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A 21-year-old woman comes to your office with a 2-day history of right ear pain. She reports that the ear pain began shortly after taking scuba diving lessons. She describes the pain as “a pressure” and also notes “crackling” in the right ear and periodically feeling dizzy.

Ear pain (Otalgia) is a common problem faced by primary care clinicians. It can occur to patients across the age spectrum but is most associated with children. Otalgia that originates from the ear is known as primary otalgia, whereas pain that originates outside the ear is secondary otalgia (Earwood, Rogers, &Rathjen, 2018).

The time frame of the pain is an indicator of the potential differential diagnoses. For example, acute onset (pain less than 48 hours) may be due to injury, bacterial or viral infection, bulging of the tympanic membrane, frostbite, or burns (Rhoads & Jensen, 2014). A slow or gradual onset of pain may be due allergies, neuropathic conditions, activation of viral infection like herpes simplex or herpes zoster. (Rhoads & Jensen, 2014). Progressively worsening pain is most likely associated with infection and primary otalgia and intermittent pain is associated with secondary otalgia (Earwood, Rogers, &Rathjen, 2018, p. 20-21).

The age of the patient can help the clinician to narrow the diagnosis. “Primary otalgia is more common in children and secondary otalgia is more common in adults” (Earwood, Rogers, & Rathjen, 2018, p. 20). In adults, the absence of hearing loss with otalgia is a sign of non-otologic disease like pharyngitis, cavities, rhinitis, temporomandibular joint disease, cancer or cardiac emergency. Adults 50 or older with risk factors of coronary artery disease are more at risk for serious diagnosis; drinking 3.5 or more alcoholic drinks per day increases the risk of head, neck and esophageal cancers concerns by two to three times (Earwood, Rogers, & Rathjen, 2018).

To determine the cause and list differential diagnosis a SOAP format may be used.

Subjective: 28-year-old female, complains of an earache started 2 days ago after taking scuba diving lessons. Pain is “a pressure”, associated symptoms: “crackling” in the right ear and periodically feeling dizzy.

According to Jarvis (2016), the following additional question are: Do you have problems with your sinuses, teeth or jaw? (looking for radiating causes: cavities, rhinitis, temporomandibular joint disease)

Have you ever been hit on the ear or side of the head? (looking for trauma e.g. rupture of tympanic membrane)

What have you tried to relieve pain? (looking for a medication e.g. aspirin, naproxen, furosemide, antibiotics, cultural related practice)

Any ear infection in the past? (looking for sequelae)

Are you having any discharge from your ears? (looking for infection or perforated eardrum)

Describe the ear drainage. (external otitis has purulent, sanguineous, or water discharge; acute OM with perforation has purulent discharge; cholesteatoma has dirty, foul order, yellow/gray discharge)

Do you have trouble hearing? Onset-did the loss come on slowly or all at once? (looking for sudden lose by trauma or gradual with infection)

Does the “crackling” seem louder at night? (tinnitus seems louder in quite room)

The dizziness, does it feel like you are spinning around, or the room seems to be spinning? (looking for dysfunction of the labyrinth)

Medical HX: What other medical conditions do you have? Looking for medical conditions, surgeries, allergies (seasonal, food or drug, other), current medication

Objective Data: outer and internal inspection of an ear (external otitis media or internal, tympanic rupture, redness, edema, exudate)

Eyes: inspection for drainage (looking for s/s of infection)

Nose: inspection for drainage (looking for s/s of rhinitis, infection)

Mouth: inspection of lesions, post nasal (infection)

Neck: inspection/palpation for swelling, masses, active ROM and thyroid (looking for infection, tumor)

Neurologic: Facial nerve assessment (cranial nerve damage due to disease) Hearing test

Plan

A diagnostic examination that needs to be ordered depending on the differential diagnosis you are trying to rule in or out.

According to Rhoads & Jensen (2014) the following diagnostic exams for ear pain are:

Otoscopy is primary exam done by a clinician to visualize the ear structures to assess for trauma, erythema, effusion, rupture or presence of a foreign body

Tympanometry measures the pressure behind the tympanic membrane. The normal level is 150 and +25 daPa.

Herpes simplex immunoglobulin G (IgG) test for the presence of herpes simplex virus consistent with neuropathic pain.

Rinne tuning-fork test can reveal bone conduction greater than air conduction (abnormal) (Jarvis, 2016).

Differential diagnosis:

Barotrauma is associated with scuba diving, on physical examination, you may be able to see tympanic membrane hemorrhage (Earwood et al., 2018).

Allergic conditions, such as seasonal and environmental can cause inflammation in the eustachian tubes. This can result in fluid accumulation in the middle ear resulting in pain. On assessment, you may see nasal congestion, nasal discharge and post nasal drip. You may see redness and drainage in the ear if there is an infection (Rhoads & Jensen, 2014).

Herpes simplex virus is a common STD and can go unnoticed or this may be the first physical presentation of the disease. According to Lyons & Ousley (2015), most of the herpes infections are transmitted by persons who shed the virus but are asymptomatic. You would see clear open blisters in the ear canal (Lyons & Ousley, 2015)

Otitis externa is associated with a history of recent swimming. Pain when pulling on the external ear is a primary sign. Drainage may be present but in all cases (Earwood, Rogers & Rathjen, 2018).

Temporomandibular joint syndrome (TMJ) is the leading cause of secondary otalgia in adults, risk factor includes biting lips/mouth and chewing gum all activities common to young adults (Earwood et al., 2018).

Reference

Earwood, J.S., Rogers, T.S., Rathjen, N. A. (2018). Ear Pain: Diagnosing Common and Uncommon Causes. American Family Physician, 97(1), 20-27. Retrieved from https://eds-b-ebscohost-com.libauth.purdueglobal.edu/eds/pdfviewer/pdfviewer?vid=2&sid=5c3babc8-c812-478e-8177-0f065c7f8f32%40pdc-v-sessmgr

Jarvis, C. (2016). Physical Examination & Health Assessment 7th edition. St. Louis, Missouri: Elsevier

Lyons, F., & Ousley, L. E. (2015). Dermatology for the Advanced Practice Nurse. New York, NY: Springer Publishing Company. Retrieved from https://eds-a-ebscohost-com.libauth.purdueglobal.edu/eds/ebookviewer/ebook/bmxlYmtfXzgxMDk2MV9fQU41?sid=f43f3877-58c7-4b88-b8f1-3a99f702ff

Mclntire, S., Boujie, L (2016). Inner Ear Barotrauma After underwater pool competency training without the use of compressed air. Journal of Special Operations Medicine: A Peer Reviewed Journal for SOF Medical Professionals, 16(2), 52-56. Retrieved from https://eds-b-ebscohost-com.libauth.purdueglobal.edu/eds/pdfviewer/pdfviewer?vid=1&sid=ff610a28-2afa-412d-85e8-a7ec7abe2608%40sessionmgr104

Rhoads, J., Jensen, M. (2014). Differential Diagnosis for the Advanced Practice Nurse. Retrieved fromhttps://eds-b-ebscohost-com.libauth.purdueglobal.edu/eds/ebookviewer/ebook/bmxlYmtfXzgxMzgzM19fQU41?sid=f5dce036-6279-4e68-80a6-9b6b6d

 

 

2.nobel posted Jul 18, 2018 1:53 PM

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