, 1 in every 20 adults and 1 in every 3 elderly citizens. Barotrauma occurs around 1 in every 1000 people. Of people presenting with ear pain, only 3% was diagnosed with eustachian tube dysfunction. == History ==

Not much was known about ear pain and acute otitis media before the 17th century. It was a common phenomenon with no treatment. That changed when the otoscope was invented in the 1840s by Anton von Troeltsh in Germany.  Another shift came with the invention of antibiotics. Before antibiotics was introduced there used to be a high rate of ear infections spreading to the bone around the ear, but that is now considered a rare complication. == Society and culture ==

There was previously a strong tradition of treating acute otitis media with amoxicillin. Increasing resistance makes antibiotics less effective. The term antibiotic stewardship is then used to describe the systematic effort to educate antibiotic prescribers to only give these medications when they are warranted. In particular to children, most ear pain resolves by itself with no complications. There are guidelines in place to help determine when antibiotics for ear pain are needed in children. The ear itself played a role in treatment via acupuncture, also known as auriculotherapy. It was believed that acupuncture of the ear could be used to correct other pain or disorders in the body. Such practices may have started as far back as the Stone Age. The first documentation of auriculotherapy in Europe was in the 1600s. One physician described stimulating the ear by burning or scarring to treat sciatic pain, while another physician applied this treatment for toothache. Paul Nogier is known as the father of ear acupuncture for his theory that parts of the ear corresponds to other areas of the body in a reliable fashion. == Research ==

There are currently studies going on delivering antibiotics directly into the middle ear. == References ==