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Ear Pain Luqman HamedLearningObjectives • Understand the anatomy of the outer, middle, and inner ear, salivary glands. • Understand the function and innervationof the facial muscle of expression and mastication. • Understand common ear pathologies and the management. • Understand some complications of ENTsurgery withrespect to major neurological issues.Anatomy–ExternalEar • The external ear is comprised of 2 parts: the Auricle, and the External Acoustic Meatus.Anatomy–Auricle • Functions to capture and direct sound waves towards to External Acoustic Meatus.Anatomy–ExternalAcoustic Meatus • An‘S’shaped tube that extends from the deep part of the Concha to the Tympanic Membrane. • The walls of the external 1/3 are formed by cartilage • The inner 2/3 are formed by the Temporal bone.Anatomy–MiddleEar • Divided into 2 parts: • Tympanic cavity –contains the malleus, incus, and stapes. • Epitympanic recess • Protective and conductive functionsAnatomy–InnerEar • Contains the Vestibulocochlear organ. • Two main functions: • Convert mechanical signals into electrical signals • Maintain balance by detecting position and motionBonyandMembranouslabyrinthAnatomy–TympanicMembrane • Please duplicate thisslide as you go along.Anatomy–TympanicMembrane • Left ear – 7 o’clock position • Right ear – 5 o’clock positionAnatomy–InnervationExternalEarV asculature Artery:es of the External Carotid •Posterior auricular artery •Superficial temporal artery •Occipital artery •Maxillary arteryFacialNerveTrigeminalNerveFacialMuscleExpression • CN VII → Motor supply to muscles of facial expression • Five main branches: • Temporal → Frontalis (eyebrow elevation) • Zygomatic → Orbicularis oculi (eye closure) • Buccal → Orbicularis oris, buccinator (cheekcontrol) • MmovementMandibular → Lower lip • Cervical → Platysma (necktension)FacialNerveDamage • Lower motor neuron lesion (LMN) (e.g., Bell’sPalsy, parotid tumour, cholesteatoma) • Ipsilateral whole-faceparalysis • Inability to close eye (risk of cornealulcer) • Drooping mouth • Upper motor neuron lesion (UMN) (e.g., stroke) • Forehead sparing due tobilateral cortical innervation MusclesofMastication • CN V3 (Mandibular division of Trigeminal nerve) → Motor supply to muscles of mastication • Four main muscles: • Masseter – Elevates mandible (closesjaw) • Temporalis – Elevates & retractsmandible • Medial pterygoid – Elevates & protrudes mandible • Lateral pterygoid –Opens jaw, moves it sidetosideCNVLesions&TMJDysfunction • Trigeminal nerve palsy: • Jaw deviates toward weak side • Loss of masticationmuscle strength • Absent jaw jerk reflex • TMJ Dysfunction & CN V3: • Pain referred to ear via auriculotemporal nerve (branchof CN V3) • Clicking, difficulty chewing, bruxism • Can alsobe misinterpreted as ear pain duetoproximity totheear canalSalivaryGlandsNeurovascularSupply&Surgical Relevance • Parotid gland: • Innervation:Autonomic supply via glossopharyngeal nerve (CN IX)→ otic ganglion→auriculotemporal nerve (CN V3) • Blood supply: External carotidartery (ECA) • Venous drainage: Retromandibular veinNeurovascularSupply&Surgical Relevance • Surgical Risk – Parotidectomy: • Facialnerve damage → weakness/paralysis • Frey’s syndrome (gustatory sweating) → aberrant autonomic reinnervation • First bite syndrome – Pain in parotid region continuese first few bites, improving as eating • Numbness – Neurological damage • Seroma/HaematomaClinicalRelevance–ReferredPain Nerve EarRegion Supplied Possible Source ofReferred Pain Auriculotemporal nerve(CN V3 Temporomandibular joint (TMJ) –Mandibularbranchof External ear, anteriorcanal,TMJ dysfunction,dentalinfections, Trigeminal Nerve) mandibularfractures Parotid glandpathology (e.g., Facial nerve(CNVII) External ear, posteriorcanal parotidtumors, parotidectomy complications) Glossopharyngealnerve(CNIX) Medial surface oftympanic Tonsillitis, pharyngealtumors, membrane post-tonsillectomy pain Vagusnerve(CN X)–Auricular Laryngealcancer,thyroid External auditory canal,concha branch(‘Arnold’snerve’) pathology, vagal schwannomas Cervical plexus (C2,C3 – Cervical spinedisease, carotid Greater auricular nerve) Lateral neck,external ear artery dissectionCausesofEarPain–Primary Ear pain can be primary or secondary. Primary causes of ear pain are: • Otitis Externa • Otitis Media • Mastoiditis • CholesteatomaOtitisExterna • Definition:Inflammation of the external auditory canal, often due to infection (bacterial or fungal). • RiskFactors:Swimming(‘swimmer’sear’), excessive cleaning, hearing aids, eczema,diabetes. • Symptoms:Ear pain, pruritus,discharge, hearing loss (if canal blocked). • CommonOrganisms: • Bacterial: Pseudomonas aeruginosa, Staphylococcus aureus. • Fungal: Aspergillus, Candida (in immunocompromised patients). • Complication:Necrotising OtitisExterna (spread to skullbase, immunosuppressedindividuals).OtitisExterna-Management • First-line: Topical antibiotics (e.g., ciprofloxacin drops) + analgesia. • NOE (infection spreads to skull base): • Surgical debridement of necrotic tissue(rarelyneeded)ions • May need mastoidectomy if infection extends intothe temporal bone. • Recurrent or obstructive OE (severe canal stenosis): • Canaloplasty (surgicalwidening ofear canal). • OE with debris in canal: • Microsuctionunder microscopytoremove fungal debris.OtitisExternaOtitisMedia • Definition: Infection of the middle ear, typically viral or bacterial. • Risk Factors: Age (children <6), recent URTI, Eustachian tube dysfunction. • Symptoms: Otalgia, fever, hearing loss, bulging tympanic membrane. • Common Organisms: Strep pneumoniae, Haemophilus influenzae, Moraxella catarrhalis. • Complication: mastoiditis,CN7 palsy, intracranial abscess/thrombosis, meningitisOtitisMediawithEffusion • commonly known as glue ear. • If the eustachian tube is unable to equalise middle ear pressure, a negative pressure develops inside the middle ear • This negative pressure draws out a transudate from the mucosa of the middle ear, creating an environment suitable for pathogens to replicate and cause infection. • Upon inspection of a patient with otitis media with effusion, the eardrum will appear inverted, with fluid visible inside the ear.OtitisMediaManagement • prolonged). Supportive care, analgesia, +/- antibiotics(if severe or • When is surgery needed? • Persistent effusion >3 months (OME/Glue Ear): • Grommetinsertion(ventilationtubes) torelieve middle ear pressure. • Complicated AOM (e.g., mastoiditis,intracranial complications): • Mastoidectomy if AOM (>3 episodes in 6 monthsor >4 in12 months): • mastoid abscess forms. • Recurrent Grommet insertion +/- adenoidectomy to improve Eustachian tube function.OtitisMediaOtitisMediaMastoiditis • Middle ear infections (otitismedia) can spread tothe mastoid air cells. Duetotheir porous nature, they are a suitable site for pathogenic replication. • The mastoid processitself canget infected, and and intothe brain,causing meningitis.ssa, • If mastoiditisis suspected, the pusmustbe mustbe taken nottodamage thehen doingso, care nearby facial nerve.Mastoiditismanagement MedicalMx IV Abx –usually broad-spectrume.g. ceftriaxone SurgicalMx • Mastoidectomy-Drainage of infected mastoid air cells +Removal of infected bone tissue • Myringotomy - Incision in theeardrum for pusdrainage • Tympanoplasty- Repair of damaged eardrum or middleear structures • Indicationsfor Surgery • Severe infection unresponsive to antibiotics • Abscess formation • Complications like hearing loss or facial nerve involvementChronicOtits Media&Cholesteatoma • COM: Long-standing middle ear infection leading to persistent tympanic membrane perforation. • Cholesteatoma: Abnormal keratinising squamous epithelium surrounding structures.r, leading to destruction of ossicles and • Symptoms: Persistentotorrhea, conductive hearing loss, vertigo (if inner ear involved). • Complication: Facial nerve palsy, brain abscess, meningitis.Management Indications for surgery • Persistent tympanic membrane perforation → Tympanoplasty (graft repair). • Cholesteatoma (ALWAYS surgical) → Mastoidectomy to remove disease. • Types of Mastoidectomy: • Canal Wall Up (CWU) –Preserves canal, better cosmesis, but higher recurrence. • Canal Wall Down (CWD) –Removes canal wall, lower recurrence but • Post-op complications:Hearing loss, dizziness, facial nerve injuryAuricularHaematoma • Definition: Blood collection between auricular cartilage & perichondrium due to trauma. • (rugby, boxing), repeated ear trauma. • Symptoms: Fluctuant swellingof external ear, pain, potential cartilage necrosis.Management • Immediate drainage + compression dressing to prevent cartilage necrosis. • Recurrent or chronic cases: • Surgical incision& drainage with quilting sutures toprevent re- accumulation. • Cartilage repair if fibrosis or deformity hasoccurred.SecondaryCauses • TMJ dysfunction • Parotid Tumour • Throat tumours • NeuralgiasTMJDysfunction • Definition: Disorder of the temporomandibular joint causing jaw pain and referred ear pain. • Risk Factors: Bruxism, malocclusion, trauma. • Symptoms: Clicking jaw, limitedmouth opening, referred otalgia.TMJManagement Non-surgical first-line: Bitesplints, physiotherapy, NSAIDs. Surgical options: • Arthrocentesis – Minimallyinvasive flushing of joint. • Arthroscopy – Keyhole surgery to remove adhesions. • Open joint surgery (rare, last resort) – TMJ replacement.ParotidTumours • Facial nerve involvement (CN VII) → referred otalgia. • Most common tumour: Pleomorphic adenoma. • Symptoms: Painless mass, facial asymmetry, referred pain to ear.ParotidtumourManagement • Indications: Suspected malignancy, large tumour, cosmetic concern. • Procedure: • Superficialparotidectomy (most common). • Total parotidectomy if deep lobe involved. • Risks: • Facialnerve damage (CN VII). • Frey’s syndrome (gustatory sweating).Laryngeal/OropharyngealTumours • Arnold’s Nerve (CN X) → referred pain to ear from throat tumours. • Symptoms: Persistent unilateral ear pain, hoarseness, dysphagia, weightloss.Management • Indications: Tumour resection in operable cases. • Procedures: • Laryngectomy(total/partial) – Removal of larynx for advanced cancer. • Neck dissection– If lymph node involvement. • Tracheostomy –If airwayobstruction.TrigeminalNeuralgia • Common Symptoms • Intensefacial pain, often triggered by touch or movement. • Pain radiates tothe ear, jaw, or cheek. • Episodes may last for seconds tominutes. • Treatment Options • Medications:Carbamazepine, gabapentin. • Surgical Options: Microvascular decompression, rhizotomy.GlossopharyngealNeuralgia • Common Symptoms • Pain in the ear, throat, or base of thetongue. • Episodes triggered by swallowing, talking, or coughing. • Pain is typically brief but very intense. • Treatment Options • Medications:Carbamazepine, baclofen. • Surgical Options: Microvascular decompression or nerve block.