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

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Karen Tong, M.D.

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

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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




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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




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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




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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




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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




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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




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Karen Tong, M.D.

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



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Karen Tong, M.D.

Sensory innervation of outer ear

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

(V3)

(C2)

(C2,C3)

(X)

Dr. Mahmoud, ENT, Ain Shans University




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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)




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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




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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




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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




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Karen Tong, M.D.

Referred otalgia from CN V





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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




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Karen Tong, M.D.

Referred otalgia from CN VII





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Karen Tong, M.D.

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

• Septal spurs irritating nasal mucosa




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Karen Tong, M.D.

Referred otalgia from CN IX





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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)




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Karen Tong, M.D.

Referred otalgia from CN X





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Karen Tong, M.D.

Referred otalgia from CN X

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




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Karen Tong, M.D.

CASE PRESENTATIONS




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Karen Tong, M.D.

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




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Karen Tong, M.D.

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



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Karen Tong, M.D.

Dx: temporal lobe abscess due to otomastoiditis




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Karen Tong, M.D.

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



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Karen Tong, M.D.

Dx: cerebellar abscess due to otomastoiditis




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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




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Karen Tong, M.D.

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




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Karen Tong, M.D.

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



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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




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Karen Tong, M.D.

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



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Karen Tong, M.D.

Dx: T-bone Langerhan Cell Histiocytosis




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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




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Karen Tong, M.D.

Case: 62 yo male w otalgia, plugged ear




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Karen Tong, M.D.

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



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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




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Karen Tong, M.D.

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



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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




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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




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Karen Tong, M.D.

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



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Karen Tong, M.D.

Case: 3 yo w periauricular swelling and ear pain




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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...

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