ear, nose, and throat disorders
Earache
Evaluation of Earache
History of present illnessshould assess the location, duration, and severity of ear pain and whether it is constant or intermittent. If intermittent, it is important to determine whether it is random or occurs mainly with swallowing or jaw movement. Important associated symptoms include ear drainage, hearing loss, and sore throat. The patient should be asked about any attempts at cleaning the ear canal (eg, with cotton swab) or other recent instrumentation, foreign bodies, recent air travel or scuba diving, and swimming or other recurrent water exposure to ears. Review of systemsshould ask about symptoms of chronic illness, such as weight loss and fevers. Past medical historyshould ask about known diabetes or other immunocompromised state, previous ear disorders (particularly infections), and amount and duration of tobacco and alcohol use. Patients should be checked for fever. Examination focuses on the ears, nose, and throat. The pinna and area over the mastoid process should be inspected for redness and swelling. The pinna is gently tugged; significant pain exacerbation with tugging suggests otitis externa. The ear canal should be examined for redness, discharge, swelling, cerumen or foreign body, and any other lesions. The tympanic membrane should be examined for redness, perforation, and signs of middle ear fluid collection (eg, bulging, distortion). A brief bedside Testing should be conducted, including the The throat should be examined for erythema, tonsillar exudate, peritonsillar swelling, and any mucosal lesions suggesting cancer. TMJ function should be assessed by palpation of the joints on opening and closing of the mouth, and notation should be made of trismus or evidence of bruxism such as wearing down of teeth. The neck should be palpated for lymphadenopathy. In-office fiberoptic examination of the pharynx and larynx should be considered, particularly if no cause for the pain is identified on routine examination and if nonotologic symptoms such as hoarseness, difficulty swallowing, or nasal obstruction are reported. The following findings are of particular concern: Diabetes or immunocompromised state or chronic kidney disease Redness and fluctuance over mastoid and protrusion of auricle Severe swelling at external auditory canal meatus Chronic pain, especially if associated with other head/neck symptoms An important differentiator is whether the ear examination is normal; middle and external ear disorders cause abnormal physical findings, which, when combined with history, usually suggest an etiology (see table). For example, patients with chronic eustachian tube dysfunction have abnormalities of the tympanic membrane, typically a retraction pocket. Patients with a normal ear examination may have a visible oropharyngeal cause, such as tonsillitis or peritonsillar abscess. Ear pain due to neuralgia has a classic manifestation as brief (usually seconds, always<2 minutes) episodes of extremely severe, sharp pain. Chronic ear pain without abnormality on ear examination might be due to a TMJ disorder, but patients should have a thorough head and neck examination (including fiberoptic examination) to rule out cancer. Most cases are clear after history and physical examination. Depending on clinical findings, nonotologic causes may require testing (see table). Patients with a normal ear examination, particularly with chronic or recurrent pain, may warrant evaluation with an MRI of the base of skull to rule out cancer. 