If It's Not in the Differential, It Won’t be in the Diagnosis: Not Another Otitis Media

If It's Not in the Differential, It Won’t be in the Diagnosis: Not Another Otitis Media

Gita Pensa, MD, and Mike Weinstock, MD

A listener wrote in to request a segment on non-infectious causes of otalgia.

Otalgia has a very broad differential diagnosis, including both infectious and non-infectious causes. Pain in the ear can come from the ear itself and adjacent structures or may be referred from various other sites.

Primary otalgia (ear or adjacent structures)

• Otitis media
• Otitis externa 
• Malignant otitis externa 
  • pseudomonas – patients with diabetes mellitus
• Mastoiditis
  • Palpate behind ear
  • Pinna may be displaced
  • Patients usually sicker
• Herpes zoster oticus (Ramsay Hunt syndrome) 
  • Rash might occur after 
• Neoplasm
• Parotitis
• Fracture 
  • If the patient denies trauma, think about trauma from a fall (alcoholic black-out or caused by other substances), intimate partner violence, or other sensitive situations.
• Eustachian tube dysfunction
  • This is a failure of the functional valve of the eustachian tube to open/close properly.
  • The exam is often normal.
  • The patient complains of popping, pain, and fullness in the ear.
  • It is rarely associated with vertigo and disequilibrium.

Referred otalgia

• The number one cause of referred pain is dental etiology.
• Temporomandibular joint (TMJ) dysfunction:
  • Bruxism, degenerative joint disease, or stress can lead to internal derangements within the TMJ.
• Referred pain from sinuses and the neck is also common.

• Peritonsillar abscess (PTA) – exam shows pain with swallowing and fever
• Retropharyngeal abscess (RPA) (harder to diagnose) – pain with swallowing and fever; exam may be normal
• Brain mass – otalgia and weight loss, headaches, history of malignancy:
  • Other cancers of the neck or sinuses can refer pain to the ear.
  • Do a thorough neck exam.
• Aneurysm compressing the otic nerve: 
  • Need an index of suspicion. 
  • Pulsatile tinnitus or whooshing may be clues
  • Magnetic resonance imaging/angiography (MRI/MRA)
• Ménière disease – additional vertigo symptoms
• Esophagitis – odynophagia
• Angina 
  • Pain can be referred to the ear, but lone otalgia is unlikely.

PEARL:
Most cases of otalgia are benign, but doing a good history, review of systems, and head/neck exam can help point toward more serious causes. Emphasize the importance of follow-up if new symptoms arise or if their pain worsens.

RELATED CONTENT:

CorePendium: Infectious Ear Emergencies

CorePendium: Acute Otitis Media