Imaging of Otalgia at 12 am Click to edit Master title style Imaging … · abscess, perimandibular...

Click to edit Master title style

» Click to edit Master text styles ~  Second level

•  Third level ~  Fourth level

•  Fifth level

Karen Tong, M.D.

Imaging of Otalgia at 12 amKaren Tong, MD. Associate Professor

No disclosures

•  Fifth level

Karen Tong, M.D.

Imaging of Otalgia at 12 am

https://apkgk.com/com.OneLife2Care.BabiesEarInfectionHelp

•  Fifth level

Karen Tong, M.D.

Objectives

• Review neurosensory pathways of ear pain • Review causes of otalgia (especially urgent/important ones)

• Case presentations

•  Fifth level

Karen Tong, M.D.

Recommended references:

• Weissman JL. “A pain in the ear: the radiology of otalgia.” AJNR 1997 Oct;18(9):1641-51.

• Scarbrough TJ, et al. “Referred otalgia in head and neck cancer: a unifying schema.” Am J Clin Oncol. 2003 Oct;26(5):e157-62.

• Chen RC, Khorsandi AS, Shatzkes DR, Holliday RA. “The radiology of referred otalgia.” AJNR 2009 Nov;30(10):1817-23.

• Dr. Lindell Gentry’s lecture, “Imaging of Otalgia”, ASHNR 2013 • Cranial nerve lectures from: Drs.Lindell Gentry, John Go, Wendy Smoker

•  Fifth level

Karen Tong, M.D.

Classification of otalgia

• Primary: ear pain resulting from pathologic conditions of the ear itself

• Secondary: pain referred to the ear from nonotologic sites, usually in the distributions of cranial nerves V, VII, IX, or X; or the cervical plexus

•  Fifth level

Karen Tong, M.D.

Primary otalgia

• In children, most cases of otalgia are primary. • In adults, less than half of the cases of otalgia are primary.

• Usually have clinical findings on exam • Simple otitis does not require imaging • If needed, temporal bone CT usually imaging of choice

•  Fifth level

Karen Tong, M.D.

Primary otalgia - etiologies• EAC disease

•  Carbuncle or furuncle (folliculitis)

•  Acute otitis externa (swimmer’s ear)

•  Necrotizing (malignant OE) – urgent, pseudomonas

•  Cholesteatoma, CA – dull pain •  Foreign bodies, trauma

• Middle ear disease •  Acute otitis media,

otomastoiditis – with complications

•  Petrous apicitis (Gradenigo’s syndrome)

•  Cholesteatoma •  Eustachian tube

dysfunction, barotrauma

•  Fifth level

Karen Tong, M.D.

Secondary otalgia•  “Convergence-projection theory”: multiple nerves converge on

single shared neural pathway, but CNS unable to differentiate origin of stimulation (sensory error)

•  Identifying cause of secondary otalgia may be challenging due to complex innervation of the ear and many potential sources of referred pain.

• May be due to non-otologic lesions that are innervated along shared pathway, or direct pathology of a shared nerve (“neuralgia”)

• Otoscopic exam usually normal; imaging may include CT and MRI

•  Fifth level

Karen Tong, M.D.

Sensory innervation by location Sensory innervation by nerve Click to edit Master title style

•  Fifth level

Karen Tong, M.D.

Sensory innervation of outer ear

Hutchens et al, “Ear Anesthesia”, Medscape 6/14/18

(C2,C3)

Dr. Mahmoud, ENT, Ain Shans University

•  Fifth level

Karen Tong, M.D.

Sensory innervation to TM and ME

• Outer/lateral side of TM – auriculotemporal nerve

• Middle ear/medial side of TM – glossopharyngeal component of tympanic plexus (Jacobson’s nerve)

•  Fifth level

Karen Tong, M.D.

Sensory innervation of inner ear

• Primarily by vestibulocochlear nerve, but does not have pain fibers

• Can have pathology of the inner ear without pain

•  Fifth level

Karen Tong, M.D.

Secondary otalgia - etiologies• Dental: infection, malocclusion, TMJ • Inflammatory: sinonasal, oral, retro/pharyngeal, laryngeal, salivary (esp. parotid), temporal arteritis, neuralgia (e.g. Ramsay Hunt, neuralgias (trigeminal, sphenopalatine, N. intermedius, IX, X) chronic paroxsymal hemicrania, migraine, longus colli tendinitis, carotidynia

• Neoplasm: sinonasal, oral, retro/pharyngeal, laryngeal, salivary, lung

• Miscellaneous: Eagle’s, GERD

•  Fifth level

Karen Tong, M.D.

Innervation of referred ear pain is complex:

•  4 cranial nerves (V,VII, IX and X)

•  2 cervical nerves (C2, C3)

•  Possibly cervical sympathetic fibers

Chen RC, Khorsandi AS, Shatzkes DR, Holliday RA. The radiology of referred otalgia. AJNR Am J Neuroradiol. 2009

•  Fifth level

Karen Tong, M.D.

Referred otalgia from CN V

•  Fifth level

Karen Tong, M.D.

Referred otalgia from CN V

• Auriculotemporal N. • Dental disease (most common cause from V3, usually mandibular molars)

• TMJ dz (70-80% pts) • Parotid infection/inflammation

•  Fifth level

Karen Tong, M.D.

Referred otalgia from CN VII

•  Fifth level

Karen Tong, M.D.

Referred otalgia from CN VII• Posterior auricular N. • Posterior ethmoid and sphenoid sinus inflammation

• Septal spurs irritating nasal mucosa

•  Fifth level

Karen Tong, M.D.

Referred otalgia from CN IX

•  Fifth level

Karen Tong, M.D.

Referred otalgia from CN IX

• Jacobson’s N. • Acute tonsillitis, peritonsillar abscess

• Oropharyngeal CA – otalgia can be early symptom

• Eagle syndrome (but only 4% pts w elongated styloid have symptoms)

•  Fifth level

Karen Tong, M.D.

Referred otalgia from CN X

•  Fifth level

Karen Tong, M.D.

Referred otalgia from CN X

• Arnold’s N. • Laryngeal CA • Lung CA • Crycoaretynoid inflammation

•  Fifth level

Karen Tong, M.D.

CASE PRESENTATIONS

•  Fifth level

Karen Tong, M.D.

Case: 12 yo male w ear pain, fever, seizure

•  Fifth level

Karen Tong, M.D.

12 yo male w ear pain, fever, seizure Click to edit Master title style

•  Fifth level

Karen Tong, M.D.

Dx: temporal lobe abscess due to otomastoiditis

•  Fifth level

Karen Tong, M.D.

Case: 61 yo male w DM, otalgia and ataxia Click to edit Master title style

•  Fifth level

Karen Tong, M.D.

Dx: cerebellar abscess due to otomastoiditis

•  Fifth level

Karen Tong, M.D.

Acute otomastoiditis & complications• Coalescent mastoiditis • Subperiosteal abscess - periauricular •  Intracranial abscess – middle cranial or posterior fossa;

epidural or parenchymal, subdural empyema • Meningitis •  Infarction • Sinus thrombosis - usually sigmoid and/or IJV • Labyrinthitis • Petrous apicitis • Bezold abscess

•  Fifth level

Karen Tong, M.D.

Case: 84-year-old female w ear/jaw pain

•  Fifth level

Karen Tong, M.D.

Dx: Malignant/Necrotizing Otitis Externa Click to edit Master title style

•  Fifth level

Karen Tong, M.D.

Malignant/Necrotizing Otitis Externa• Rare complication of otitis externa that spreads to skull base and causes osteomyelitis

• Usually due to pseudomonas aeruginosa but can be fungal (aspergillus, mucor)

• Sx: severe otalgia, facial nerve palsy, also CN IX to XII • Usually elderly diabetics, but increasingly seen with immunocompromise (HIV)

• Can be life-threatening if there are intracranial complications

•  Fifth level

Karen Tong, M.D.

Case: 12 mo old w bilateral otalgia, ear drainage Click to edit Master title style

•  Fifth level

Karen Tong, M.D.

Dx: T-bone Langerhan Cell Histiocytosis

•  Fifth level

Karen Tong, M.D.

T-bone Langerhans Cell Histiocytosis

• Usually in children < 10 yo • Histiocytic tumor-like proliferation • Otologic symptoms in 25% cases: conductive hearing loss, otorrhea, otalgia, periauricular soft tissue swelling, CN VII palsy

• Soft tissue mass w osseous destruction, may have fluid-fluid levels

•  Fifth level

Karen Tong, M.D.

Case: 62 yo male w otalgia, plugged ear

•  Fifth level

Karen Tong, M.D.

Case: 10 yo w severe ear/facial pain, sound sensitivity Click to edit Master title style

•  Fifth level

Karen Tong, M.D.

Nasopharyngeal tumors

• Can obstruct eustachian tube and cause otitis and ear pain

• In adults: NPC most common • In children: rhabdomyosarcoma most common

•  Fifth level

Karen Tong, M.D.

Case: 30 yo w facial, jaw and ear pain Click to edit Master title style

•  Fifth level

Karen Tong, M.D.

Dental infection

• Dental infections are a frequent cause of referred otalgia

• Pain from molars, especially mandibular molars, radiates to the ear

• Include: dental caries, acute periapical abscess, perimandibular abscess

•  Fifth level

Karen Tong, M.D.

Cases: ear pain, sore throat, fever

Dx: retropharyngeal abscess

Dx: tonsillitis Dx: peritonsillar abscess

•  Fifth level

Karen Tong, M.D.

Tonsillar & Retropharyngeal infection

• Severe ear pain is one hallmark of peritonsillar abscess

• Diseases of retropharyngeal nodes (of Rouviere) can present with otalgia

•  Fifth level

Karen Tong, M.D.

Case: 14 yo w ear/facial pain, swelling Click to edit Master title style

•  Fifth level

Karen Tong, M.D.

Case: 3 yo w periauricular swelling and ear pain

•  Fifth level

Karen Tong, M.D.

Parotid infection

• Acute parotiditis presents w marked periauricular tenderness and fever; can be associated with cellulitis, abscess is rare

• Recurrent parotid abscess in child should suggest underlying 1st branchial cleft cyst

•  Fifth level

Karen Tong, M.D.

Summary

• Most ear pain in children arises from primary otologic source • Otalgia can be a pain to diagnose, especially if secondarily referred from a non-otologic source

• Referred pain can travel along shared neural pathways involving CNs V, VII, IX, X; cervical nerves C2, C3, and possibly cervical sympathetic fibers

• Source of pain can range from sinonasal to lung • Diagnostic steps may include: clinical → CT → MRI

Imaging of Otalgia at 12 am Click to edit Master title style Imaging … · abscess, perimandibular...

Documents

Transcript of Imaging of Otalgia at 12 am Click to edit Master title style Imaging … · abscess, perimandibular...

Click to edit Master title style Click to edit Master text ... · Click to edit Master title style Click to edit Master text styles •Second level –Third level –Fourth level

Click to edit Master title Risk Management Mentor Program ......Click to edit Master title ... Risk Management Mentor Program. Click to edit Master title style Click to edit Master

Click to edit Master title style Click to edit Master text styles Click to edit Master title style Click to edit Master text styles 4a. Reunião do Grupo.

Texas and Obamacare: Click to edit Master title style A Status …forabettertexas.org/images/HW_2015_TX_ACAupdate_presentation.pdf · Click to edit Master title style Click to edit

Click to edit Master title style Click to edit Master text ...¹„วรัส การแก้ไข... · Click to edit Master title style •Click to edit Master text styles

Click to edit Master title style Click to edit Master text styles Click to edit Master title style Click to edit Master text styles 16 a. Plenária do Fórum.

Click to edit Master title style - dspace.mit.edudspace.mit.edu/bitstream/handle/1721.1/45593/15... · Click to edit Master title style • • • • • 3 Click to edit Master

Click (edit)

Click to edit Master title style CASE STUDY • Click to edit Master … · 2017-10-12 · Click to edit Master title style • Click to edit Master text styles –Second level •Third

Click to-edit

Click to edit Master title style - Victorian Institute of ...€¦ · Click to edit Master title style Click to edit Master text styles •Click to edit Master text styles –Second

1 Click to edit Master title style Click to edit Master subtitle style 1 Click to edit Master title style Click to edit Master text styles Second level.

Click to edit Master title style - enrd.ec.europa.euenrd.ec.europa.eu › enrd-static › app_templates › enrd... · Click to edit Master title style •Click to edit Master text

Next Gen Leadership · Click to edit Master title Click to edit text Click to edit Master title Click to edit text Change vs. Transition Beginning Middle End Ending Neutral Zone Beginning

Click to edit Master title style • Click to edit Master text styles … · 2017. 5. 19. · Click to edit Master title style • Click to edit Master text styles • Second level

itNederland Click to edit Master title style Videodspace.ou.nl/bitstream/1820/757/1/BURGOSDaniel_eQualitiySeminar... · Click to edit Master title styleOTEC • Click to edit Master

Click to edit Master title style · Click to edit Master title style • Click to edit Master text styles –Second level • Third level – Fourth level » Fifth level • Click

Click to edit presentation title Inter-task project€¦ · Click to edit presentation title Click to edit event subtitle Click to add presenter name Inter-task project: Measuring,

Click to edit Master title style Click to edit Master subtitle style ©2008 Howard Hughes Medical Institute Click to edit Master title style Click to edit.

Traffic Incident Click to edit Master title style Management Click to edit Master … · 2020-03-30 · Click to edit Master title style •Click to edit Master text styles –Second