sign in sign up
<<
Home , Auriculotemporal nerve, Eagle syndrome, Ear pain, Eustachian tube, Lesser occipital nerve

Special Report

A in the : The of Otalgia

Jane L. Weissman, Departments of Radiology and Otolaryngology, University of Pittsburgh (Pa) Medical Center

Otalgia is . Ear disease causes pri- glands, and thyroid gland (2, 4, 5) (Fig 1C). mary otalgia. Secondary (referred) otalgia is Synalgia and telalgia are rarely used synonyms referred to the ear from disease in structures for (6). remote from the ear. Otalgia, especially referred otalgia, can be a diagnostic challenge. The radiologic approach to a patient with Pathways Mediating Primary Otalgia otalgia relies on the physical examination. If the The skin of the ear is an interface between otoscopic findings are abnormal, the computed branchial and postbranchial innervation. There- tomographic (CT) or magnetic resonance (MR) fore, sensory innervation of the external ear is study focuses on the temporal . (The ap- mediated by both cutaneous and cranial propriate radiologic study depends on the dis- (5). However, innervation is variable, and the ease.) The physical examination for ear pain map of the sensory innervation of the ear re- includes the ear ( and ) mains imprecise (5). and structures that are potential sources of re- Trigeminal .—The mandibular division ferred pain. Imaging studies can show clinically of the (V3) gives off the auri- occult temporal bone disease as well as sources culotemporal nerve (1, 2, 7), which runs with of referred pain in the nasopharynx, retrophar- the superficial temporal artery and vein (7). The ynx, and , tem- auriculotemporal nerve receives sensory input poromandibular joint (TMJ), , oro- from the anterior portions of the : the and oral cavity (including teeth), anterior auricle (pinna), the , the anterior hypopharynx and larynx, thyroid gland, esoph- and superior walls of the external auditory canal agus, and trachea. Tailoring a CT or MR study to (EAC), and the lateral (EAC) surface of the evaluate primary or referred otalgia requires an tympanic membrane (TM) (1, 2, 4, 5, 7). understanding of the (admittedly complex) .—The facial nerve is primarily a of ear pain. motor nerve. Its small sensory branches include the nervus intermedius of Wrisberg, the poste- rior auricular nerve, and the greater superficial Sensory Innervation petrosal nerve (GSPN). The nervus intermedius Briefly, sensation from the ear and adjacent carries sensation from a small part of the medial structures travels along four (V, EAC (8); its branches include the posterior au- VII, IX, and X), the upper , and ricular and greater superficial petrosal nerves. (possibly) cervical sympathetic fibers (1–5). The posterior auricular branch carries sensation These nerves mediate primary otalgia (Fig 1A from the posterior wall of the EAC, the posterior and B). TM, and the skin behind the pinna (1, 2, 5, 7). Referred pain is the subjective experience of The GSPN mediates referred otalgia, and is dis- pain in a structure remote from the disease. Pain cussed below. is referred along routes of shared innervation. In Glossopharyngeal Nerve.—The tympanic other words, referred pain (secondary otalgia) is branch of the glossopharyngeal nerve (Jacob- referred to the ear from distant structures that son’s nerve) carries sensation from the medial receive sensory innervation from the same four () surface of the TM (7), the middle cranial nerves as the ear itself: the upper and ear mucosa, and the upper (4). lower aerodigestive tracts, TMJs, teeth, salivary Jacobson’s nerve anastomoses in the tympanic

Address reprint requests to Jane L. Weissman, MD, Department of Radiology, Room D-132 PUH, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213. Index terms: Ear, diseases; Special reports AJNR 18:1641–1651, Oct 1997 0195-6108/97/1808–1641 © American Society of Neuroradiology 1641 1642 WEISSMAN AJNR: 18, October 1997

Fig 1. Sensory innervation of the ear and surrounding structures: primary and secondary otalgia. A, Primary otalgia: sensory innervation by location. B, Primary otalgia: sensory innervation by nerve. C, Secondary (referred) otalgia: the structures that refer pain to the ear, and the pathways of referred pain.

plexus of the middle ear. The tympanic plexus Cervical Nerves.—The cervical plexus re- also contains sympathetic and parasympathetic ceives cutaneous innervation from the neck (1). fibers (5, 9). C2 and C3 contribute to the greater auricular .—Sensory input from the poste- and lesser occipital nerves. The greater auricu- rior-inferior ear travels along the auricular lar nerve runs with the external jugular vein to branch of the vagus nerve (Arnold’s nerve). Ar- supply the skin over the parotid gland (4), the nold’s nerve arises from the superior (jugular) lower (1, 9) and superior-medial pinna (5), and ganglion of the vagus (5), and can receive fibers the mastoid (2, 5). The lesser occipital nerve from the facial and glossopharyngeal nerves as innervates the skin over the mastoid (7) and well as the vagus (1, 5). Arnold’s nerve receives behind the ear (1, 4). input from the auricle and from the inferior and Sympathetic Nerves.—The sympathetic posterior portions of the EAC and TM (5). plexus accompanies the internal carotid artery AJNR: 18, October 1997 PAIN IN THE EAR 1643

Fig 2. Malignant externa. A, Axial CT scan (soft-tissue algorithm) shows infiltration of the fat around the right internal carotid artery and internal jugular vein and in the stylomandibular tunnel (wavy arrows). Compare to the normal left side. The pinna is edematous (straight arrows). This image was obtained at a level below the EAC. B, Axial CT image (bone algorithm) shows erosion of the mastoid cortex (arrows) along the posterior wall of the EAC. The mastoid air cells are opacified (curved arrow). C, Axial T1-weighted MR image (625/20/1 [repetition time/echo time/ excitations]) below the EAC shows infiltration of the fat beneath the skull base (open arrows), around the mandibular condyle (black arrow), and partially surrounding the internal carotid artery (curved arrow). This could be edema or granulation tissue. There is also a sympathetic mastoid effusion (straight white arrow). D, Axial contrast-enhanced T1-weighted MR image (625/20/1) with fat suppression at a slightly higher level than C shows hyperin- tense signal from the soft tissue (arrows).

through the upper neck and skull base. Sympa- to the ear along the auriculotemporal branch of thetic fibers join Jacobson’s nerve in the tym- the trigeminal nerve. panic plexus of the middle ear (7). It is not clear Facial Nerve.—The GSPN arises from the whether and how these autonomic fibers trans- of the facial nerve. Sympa- mit pain (9). thetic fibers that accompany the internal carotid artery join the GSPN to form the vidian nerve (the nerve of the pterygoid canal). The vidian Pathways Mediating Referred Otalgia nerve enters the , where it Trigeminal Nerve.—Diseases of the mouth synapses in the sphenopalatine ganglion (5, 7). and face are the most frequent sources of re- The vidian nerve innervates the mucosa of the ferred otalgia, and the trigeminal nerve is the nasal cavity, the posterior ethmoidal sinus, and most frequent pathway for referred otalgia (2). the sphenoidal sinus (4), but the exact distribu- The central pathway involved is most likely the tion of sensory innervation by the GSPN is not spinal tract nucleus of the trigeminal nerve (3). known (5). The nervus intermedius, which con- The maxillary and mandibular divisions of the tributes fibers to the GSPN (1), is the presumed trigeminal nerve receive sensory innervation path along which pain from the nose and si- from the nasopharynx, paranasal sinuses, up- nuses can be referred to the ear. (The nervus per and lower teeth, and three pairs of major intermedius also carries sensation from the salivary glands, most notably (for referred otal- EAC and so is also a pathway of primary otal- gia) the parotid gland (5, 9). The mandibular gia.) division supplies both motor and sensory inner- Glossopharyngeal Nerve.—The glossopha- vation to the and the ryngeal nerve receives sensory input from the tensor tympani and tensor veli palatini muscles nasopharynx down to the hypopharynx (4, 7). (2). Pain from all of these structures is referred Pain from the anterior eustachian tube, the soft 1644 WEISSMAN AJNR: 18, October 1997

Fig 3. CT images (bone algorithms) of EAC masses. A, Coronal image of a young patient with keratosis obturans shows soft tissue (k) filling both EACs. There is no erosion of the canal walls, but the right EAC ap- pears to be expanded. B, Axial image of a squamous cell car- cinoma (arrows) that has eroded the pos- terior wall of the EAC (open arrow).

(4), the posterior third of the tongue or can cause excruciating ear pain, is unilateral or tongue base (1, 4, 7), the pharyngeal tonsils bilateral, and can be accompanied by a (“sym- (7), and the lateral wall of the pharynx (1, 4, 7) pathetic”) middle ear effusion (11). Bullous my- is referred to the ear along the tympanic branch ringitis is diagnosed and treated clinically. of the glossopharyngeal (Jacobson’s) nerve Malignant external otitis (MEO), or malignant (4). external otitis, is a virulent, necrotizing infec- Vagus Nerve.—The vagus nerve carries sen- tion, not (despite the name) a (14, sory innervation from the lower aerodigestive 15) (Fig 2). This potentially fatal pseudomonas tract (1, 7). Sensation from the mucosa of the of the skull base occurs in pa- valleculae, piriform sinuses, and larynx travels tients immunosuppressed by tumor, drugs along the internal branch of the superior laryn- (chemotherapy, steroids), and diabetes mellitus geal nerve (1, 10). The recurrent laryngeal (11). The clinical findings are severe ear pain nerve receives sensation from the cervical that wakes the patient from sleep, ear dis- esophagus and trachea, besides supplying mo- charge, and an elevated erythrocyte sedimen- tor fibers to the intrinsic muscles of the larynx tation rate (14). Both CT and MR studies delin- (1). The bronchial tree and lung refer pain along eate the extent of disease, including the bronchial branch of the vagus (3). Pain from in the mastoid and middle ear, structures innervated by the vagus is referred to around the eustachian tube, and beneath the the ear along the auricular branch of the vagus skull base (16) (Fig 2B–D). CT bone algorithms (Arnold’s nerve) (4). show EAC erosion (Fig 2B). These studies also document regression of inflammation after treatment (15, 16). Sources of Primary Otalgia In keratosis obturans, desquamated keratin accumulates in the EAC, causing severe ear Auricle, External Auditory Canal, and pain (14). The process is often bilateral and is Tympanic Membrane usually encountered in young people who might Diseases of the auricle (pinna), such as re- also have bronchiectasis and (14). CT lapsing chondritis, , and burn (2, 11, scans can show concentric enlargement of the 12), are apparent on clinical inspection and are EAC (Fig 3A). An EAC is usu- not usually referred for radiologic studies. Auri- ally unilateral, occurs in older patients, and cle edema can be identified on studies obtained causes dull pain unlike the severe pain of MEO for other reasons (Fig 2A). Acute (14). The localized EAC erosion of a cholestea- (“swimmer’s ear”) and an EAC carbuncle or toma (Fig 3B) can appear identical to the ero- furuncle () are among the most fre- sion of a squamous cell or another, quent causes of earache (13). Foreign bodies, even more rare, benign or malignant EAC neo- eczema, and fungal of the EAC also plasm (15). is necessary for diagnosis. cause pain (2, 12). None of these routinely re- CT studies define the extent of bone erosion; CT quires radiologic studies. Bullous myringitis is a and MR studies delineate the soft tissue compo- viral of the tympanic membrane that nent. AJNR: 18, October 1997 PAIN IN THE EAR 1645

Fig 4. Mastoid and middle ear effusions on axial images. A, CT image (bone algorithm) shows opacification of the middle ear (thin arrows), the mastoid antrum (thick arrows), and the peripheral mastoid air cells (open arrow). There is some residual aeration of one mastoid air cell. C indicates ; V, vestibule. B, T1-weighted contrast-enhanced MR image (525/27/2) shows stippled soft tissue throughout the left mastoid (large white arrows). This is fluid in the mastoid air cells. The petrous apex air cells also contain fluid (wavy arrow). Fluid in the middle ear silhouettes the signal void of the (small arrow). The meningeal enhancement in the posterior fossa and internal auditory canal (black arrows) reflects prior . The effusion fluid does not enhance. C, T2-weighted MR image (4000/108 effective/1) shows the hyperintense effusion fluid throughout mastoid air cells (large arrows) and petrous apex air cells (open arrow) and silhouetting the ossicles in the middle ear (small arrow).

Fig 5. Petrous apex mucocele on axial images. A, CT scan (bone algorithm) shows a solitary, opacified petrous apex air cell (open arrows) on the right side. The pneumatized left petrous apex contains many small, clear air cells (curved arrow). It is not possible to determine whether the findings on the right represent a single, expanded air cell or many smaller air cells that became confluent because the septations were destroyed. B, T2-weighted MR image (4000/80/2) shows the high signal of the obstructed air cell on the right (arrow). The signal void in the left petrous apex could be pneumatized air cells or cortical bone. C, T1-weighted contrast-enhanced MR image (625/25/1) shows that the mucosa lining the air cell enhances intensely (arrows) and the mucocele contents are slightly hyperintense to cerebrospinal fluid.

Middle Ear and Mastoid Disease in a petrous apex air cell is a rare Acute and acute are cause of pain. An obstructed, expanded air cell frequent causes of otalgia (12). These are rec- is a mucocele (Fig 5A–C); this can be hemor- ognized and treated clinically. Chronic otitis rhagic (cholesterol cyst) or can become in- media and chronic mastoid disease are usually fected. A cholesteatoma can also expand the not painful (12), and can be identified as inci- petrous apex. dental findings on studies done for other rea- Gradenigo syndrome, or painful ophthalmo- sons (Fig 4). Usually, pain in the setting of plegia (13, 17), is abducens dysfunction, pain chronic otitis media is a clue to a complication in the distribution of the trigeminal nerve, and such as petrous apicitis, dural venous sinus suppurative otitis media (17). The middle ear thrombosis, and temporal lobe or cerebellar ab- infection spreads through air cells or nonpneu- scess (2, 12). In children with “eustachian tube matized (diploic) bone to the petrous apex, and dysfunction,” chronic serous otitis media, which from there to the gasserian ganglion in Meckel’s is painful even in the absence of superimposed cave and the abducens nerve in Dorello’s canal acute infection, develops (13). (17). Imaging studies play an important role in 1646 WEISSMAN AJNR: 18, October 1997

Fig 6. Nasopharyngeal squamous cell carci- Fig 7. Retropharyngeal adenopathy on axial contrast-enhanced CT images. . Axial T1-weighted contrast-enhanced MR A, There is an enlarged, heterogeneous retropharyngeal lymph node (N). This image (500/25/1) with fat suppression shows a was metastatic squamous cell carcinoma. Retropharyngeal nodes (nodes of Rou- small tumor infiltrating around the left torus viere) are medial to the internal carotid artery (arrows). tubarius (open arrow) and extending into the B, This necrotic retropharyngeal mass (solid arrows) medial to the internal fossa of Rosenmuller (small arrows). There is carotid artery (open arrow) was a retropharyngeal abscess. normal enhancing mucosa in the right fossa (large arrow). diagnosis and subsequent treatment of these the geniculate ganglion (5). Both acute (viral patients. and bacterial) sinusitis and chronic sinusitis can Tumors of the middle ear are rare, and rarely cause pain (4). A deviated that cause otalgia. Fungal infection after mastoidec- touches or compresses a nasal turbinate is also tomy can cause pain and discharge from the believed to cause pain (8, 20) (Fig 8). Neo- mastoidectomy bowl (13). plasms are usually not painful unless they ob- struct a sinus or invade adjacent structures (13). Sources of Referred Otalgia Nasopharynx and Retropharynx Oropharynx and Oral Cavity The clinical manifestations of nasopharyn- The oropharynx is the most frequent site of geal carcinoma depend on the location and ex- primary carcinoma of the upper aerodigestive tent of the primary tumor (18) (Fig 6). Otalgia is tract (21). The oropharyngeal tumors that not a frequent presentation (13). More often, present with otalgia include squamous cell car- patients report because the tumor, cinoma of the base of the tongue (Fig 9) and especially one in the fossa of Rosenmuller, ob- of the palatine tonsil (22) (Fig 10A). Tumors structs eustachian tube drainage, causing a se- of the base of the tongue are more rare than rous otitis media and a tumors of the oral tongue and have a worse (14). prognosis, both because they are histologically Disease of the retropharyngeal lymph nodes high-grade tumors and because they tend to (nodes of Rouviere) presents with deep eye pain remain clinically silent until large and bulky and occipital pain, but can cause otalgia. Such (22). pain might be the first clue to metastatic tumor The palatine (faucial) tonsils are lymphoid in these nodes (Fig 7A). Suppurative adenitis of tissue covered by squamous epithelium. Each a retropharyngeal node (a retropharyngeal ab- tonsil fills the between the ante- scess) causes fever, dyspnea, and rior tonsillar pillar or arch (palatoglossus mus- (Fig 7B). Clinically, the abscess is a fluctuant cle) and the posterior tonsillar pillar or arch mass that creates a bulge under intact mucosa (palatopharyngeus muscle) (1). The two mus- of the posterior pharyngeal wall (19). cles and the interposed tonsil might not be iden- tifiable as distinct structures on imaging studies; Paranasal Sinuses and Nasal Cavity the term tonsillar pillar refers to the soft tissues flanking the airway at the level of the oral cavity Disease in the sinuses and nasal cavity and oropharynx (Fig 10). causes otalgia referred along the GSPN (4) to Nonneoplastic tonsil disease can present with AJNR: 18, October 1997 PAIN IN THE EAR 1647

Fig 8. Coronal CT image (bone algo- Fig 9. Squamous cell carcinoma of the base of tongue. rithm) shows a nasal septal spur (arrow) A, Axial enhanced CT image shows the carcinoma (arrows) infiltrating the normal fat that touches the mucosa of the left inferior planes of the left base of the tongue. turbinate. B, Axial contrast-enhanced T1-weighted MR image (650/25/1) with fat suppression shows the enhancing tumor infiltrating the left base of the tongue (arrows).

Fig 10. Disease in the pharyngeal tonsils on axial CT images. Fig 11. Periapical (dental) radiograph of the A, A heterogeneously enhancing squamous cell carcinoma (T) replaces the left mandibular premolar (p) and two molars (m). The tonsil and infiltrates into surrounding soft tissues. There is a small, necrotic retro- premolar has a normal lucent pulp chamber (ar- pharyngeal lymph node on the left (arrow). The normal right tonsillar pillar (high- rowheads), lucent periodontal ligament (small lighted arrows) is not very conspicuous in this older adult. solid arrow), and dense lamina dura (larger ar- B, A low-density mass with a thick, enhancing rim (black arrow) widens the row). There is periapical sclerosis (S) around the right tonsillar pillar in a young patient with a peritonsillar abscess. In this case, the roots of the molars and widening of the periodon- clinical information is especially important, because carcinoma and abscess can tal ligament (highlighted arrows). The root canal have a similar appearance. The individual components of the normal left tonsillar of the second molar is obliterated. The metallic pillar (highlighted arrow) (the palatoglossus and palatopharyngeus muscles and material in the pulp canals of the first molar is the tonsil) cannot be identified as distinct structures. from a root canal procedure (open arrow). These findings can also be seen on CT scans. a sore and ear pain (2, 19). Acute tonsil- (2, 20, 23). Pain from molars, especially man- litis is diagnosed by physical examination and dibular molars, radiates to the ear (3, 7). cultures, not imaging. A quinsy tonsil (periton- Blood vessels and nerves within the crown sillar abscess) is a complication of untreated or and root of a tooth are called the dental pulp. inadequately treated (Fig 10B). Se- The pulp cavity or chamber is visible on plain vere ear pain is one hallmark of a peritonsillar films and CT scans as a lucency within the tooth abscess. Pus usually collects between the tonsil (1) (Fig 11). Caries (cavities) can cause ab- and the anterior pillar (19). CT scans confirm scess and necrosis of the pulp. Patients can the presence of an abscess that is amenable to have difficulty locating the pain of ac- surgical drainage. curately (13). Dental infections are a frequent cause (some Periapical dental radiographs of an acute say the most frequent cause) of referred otalgia might be normal (3), or they can 1648 WEISSMAN AJNR: 18, October 1997

Fig 12. and related dis- ease. A, Coronal CT image shows malocclu- sion on the patient’s right side. On the nor- mal left side, the lingual (medial) cusp of the maxillary tooth is lateral to the cusp of the mandibular tooth (open arrows). In comparison, on the right, the lingual (me- dial) cusp of the maxillary tooth (small solid arrow) is medial to the lingual cusp of the mandibular tooth (large solid arrow). This is called a full . There is an incidental retention cyst in the left maxil- lary sinus. B, Coronal T1-weighted MR image (600/25/1) shows hypertrophy of the tem- poralis muscles (arrows), which can be seen in patients with (clenching of the teeth). show widening of the periodontal membrane at cause the disk and articular surfaces are not the root apex (24). Periapical lucency (loss of innervated (7). Exposure of bone or overgrowth bone around the apex of a root) is evidence that of synovium can cause TMJ pain (7), because bacteria have spread beyond the tooth into the synovium and subcortical bone are innervated. surrounding bone (3, 24). This lucency is visible Internal derangement is a malpositioned articu- on CT scans as well as dental radiographs (Fig lar disk (meniscus); most often the disk is an- 11). An acute periapical abscess can subside terior to the articular surface of the condyle (3) into chronic abscess (3, 24), which can be pain- (Fig 13B). Malocclusion and bruxism (clench- less (3), or a dental granuloma (24); either one ing) contribute to TMJ disease and pain, prob- can cause periapical lucency (Fig 11). Chronic ably through associated muscle spasm. periapical infection can also create sclerosis (“condensing osteitis”) (24) in the surrounding bone (Fig 11). Parotid Gland Malocclusion (Fig 12A), impacted teeth, and Before development of the vaccine, erupting teeth are other important sources of mumps virus was the most frequent cause of otalgia. These are best assessed clinically, but (25). Viral (mumps) and bacterial pa- can be identified on imaging studies. Molars rotitis both cause referred otalgia (7). A CT scan and premolars have cusps, or tubercles, that can help the clinician exclude an obstruction as help grind food (5). In normal occlusion, the the cause of inflammation and infection. Calculi lingual (medial) cusp of a maxillary tooth is are radiopaque on CT studies. Mucus plugs and lateral to the corresponding cusp of the man- strictures are not themselves visible on CT dibular tooth (Fig 12A). Abnormalities of the scans, but the dilated duct and inflamed gland teeth, jaws, and TMJ can contribute to maloc- are (Fig 14). A parotid neoplasm is another clusion. Malocclusion also contributes to TMJ potential cause of referred otalgia (7). dysfunction and pain. Bruxism, or teeth clench- ing, causes referred otalgia, possibly from spasm of the medial or lateral pterygoid mus- Hypopharynx and Larynx cles (3) (Fig 12B). Unlike many other sources of otalgia, the otalgia of bruxism is often bilat- Referred otalgia can be the presenting symp- eral (3). tom of carcinoma of the hypopharynx. Sore throat and dysphagia usually accompany the otalgia (6, 19). Piriform sinus tumors are an TMJ important source of referred otalgia (Fig. 15). The TMJ is a frequent, and frequently over- Both rheumatoid and ankylosing spon- looked, cause of ear pain (13) (Fig 13A). Joint dylitis can involve the cricoarytenoid joint and pain comes from the capsule, collateral liga- cause otalgia (13). Chondritis of laryngeal car- ments, and retrodiskal bilaminar fold (7), be- tilage can also present as ear pain (2) (Fig 16). AJNR: 18, October 1997 PAIN IN THE EAR 1649

Fig 13. TMJ disease. Fig 14. Acute viral parotitis. Axial A, Axial CT image (bone algorithm) shows sclerosis, irregularity, and subchondral lucencies contrast-enhanced CT image shows of the left mandibular condyle and narrowing of the left TMJ (solid arrow). The right condyle enlargement and intense enhance- and joint space are normal (open arrow). ment of the right parotid gland (p) B, Direct sagittal T2-weighted MR image (2100/92.2 effective/2) shows the hypointense and accessory lobe (arrows). No ob- disk (white arrow) anterior to the mandibular condyle (C). Normally, the disk covers the structing calculus is present, and articular surface of the condyle; this is an anterior displacement. There is also a small joint Stensen’s duct and the intraglandular effusion (black arrow). ducts are not dilated.

Fig 15. Squamous cell carcinoma of the Fig 16. Radiation chondritis. Axial en- Fig 17. . Ax- piriform sinus. Axial enhanced CT image shows hanced CT image of a patient who had received ial CT image (soft tissue algo- tumor (t) thickening the walls of the right piri- radiation for a squamous cell carci- rithm) shows an enlarged and form sinus. noma of the hypopharynx shows the posterior densely calcified right styloid pro- portion of the cricoid to be thicker and cess (large arrow). The left stylo- of lower density (large arrows) than the more hyoid ligament is normal (small normal anterior portion (small arrows). arrow). The patient’s symptoms resolved after surgical removal of the right styloid process.

Carotidynia and Eagle Syndrome or a scar in the fossa after (5). CT Carotidynia is a disputed entity (26) that scans (axial images and three-dimensional re- causes unilateral pain around the carotid bulb. constructions) and orthopantomograms show The cause of carotidynia is unknown, although the styloid process well (Fig 17). inflammation (vasculitis) might play a role (8). The pain radiates to the ipsilateral ear (4). An Thyroid Gland, Esophagus, and Trachea elongated styloid process or calcified stylohyoid ligament is one proposed cause of carotidynia Thyroid inflammation, including early and (12). subacute thyroiditis, can cause pain that is re- In Eagle syndrome, an elongated styloid pro- ferred to the angle of the and the ear cess or calcified stylohyoid ligament is impli- (2, 20, 23). The entire gland or one lobe can be cated as a cause of throat and ear pain (5, 11, involved. Gastroesophageal reflux is a rare cause 23). An elongated, deviated styloid can impinge of otalgia (2, 27, 28). Rarely, esophageal carci- on the external or internal carotid artery to noma presents with otalgia (12). A cause carotidynia, or irritate the tonsillar fossa is another esophageal source of otalgia (2). 1650 WEISSMAN AJNR: 18, October 1997

Tracheal chondritis, like laryngeal chondritis, can cause referred otalgia. Lung cancer (29, 30) and a thoracic aortic aneurysm (7) have also reportedly presented as otalgia, possibly referring pain to the ear from the bronchial branches of the vagus nerve.

Neuralgias Primary of the trigeminal, facial, glossopharyngeal, and vagus nerves can cause a variety of ear (8, 31). Some authors consider these primary otalgia; oth- ers have classified them as referred otalgia (2, 8, 31). CT and MR studies play an important role in the evaluation of patients with cranial nerve neuralgias. A tumor arising from or adja- cent to the nerve can be the cause of pain that is Fig 18. Ramsay Hunt syndrome (herpetic neuralgia). Axial contrast-enhanced T1-weighted MR image (625/25/2) shows in- clinically indistinguishable from idiopathic neu- tense enhancement of the labyrinthine (thick solid arrow) and ralgia (9). tympanic (open arrow) portions of the right facial nerve and of the (tic douloureux) most GSPN (long arrow). often causes agonizing, unilateral facial pain. Occasionally there is ear pain as well (2, 23). neuralgia is usually idiopathic, but it can be All of the sensory branches of the facial nerve caused by intracranial and extracranial neo- have been implicated in otalgia. Sluder (sphe- plasms and vascular malformations (33) that nopalatine) neuralgia is pain of the eyes and might first be detected on imaging studies. Va- nose, with radiation to the ear (7, 23). The gal (superior laryngeal) neuralgia is a rare GSPN is most likely the pathway along which cause of ear pain, more often causing pain in this pain radiates to the ear. It is crucial to ex- the larynx and hypopharynx (2). clude benign and malignant sinus disease be- fore making the diagnosis of (idiopathic) sphe- nopalatine neuralgia (7). Chorda tympani Myofascial Pain Syndromes and Pain of Spinal neuralgia has been described in patients with Nerve Origin otalgia; sectioning chorda tympani alleviated For patients with , their pain (9). There is one report of nervus pressure on a trigger point recreates their pain intermedius neuralgia (9). Geniculate neuralgia (7). Myofascial trigger points known to cause can be idiopathic or herpetic (7). Herpetic otalgia are found in the masseter, trapezius, ster- geniculate neuralgia (the Ramsay Hunt syn- nocleidomastoid, and medial and lateral ptery- drome) is herpes of the external auditory canal goid muscles (3, 7). Whiplash and other injuries and auricle, and facial nerve palsy. The facial to these muscles can also cause referred otalgia nerve enhances intensely (32) (Fig 18). The (3). Herpetic neuralgia of the cervical spinal roots patients may also have sensorineural hearing causes a nonlocalized ear pain that is difficult to loss, , , and ear pain. Herpetic diagnose before the herpetic vesicles appear (13). neuralgia can affect any cranial or spinal nerve Musculoskeletal diseases of the neck such as cer- (2), with pain lasting long after the vesicles heal vical facet arthropathy, intervertebral disk dis- (postherpetic neuralgia). Thus, otalgia can per- ease, and whiplash can also cause pain that radi- sist after the eruption and other findings of Ram- ates to the ear (13, 20, 34). say Hunt syndrome have resolved. Glossopharyngeal neuralgia causes paroxys- Conclusion mal pain in the ear, tonsil, tongue base, and pharynx, often elicited by (2, 9, 23, The patient with otalgia presents a diagnostic 33). Some authors consider isolated ear pain challenge to the clinician and the radiologist. alone as “partial” glossopharyngeal neuralgia, Normal otoscopic findings can conceal primary or Jacobson neuralgia (8). Glossopharyngeal temporal bone disease such as petrous apicitis AJNR: 18, October 1997 PAIN IN THE EAR 1651 that is readily apparent on a CT or MR study. 14. Weissman JL. State of the art: hearing loss. Radiology 1996;199: Normal findings can also be a clue to pain re- 593–611 15. Grandis JR, Curtin HD, Yu VL. Necrotizing (malignant) external ferred to the ear from remote disease. The radi- otitis: prospective comparison of CT and MR imaging in diagnosis ologist may be the first to identify the remote and followup. Radiology 1995;196:499–504 source of ear pain. In the radiographic evalua- 16. Rubin J, Curtin HD, Yu VL, Kamerer DB. Malignant external otitis: tion of patients with otalgia, it is important to utility of CT in diagnosis and followup. Radiology 1990;174:391– cast the imaging net wide, to include sources of 394 17. Chole RA, Donald PJ. Petrous apicitis: clinical considerations. referred pain. Ann Otol Rhinol Laryngol 1983;92:544–551 18. Neel HB. Benign and malignant of the nasopharynx. Acknowledgments In: Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Schul- ler DE, eds. Otolaryngology–Head and Neck Surgery. 2nd ed. St I am grateful to Eric Jablonowski for his patience and Louis, Mo: Mosby-Year Book; 1993:1355–1371 talent in developing the illustrations; to Sabrina L. Jen- 19. Zalzal GH, Cotton RT. and adenotonsillar disease. In: nings for her superb secretarial support and her constant Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Schuller good nature in the face of alterations and revisions; and to DE, eds. Otolaryngology–Head and Neck Surgery. 2nd ed. St Barry Hirsch, MD, for suggestions, references, ideas, and Louis, Mo: Mosby-Year Book; 1993:1180–1198 20. Harvey H. Diagnosing referred otalgia: the ten Ts. J Craniomandib feedback during the preparation of this article. Prac 1992;10:333–334 21. Sinard RJ, Netterville JL, Garrett CG, Ossoff RH. Cancer of the References larynx. In: Myers EN, Suen JY, eds. Cancer of the Head and Neck. 3rd ed. Philadelphia, Pa: WB Saunders Co, 1996:381–422 1. Hollinshead WH. Textbook of Anatomy. Hagerstown, Md: Harper & 22. Civantos FJ, Goodwin WJ. Cancer of the oropharynx. In: Myers Row; 1974 EN, Suen JY, eds. Cancer of the Head and Neck. 3rd ed. Phila- 2. McDonald JS. Otalgia. In: Jackler RK, ed. Textbook of Neurotol- delphia, Pa: WB Saunders Co; 1996:361–380 ogy. St Louis, Mo: Mosby-Year Book Inc; 1994:167–177 23. Yanagisawa K, Kveton JF. Referred otalgia. Am J Otolaryngol 3. Kreisberg MK, Turner J. Dental causes of referred otalgia. Ear 1992;13:323–327 Nose Throat J 1987;66:30–48 24. Stafne EC, Gibilisco JA. Oral Roentgenographic Diagnosis. 4th 4. Levine HL. Otorhinolaryngologic causes of headache. Med Clin N ed. Philadelphia, Pa: WB Saunders Co; 1975 Am 1991;75:677–692 25. Rabinov K, Weber AL. Radiology of the Salivary Glands. Boston, 5. Hollinshead WH. Anatomy for Surgeons, Vol 1: The Head and Mass: GK Hall Medical Publishers; 1985 Neck. New York, NY: Harper & Row; 1968 26. Biousse V, Bousser M-G. The myth of carotidynia. 6. Stedman’s Medical Dictionary. 26th ed. Baltimore, Md: Williams & 1994;44:993–995 Wilkins; 1995 27. Gibson WS, Cochran W. Otalgia in infants and children: a mani- 7. Wazen JJ. Referred otalgia. Otolaryngol Clin North Am 1989;22: festation of gastroesophageal reflux. Int J Ped Otorhinolaryngol 1205–1215 1994;28:213–218 8. Rareshide EH, Amedee RG. Referred otalgia. J La State Med Soc 28. Blau JN. Ear pain referred by the vagus. Br Med J 1989;299: 1990;142:7–10 1569–1570 9. Cook JA, Irving RM. Role of tympanic neurectomy in otalgia. J 29. Bongers KM, Willigers HMM, Koehler PH. Referred facial pain from Laryngol Otol 1990;194:114–117 lung carcinoma. Neurology 1992;42:1841–1842 10. Thawley SE, O’Leary M. Malignant neoplasms of the oropharynx. 30. Bindoff LA, Heseltine D. Unilateral facial pain in patients with lung In: Cummings CW, Fredrickson JM, Krause CH, Harker LA, cancer: a referred pain via the vagus? Lancet 1988;9:812–815 Schuller DE, eds. Otolaryngology–Head and Neck Surgery. 2nd 31. Rupa V, Saunders RL, Weider DJ. Geniculate neuralgia: the sur- ed. St Louis, Mo: Mosby-Year Book Inc; 1993:1306–1354 gical management of primary otalgia. J Neurosurg 1991;75:505– 11. Jahn AF, Hawke M. Infections of the external ear. In: Cummings 511 CW, Fredrickson JM, Krause CJ, Harker LA, Schuller DE, eds. 32. Anderson RE, Laskoff JM. Ramsay Hunt syndrome mimicking Otolaryngology–Head and Neck Surgery. 2nd ed. St Louis, Mo: intracanalicular acoustic neuroma on contrast-enhanced MR. Mosby-Year Book Inc; 1993:2787–2794 AJNR Am J Neuroradiol 1990;11:409 12. Paparella MM. Otalgia. In: Paparella MM, Shumrick DA, eds. Oto- 33. Chalmers AC, Olson JL. Glossopharyngeal neuralgia with syn- laryngology. 2nd ed. Philadelphia, Pa: WB Saunders; 1980:1354– cope and cervical mass. Otolaryngol Head Neck Surg 1989;100: 1357 252–255 13. Birt D. Headaches and head pains associated with diseases of the 34. Edmeads J. Headaches and head pains associated with diseases ear, nose, and throat. Med Clin North Am 1978;62:523–531 of the cervical spine. Med Clin North Am 1978;62:533–544