Case scenario

A 40 year old male patient presents to you with persistent otalgia. Lately he has been suffering from odynophagia (painful swallowing). He is a lifelong smoker and drinks heavily.

What issues to cover?

Otalgia is a common presentation in general practice. It has many origins and distinguishing
otological from referred pain causes can be done based on an accurate history and examination. Otalgia may also sometimes be the only symptom of underlying malignancy and therefore should not be taken lightly.

• Onset and duration of otalgia
  
• Associated otological symptoms e.g. hearing loss, tinnitus and vertigo. Unilateral, conductive type of hearing loss (from glue ear) in an adult may the sign of nasopharyngeal carcinoma.
  
• History of progressive dysphagia, odynophagia, food sticking in the throat and/or hoarseness and weight loss suggests laryngopharyngeal lesion e.g. tumours
  
• Fevers or rigors, rapid onset and progression may be a sign of an infective process e.g. tonsillitis, peritonsillar abscess or supraglottitis.
  
• Smoking and alcohol history has a strong associated with head and neck cancers
  
• Referred pain can originate from dental disease (Vth cranial nerve), temporomandibular joint dysfunction and cervical spondylosis (C2,C3 nerve)

What should you do?

Examination

Examine the ear

• Pinna- look for perichondritis, vesicles (Herpes zoster)
  
• External auditory canal- wax, debris/pus canal (otitis externa, otitis media),
  
• Tympanic membrane-red bulging drum (acute otitis media), perforation (underlying cholesteatoma, chronic otitis media), unilateral glue ear (nasopharyngeal carcinoma)
  
• Postauricular swelling/tenderness (Mastoiditis)

Head and neck examination

• Oral cavity, tonsils, tongue and nose should all be examined for infection or suspicious malignant lesion
  
• Any neck swelling should raise the suspicion of malignancy. Of the head and neck neoplasms that present as an isolated neck mass, 40% are due to metastatic squamous carcinoma and 40% are lymphomas.
  
• One should also examine the dental status, temporomandibular joint (TMJ) tenderness/clicking and cervical tenderness and range of movement (spondylosis)

Treatment (see table)

• Any suspicion of malignancy (history of smoking and alcohol in a middle-aged person, persistent hoarseness-duration>3 weeks, dysphagia) should be referred to an ENT surgeon for fibreoptic endoscopic examination.
  
• Features suggestive airway compromise or inadequate oral intake may suggest supraglottitis or tumour, also need immediate referral.
  
• Sudden hearing loss, facial paralysis, features or mastoidits or suspicion of malignant otits externa should be referred to ENT immediately.
  
• Acyclovir should be started early in Ramsay Hunt syndrome to prevent progression
  
• Dental or TMJ dysfunction should be referred to the dentist and maxillofacial surgeons respectively.