This article is protected by isprotected This article copyright. All rightsreserved. 10.1111/coa.13069doi: t lead copyediting, paginationbeen throughthe proofreadingtypesetting, and process,may which This article accepted forpublicationhas been andundergone review fullpeer buthas not 5 demonstrated that the majority aredue tomusculoskeletal sources referredof otalgia has a dental origin whereas twostudies have de been proposed previously aide memoire when addressing apatient with secondary otalgia has to theirrespective protocols theof complaint but none have applied the actua addressing astructured evidenced well extensive andwell encounter ineveryday practice while theaetiologies relate seriousness theof underlying cause intensity and characteristics while severity isnot proportional tothe common ne from ofnon Referred orsecondary Dear Sir, Dept. ORL Fenton JE, Uzomefuna V, O’Rourke C,Kaare M. Title: Applying the Ts of referred otalgiato acohortof 226 patients. Experience :Our type Article : 0000 ID (Orcid EFENTON JOHN PROFESSOR The frequency of causes in referrals toageneral secondary ENT [email protected] - 8

Accepted. Article partment remains contentious

o differences betweenversion the of citethisarticle this and as Version Record.Please - recognised

- ural HNS, University ofLimerick , Ireland.

2 pathways. The pain canpresent invarious degrees of .

As aresult several attempts have been madeat - documented aural nervesupply are numerous and

- otalgia otologic locations with which the ear shares

4 .

1,3 .

is the complaint ofear pain arising

- The Ten Tsof referred 0001

where several authors report that 50% - based approach tothe management - 1,2 8601 .

It is arelatively common - 2288)

l frequency ofcauses

otalgia d tothe

as an 1

- 2,

This article is protected by isprotected This article copyright. All rightsreserved. attributed tothe tympanic membrane butwas omitted it as did not fit revealed byour study. 9 ofwhich were part theof original ten letterthe T. these were collated intoloose anatomical categories beginning with A review oftheliterature produced an extensivel Results diagnosis wasallocated totherelevant category of T group. diagnosis wasmade were include were subsequently followed up until a definitive or presumptive 2012. the senior author (JEF) during a10 primary symptom that presented tothe r prospectively onall adultpatients 18 years ormore withotalgia asa A retrospective assessment ofaconsecutive series ofdata collected groupings eachcommencing with the letter T. were assessed and subsequently refined to scholar, referred using online search engines Medline andGoogle using aliterature review of the search terms earpain, otalgiaand A documenting of known causes ofreferred otal committee at theUniversity Hospital Limerick wasobtained. Discretionary ethical approval from theChairman ofthe local Ethics Materials and methods but under our findings toan evaluation ofthe usefulness ofthis longstanding but guided approach inthe management ofthis condition andto apply cohort of adult patients, to shapethe results in orderto provide aloose frequency ofdiagnosis ofthe primary sources review recognised causes of non referred otalgia as described byapplying each category tothe Our objective wastoreview the accuracy oft Accepted Article

4 Patients without an activediseaseprocess inthe earand who

.

The identified causesof referred Our subsequent aims were to present our experience inthe - utilise

Thirteen convenient groupings(Table 1)were produced, d aide memoire.

One ofthe

- otogenic ear painusing aliterature

d in thestudy.

subsets described by Harvey was - year period from 2003 to

Ts and 4 morecategories outine out

otalgia fit loosely intoconvenient

he 10Ts axiom of

of referred otalgiain a

gia was performed The ultimate

ist of causesand fromliterature the - patients service of

This article is protected by isprotected This article copyright. All rightsreserved. the earfrom structures asdistant asthe thorax associated . was found to bethe cause of cases oftonsil/ base malignancy and anoesophageal carcinoma : these inclu cases while dental causes wereidentified in 5.75%. 33 (14.6%) patients. Throat pathology accounted for 17% of causes Mo undiagnosed. although 10 cases (4.4%)in the throat andthyroid groups remained . Specific diagnoses are presented in Table 3 attributable tocervical muscles orspine and 15%from the musculoskeletal fr The majority ofreferred months with amean duration of10.3 months. available in age severe joint severe in severity and had more severe symptoms. presented earlierthan males and females presenting with to 94with amean age of47.6 years. Thepopulation ratio of males to with amean ageof 38.4years, while theage range forfem included inthestudy. A total of 226patients, comprising 64 males and 162 females were grouping. decided toappl cervical cohort including muscular orcervical spine causes and itwas the defined diagnosis AcceptedThe wide Discussion Article

39.7 years versus 47.1 years).

disorders.

(5.75%) were found tobedue tounderlying sinister

otalgia 8 - 9/10 tended tobefrom temporomandibular

-

spread shared innervation can p related more

125 casesrevealing aninterstice ranging from1 to 72

(n=35), the males were younger than females(mean

y theterm Torticollis or 'Tender Neck' tothis

Among patients presenting with om jawand neck (66%), outofwhich 51% were re thanone aetiological condition wasreported in 4

.

The age range(in years)for males was 26to 84

ded 8cases oflaryngopharyngeal SCC, 4

A degree of latitude was required forthe

to otalgia otalgia

otalgia

otalgia

to ourservice was

in adults (Table 2) was

younger patients presented earlier Mild tomod

of cervicogenic

Record of duration of

in onepatient presenting with otentially transmit pain to

erate 3

. Itisone of the few Thirteen

origin 2:5. Females

pain score at4

while otalgia ales was 18

was - 6 This article is protected by isprotected This article copyright. All rightsreserved. secondary otolaryngology centres are musculoskeletal and notof most cases of non In accordance with Jaberet alandAl Comparisons with other studies; All patients attended to andfollowed upby senior author (JEF) Strengths ofthe study; appears to bean opinion either quote other reviews, cite are themost common aetiology of secondary painon reviews that number of authors that have basedtheir assertions that dental causes pathologies. teeth consisting only 5.7% andimportantly 5%will will be caused by mechanical disorders of neck andjaw (66%), the indicates that the majority of adult referred memoire, resulting intheevolution of 13Ts. beginning with ‘T’ toretain a similar scaffold to therelevant referredof otalgia, eachof which we have assigned nomenclatures tympanic membrane inthis study, we have described 4 more sources abno normal otoscopy but itquite obviously canoccur inpatients with authors have defined referred otalgia asthepresence ofear pain with be classified asprimary rather than referred one category, but referred otalgia, however thetympanic membrane was included as conditions. categorisation should allow forthe inclusion of new or omitted comprehensive b Our study produced a list of causes presented in Table 1 which is Synopsis ofkey/new findings; remember and perform. canvas demanding astructured application that isrelatively easy to assessment ofpatient specialty and involves many allieddisciplines. diagnoses inourarea that encompassesthe entire spectrum of our Accepted Article rmal butquiescent changes

Harvey introduced the conceptinvolving the10Ts of

A further misconception identified byoursurvey isthe ut not exhaustive and therelatively flexible

- otalgia otogenic s with this conditiontherefore is quite a broad

1

-

from 2,5

- otalgia 7 .

tympanic membrane pathology should

an abstract orreport what ultimately

1,6

- 7

. that are referred to routine

- In addition toexcluding Sheikhli, this

otalgia 4

.

Our experience Furthermore some

The approach tothe

in such asetting study reveals that arise from sinister aide

This article is protected by isprotected This article copyright. All rightsreserved. provide guidance forfurther research into this common complaint. Admittedly this isarelatively small uncontrolled study butit does also including those withidiopathic orun targeted atany of the 13Ts dependent on thesuspected diagnosis but is associated with any throat symptoms potential HPV risk patients mindful ofthe younger non temporalor bone malignancy but canbethe only complaint inthe lessfrequent cases ofskull base isolated pre all of our patients had associated symptoms signs.or of mitotic disease inacohort of patients with secondary otalgia and patients with upper aero presented with referred base tumours diagnosed atatertiary referral neuro any clinician's mind. throatof symptoms and ina smoker should be foremost in features onhistory and tongue base palpation cannot be over nasopharyngoscopy in addition tothe advocated use ofdigital tonsil and complete clinical examination including cranial nerves and clinically inalmost 70% of cases. should be assessed after otoscopy reaching a probable diagnosis upper insertion of sternocleidomastoid intothe mastoid process The neck andjaw includingfrequently a subtle tender point atthe Clinical applicability thestudy; of degenerative disease ofthe cervical spine thatof particular cohort in our study wasmuscular rather than musculoskeletal group was lower thanJaber et albutthe breakdown improvements in dentalservices aetiology which may reflect changes in referral patterns and mirror our results except that pharyngeal causes have replaced dental cases are due tothree conditions including neck, jawjoint andteeth reports primary dentalorigin unlike themajority of published Accepted Article 1 - 2,5 - 8 .

senting symptom is unusual in pharyngo

Al - related tumours, particularly where persistent ear pain - Sheikhli's findings in his1980 s - taking areparamount and ther

It has been shown that 5% of malignant skull

otalgia - digestive malignancy reflects this incidence 9 - 10

9 . . 8

.

Special attention iscrucial in high Our rate ofapproximately 5% of

The importance of history The

10 age profile of our - . smoking patient w

-

-

7 emphasised. responding persistent pain. .

Investigations should be tudy that80% of ed flag combination - otologic centre -

laryngeal cancer

Ear pain

Associated ith

taking

as an

This article is protected by isprotected This article copyright. All rightsreserved. 10. malignant infratemporal tumors. 9. referred pain. JLaryngol Otol 1980; 94:1433 8. 138(4); 479 causes for referred otalgia. 7. Laryngol Otol. 2007:121(12); 1129 6. Otolaryngol Head NeckS Suonpää JT. Secondary otalgiain an adultpopulation. 5. 10(4):333 4. 61(6):1015 approach to 3. 1992; 13(6):323 2. 2010; 35(5):409 evidence References than 6% of cases. Dental causes excluding temporomandibular abnormalities are less The definition should notinclude normal otoscopy. 85% ofconditions will If Pharyngeal causes(Throat Tonsil Tube) areincluded more than secondary centre is of musculo Two aide “Thirteen Ts” isa useful, memorable andstraightforward Keypoints 1.

Accepted Article

Leonetti JP,Li J, Smith PG. Jaber JJ,Leonetti JP,Lawrason AE,Feustel PJ. Kim DS,Cheang P, Dover S, Drake Kuttila SJ, Kuttila MH, Niemi PM, LeBell YB, Alanen PJ, Harvey H.Diagnosing referredotalgia: the tenTs. Cranio. Charlett SD,Coatesworth AP. Referred otalgia: astructured Yanagisawa K,Kveton JF.Referred otalgia. Am JOtolaryngol

Visvanathan V, KellyG. Al - Tikka T,Pracy P,Paleri V. - memoire in the thirds of secondary otalgiain adults presenting to aregional or - Sheikhli ARJ. - based management ofre -

334.

- - 1021 diagnosis andtreatment. Int J Clin Pr 485.

- -

327. 414.

approach toreferred otalgia.

Pain in theear

be identified. urg. 2001 Apr;127(4):401

Otolaryngol Head NeckSur

12 minute consultation: an -

skeletal origin, either neck orTMJ.

Otalgia. Refining the head and neck cancer

Am JOtol. 1998 ferred otalgia. -

1134. - with special reference to - Lee AB.

An isolated symptom of

- 40

Clin Otolaryngol. act. 2007; Dental otalgia. J

Jul; 19(4):496

- Cervical spine 5.

Arch g (2008)

1992; - 8.

This article is protected by isprotected This article copyright. All rightsreserved. Trigerminal Midneuralgia, Trigeminal 8. dysphonia orparapharyngeal Neoplasms,Retropharyngeal absces (hypopharynx/larynx) Throat 7. neuralgiaGlossopharyngeal tonsiloliths, malignancy,Tonsillitis, peritonsillar abscess, Eagle's Syndrome, (oropharynx) Tonsil 6 carcinomas,, trauma Tongue 5. abscesses,caries,Dental impacted , tooth Teeth 4. tumours Thyroiditis (&Salivary) Thyroid 3 Syndrome,TMJ dysfunction, , dentures, Arthritis, Joint(TMJ) Temporomandibular 2. carotidynia muscleArthritis, spasms, radiculopathy, trauma, lymphadenitis, cervical neck abscesses, neck Torticollis/Tender spine) (musclesCervical & 1. 1 Table Otolaryngol. 2016; 41(1):66 referral guidelines: atwo Accepted Article

-

Hashimoto, De Quirvan’s, thyroid cyst haemorrhage, , salivary sialadenitis, Hashimoto,De Quirvan’s,thyroid cyst haemorrhage,

Aetiology of referred otalgia ofreferred presentedAetiology as13Ts.

-

facial Segment Pain

- centre analysis of4715 referrals.

- 75

s, vocallaryngitis, cordtension

Clin This article is protected by isprotected This article copyright. All rightsreserved. ofaorta andinnominatedisease reflux,Oesophagitis/Gastroesophageal carcinomas,infarct, aneurysmal angina/myocardial Thorax 13. Tracheitis, Trachea 12. CPA/ tumours (primary &metastatic) TemporalMyositis, petrous arteritis, Tympanic apicitis, Intermediate or nerve neuralgia, bone Temporal 11. Tube(nasopharynx) 10. contact pointrhinogenic otalgia conditions: Sinusitis,Nasal rhinosinusitis,neoplasms, (Sluder's) Neuralgia, Sphenopalatine Turbinates 9. Accepted Article Nasopharyngitis. Nasopharyngeal malignancy, tracheobronchitis, chondritis,tracheobronchitis, neoplasms,

This article is protected by isprotected This article copyright. All rightsreserved. Trachea Thorax NeuralgiaTrigeminal Temporal Tube Tongue Turbinate Thyroid Tonsil Teeth TMJ dysfunction Throat TorticollisTender/ neck T 13 Ts Table 2 Accepted Article

Frequency Diagnosis of in226patientswithreferred otalgia to applied

(>( condition 1 counted(> each for category seeTable3)

rig

0 1 1 2 4 6 7 7 13 34 38 116 No.

1

2.6% 3% 3% 5.75% 15 % 17% 51% % 0% 0.4% 0.4% 1.3% 1.76%

0.4%

T

This article is protected by isprotected This article copyright. All rightsreserved. Thyroid unspecified tenderness Left ThyroidNodule Autoimmune Thyroid (&Salivary) TMJ +LPR TMJ Arthritis+Dental TMJ Arthritis+NeckSpasm TMJ Arthritis/Dysfunction Temporomandibular Joint(TMJ) Other unspecifiedthroatpain Vocal CordTensionDysphonia Pyriform SinusSCC Tonsillitis +Neckm LPR +TMJDysfunction Supraglottic SCC LPR +NeckMuscleSpasm Laryngopharyngeal SCC LPR Pharyngitis nonspecific Throat Neck muscleandtonsillitis Laryngopharyngeal reflux(LPR)+neckspasm Tender Neck+Toothache Muscle Spasm+C C Combined MuscleSpasm+TMJArthritis SCM/Muscle NeckSpasm Torticollis/Tender Neck Specific Diagnosesrelatedto13ts - Accepted Article Spine Arthritis

- spine andTMJArthritis

uscle

6 1 1

5 10 1 12 86 3 1 2 19 1 1 1 2 4

1 1 2 13 13 7 1

This article is protected by isprotected This article copyright. All rightsreserved. Trachea Trigeminal Neuralgia Thorax Temporalis Fibromyalgia/myos Temporal Nasopharyngitis Tube Tongue/Tongue base Chronic Rhinosinusitis/nasalpolyps Septal Spurscontactpoint Turbinates Tonsillitis +neckspasm To Tonsil Teeth +NeckPain Teeth +TMJDysfunction Dental Caries/Toothache Teeth Parotid Tumours Submandibular Sialadenitis Tongue baseSCC AcceptedOesophageal SCC Article nsillitis/

itis

2 0 1 2

1 7 1 2 10 1 4

2 4 2 2