Referred Otalgia in Head and Neck Cancer

Abstract

Pain referred to the ear is a commonly encountered clinical event, and the differential diagnoses that must be considered for pain in a normal ear are numerous. For physicians involved in the treatment of patients with referred ear pain, especially those involved in the care of patients with head and neck malignancies, a basic understanding of the mechanisms involved to produce this phenomenon is required. Several sources offer figures outlining the neuroanatomic basis of nonotogenic ear pain. On occasion, there has been omission of various components in this referred otalgia pathway, however. The authors propose a unified schema and outline potential areas of "nervous system error" giving rise to pain in a clinically normal ear.

The Radiology of Referred Otalgia

“…There are 4 cranial nerves and 2 upper cervical nerves that contribute to sensory innervation of the ear: cranial nerves V, VII, IX, and X and upper cervical nerves C2 and C3. 8,9 Although the sensory innervation to the ear may appear fairly well defined, there is considerable overlap and ambiguity in the sensory distribution of these nerves.…”

“…9 The glossopharyngeal nerve (IX) supplies the inner ear and inner tympanic membrane, whereas the vagus nerve (X) supplies a similar distribution to IX but also innervates the concha. 8,9 The upper cervical nerves (C2 and C3) innervate the skin in front of and behind the ear and also of the medial and lateral aspect of the auricle and lobule. 8,9,11,12 Sources of Referred Otalgia, Grouped According to Cranial and Cervical Nerves…”

“…26 Otalgia is an infrequent symptom of nasopharyngeal cancer, but some sources describe its presence in as many as 14% of patients. 8 The usual presentation is a neck mass from metastatic adenopathy, conductive hearing loss, and bloody nasal discharge. 25 Cross-sectional imaging will reveal a mass in the lateral pharyngeal recess, often accompanied by metastatic cervical lymphadenopathy (Fig 9).…”

Referral to Dentist in Clinical ENT Practice

“…The neuroanatomic basis of referred otalgias originating from dental and related pathologies rests within one of three general neural pathways [5]. Hence, pathology in dental and associated structure of the body innervated by these neural pathways may refer pain to the ear.…”

Referred otalgia: a structured approach to diagnosis and treatment

“…The vagus nerve, on the contrary, innervates the supraglottis, and direct neural involvement in these cases manifests as a less severe, superficial pain from the concha and ear canal. The lower parts of the nasopharynx, posterolateral oropharynx and hypopharynx produce pain in a less predictable distribution, owing to the overlapping innervation of the glossopharyngeal and vagus nerves (23).…”