PRIMARY OTALGIA The mandibular division of the trigeminal nerve mediates sensory innervation from the anterior outer ear: the auricle, tragus, EAC, and external surface of the TM. The facial nerve carries sensory innervation from the EAC and the skin behind the auricle. The glossopharyngeal nerve and the auricular branch of the vagus nerve (the Arnold nerve) carry sensory input from the medial ear structures. Branches of the second and third cervical nerves form the greater auricular and lesser occipital nerves, which receive input from the skin over the parotid gland and behind the ear, respectively.
Disease from any portion of the ear or its surrounding skin and structures may result in primary otalgia. A history and physical examination of the external ear, EAC, and TM will usually identify the cause of primary otalgia, with specific therapy as appropriate.
REFERRED OTALGIA The maxillary and mandibular divisions of the trigeminal nerve receive sensory input from the nasopharynx, paranasal sinuses, teeth, parotid gland, and muscles of mastication. The facial nerve carries sensory innervation from the nasal mucosa and the ethmoid and sphenoid sinuses. The glossopharyngeal nerve carries sensory innervation from the nasopharynx, eustachian tube, soft palate, posterior pharynx, and tonsils. The vagus nerve mediates sensation from the valleculae and piriform sinuses, from the larynx via the superior laryngeal nerve, and from the cervical esophagus and trachea via the recurrent laryngeal nerve.
Abscessed and impacted teeth, usually mandibular molars, frequently cause ear pain. Malocclusion, bruxism, mandibular trauma, temporomandibular joint (TMJ) disorders, and ill-fitting dentures are frequent causes of otalgia. 1 Trigeminal neuralgia, or tic douloureux, causes severe unilateral facial pain. Herpetic geniculate neuralgia, or Ramsay Hunt syndrome, is herpes simplex of the EAC and auricle with facial palsy which may persist long after the disappearance of the vesicles (postherpetic neuralgia).
The diagnosis of the source of referred otalgia requires a history and physical examination that encompasses the nasal and oral cavities, nasopharynx, oropharynx, throat, and neck. Again, further evaluation and treatment depend upon diagnosis.
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