Foramen Tympanicum (Foramen of Huschke) as a Cause of Unexplained Spontaneous Otorrhea: A Case Report.

The foramen of Huschke or foramen tympanicum is a developmental defect in the bony part of the external auditory meatus. It occurs due to incomplete obliteration of the tympanic canal and the persistence of openings along the canal. This leads to the presence of a salivary fistula and the most common symptoms of the condition are otalgia, otorrhea, and hearing loss. We report a case of a 69-year-old female patient who presented to the ENT with symptoms of watery discharge from the left ear for 12 years. In the last two weeks, pain and itching appeared. Otoscopy showed the presence of a clear fluid in the external auditory meatus with a normal tympanic membrane. Biochemical analysis of the fluid proved the presence of amylase. Computed tomography showed a fistula between the parotid gland and the external ear canal. The diagnosis of the persistent foramen of Huschke remains difficult due to the fact that it could mimic many other conditions. The otalgia and otorrhea are symptoms that suggest a very wide differential diagnosis. Misdiagnosis and inappropriate treatment are common.

External auditory canal involvement by nasopharyngeal carcinoma via eustachian tube spread: A case report.

We present the imaging findings of a 44-year-old female patient who was diagnosed with nasopharyngeal carcinoma (NPC) extending from the nasopharynx to the external auditory canal (EAC) through the Eustachian tube (ET). The patient presented with a left neck submandibular lump on initial presentation that showed NPC upon fine needle aspiration, leading to chemoradiotherapy. Despite treatment, the patient experienced multiple relapses and later presented with aural symptoms, including left ear pain, foul-smelling drainage, and trismus on recurrence, and was subsequently diagnosed through biopsy. CT, MRI, and PET-CT scans revealed an extensive infiltrative nasopharyngeal mass extending into the left ET, involving the EAC. This rare case highlights the importance of considering the extension of NPC into the EAC as a potential etiology in patients who present with aural symptoms.

Referred otalgia in patients with thyroid cancer: Case series from Saudi Arabia.

INTRODUCTION AND IMPORTANCE: Referred Otalgia is very unlikely to be the first presentation of thyroid carcinoma, however, it is important to examine thyroid in cases of otalgia lacking any evidence of primary origin. CASE PRESENTATION: We report five cases of thyroid carcinoma, variant types, presented by secondary otalgia in Al-Baha region, KSA followed by proper surgery and patient relief during the last eight years. Patients' ages ranged from 25 to 65 years old. CLINICAL DISCUSSION: Thyroid inflammation, including acute and subacute thyroiditis, was reported as a possible cause of the pain referred to the ear and the angle of the mandible, however otalgia caused by thyroid cancer is an extremely rare presentation. CONCLUSION: Otolaryngologists should be aware that thyroid cancer may be associated with otalgia in any age group, however extremely rare. With very limited sources for this clinical entity, we recommend further studies on the different varieties of thyroid cancer presentations and the possibilities of the unexplained otalgia.

Role of the Surgical Approach in the Treatment of Eagle Syndrome.

Introduction Eagle syndrome is a rare and an often misdiagnosed entity in otorhinolaryngology. Objective To determine the efficacy of the surgical treatment for Eagle syndrome. Methods The present prospective study included 25 patients who presented with complaints of pain in the throat, ear, and neck, as well as difficulty and/or pain while swallowing; they were assessed for Eagle syndrome. As per patient profile, we performed a clinical assessments along with orthopantomograms (OPGs), three-dimensional computed tomography (3D CT) scans, and cone beam computed tomography (CBCT). Pain was assessed pre- and postoperatively through the Numerical Rating Scale-11 (NRS-11), whose score ranges from 0 to 10. Microscopic tonsillo-styloidectomy was performed in cases in which the conservative treatment failed to relieve pain. Results The mean age of the entire study population was of 36.08 ± 7.19 years, and the male-to-female ratio was of 1.08:1. Referred otalgia was the commonest (44%) complaint. Radiologically, out of 25 patients, 20 patients presented elongated styloid processes. The longest symptomatic styloid process measured radiographically was of 64.7 mm while the shortest was of 28.2 mm. Out of 20 patients, 12 underwent surgery. The postoperative pain assessment through the NRS-11 was performed on day 0 (3.83 ± 0.83), day 7 (1.5 ± 0.52), week 4 (0.5 ± 0.52), and week 12 (0.41 ± 0.51). By 12 weeks, 7 patients were symptom-free, while 5 patients still reported mild pain. Conclusion Eagle syndrome associated with an elongated styloid process is not a rarity, but it often goes undiagnosed. Microscopic tonsillo-styloidectomy shows excellent results in the management of patients with Eagle syndrome.

Symptoms and Factors Associated With Eustachian Tube Dysfunction Among the Population of Qassim, Saudi Arabia.

Introduction The Eustachian tube regulates middle ear functions such as ventilation and pressure normalization. Eustachian tube dysfunction (ETD) is defined as the failure of the Eustachian tube to maintain one or more of its functions. It is a common condition that is associated with other middle ear disorders such as cholesteatoma, tympanic membrane atelectasis, and otitis media with effusion (OME). This study aims to assess ETD prevalence and risk factors in the Qassim region. Methodology This cross-sectional study was conducted in the Qassim region of Saudi Arabia during the period from September 20 to October 10, 2023. Data were gathered via a validated, self-administered electronic questionnaire that encompasses socio-demographic information, the prevalence of ETD, and the prevalence of its various symptoms, as assessed by the Eustachian Tube Dysfunction Questionnaire (ETDQ-7). Results Our study in Qassim, Saudi Arabia, with 467 participants reveals a high prevalence of ETD at 12.2%. The 18-25 age group dominates (50.1%), with a majority of females (66.2%). Symptom analysis using the ETDQ-7 questionnaire shows varied prevalence, with severe pain (7%) and muffled hearing (29.8%) notable. Logistic regression identifies significant predictors, including hearing loss history (odds ratio = 28.2) and smoking (odds ratio = 3.70). Specific symptoms, such as feeling blocked or underwater, significantly correlate with more severe ETD symptoms (odds ratio = 1.73). Conclusion Our study highlights a notable prevalence of ETD. Significant predictors, including hearing loss history and smoking, were identified. Specific symptoms, such as feeling blocked or underwater, were associated with more severe ETD symptoms.

External Auditory Canal Squamous Papilloma Presenting with Otitis Externa and Severe Bony Erosion.

We present a case of a 68-year-old lady with an insidious progressive history of otorrhea, otalgia, and reduced hearing for 3 months. She was treated for malignant otitis externa and was treated with systemic antibiotic but showed subtherapeutic response to treatment. She underwent examination under anaesthesia and biopsy with tumour debulking of the right ear via posterior auricular approach and histopathological examination revealed squamous papilloma of the external auditory canal. She recovered well after surgery and was asymptomatic during follow-up.

Microvascular decompression for intermediate nerve neuralgia: a case report and literature review.

Intermediate nerve neuralgia (INN) is a rare craniofacial pain syndrome. The diagnosis of INN is challenging because of the complex ear sensory innervation that results in a clinical overlap with both trigeminal neuralgia (TN) and glossopharyngeal neuralgia (GPN). A 76-year-old woman with a remarkable medical history presented with right otalgia and mandibular pain for 7 years. Neurological examination revealed a diminished sensation in the distribution of the intermediate nerve (IN). Magnetic resonance imaging demonstrated an impression of the anterior inferior cerebellar artery (AICA) on the facial-vestibulocochlear nerve complex (VII/VIII complex). The patient underwent microvascular decompression (MVD) after long-term oral medication. We confirmed that the responsible vessel was close to the VII/VIII complex and isolated the vessel under the microscope via a right-sided suboccipital retrosigmoid approach. The patient's otalgia and mandibular pain disappeared after the operation. There were no additional neurological deficits. In conclusion, MVD is a safe and feasible option for patients with INN who fail to respond to adequate pharmacotherapy.

Beyond Vertigo: Vestibular, Aural, and Perceptual Symptoms in Vestibular Migraine.

PURPOSE: To review the vestibular, aural, and perceptual symptoms of vestibular migraine (VM) that may present alongside vertigo. RECENT FINDINGS: Increased research attention to the wide spectrum of symptoms presenting in VM patients has improved understanding of this disorder, with recent identification of five different VM phenotypes. Research into the clinical overlap between VM and other chronic vestibular syndromes such as persistent postural-perceptual dizziness and mal-de-debarquement syndrome reveals a range of vestibular symptoms and hints at pathophysiological connections between migraine and vestibular dysfunction. Studies of migraine treatment for hearing loss suggest patients presenting with aural symptoms may have an underlying diagnosis of migraine and deserve a trial of migraine preventives. Research into the neurologic basis of the perceptual disorder Alice in Wonderland syndrome has revealed brain areas that are likely involved and may help explain its prevalence in VM patients. VM is a sensory processing disorder that presents with more than just vertigo. Understanding the range of potential symptoms improves diagnosis and treatment for migraine patients whose diagnosis may be missed when only the symptoms identified in the diagnostic criteria are considered.

Squamous Cell Carcinoma of the Middle Ear-A Common Tumor at an Uncommon Site.

Squamous cell carcinoma of the middle ear is a very rare tumor. Early detection is uncommon as the tumor usually manifests as persistent ear discharge and otalgia, often misdiagnosed as chronic suppurative otitis media. We present a rare case of squamous cell carcinoma of the middle ear which clinically presented as chronic suppurative otitis media. Therefore, clinicians should have a high index of suspicion for clinically refractive cases of otorrhea, otalgia, excess bleeding, and non-responsiveness to treatment. All polyps and granulation tissue in EAC and middle ear should be submitted for histopathological examination especially in cases refractory to treatment.

Efficacy of rehabilitative therapies on otologic symptoms in patients with temporomandibular disorders: A systematic review of randomised controlled trials.

BACKGROUND: The term temporomandibular disorder (TMD) indicates a set of musculoskeletal conditions involving temporomandibular joint (TMJ), masticatory musculature, and related anatomical structures. Pain is the most common clinical manifestation of TMD, and the auditory system might be involved and affected, through tinnitus, dizziness, otalgia and ear fullness sensation. OBJECTIVES: The aim of this systematic review of randomised controlled trails (RCTs) was to evaluate the efficacy of rehabilitative approaches on otologic symptoms in patients with TMD. METHODS: PubMed, Scopus and Web of Science were systematically searched from the inception until 8th October 2023 to identify RCTs presenting participants with a diagnosis of TMD associated with otologic signs and symptoms, rehabilitative approaches as interventions, and modification of the otological symptoms as outcome. RESULTS: Out of 931 papers suitable for title/abstract screening, 627 articles were assessed for eligibility. Five studies were included reporting the efficacy of occlusal splint therapy, low-level laser therapies, and physical therapy in patients diagnosed whit secondary otalgia or tinnitus associated with TMD. No RCTs evaluating other otologic symptoms, ear fullness, dizziness or vertigo were found. CONCLUSIONS: Results of this systematic review suggested that rehabilitative approaches might be effective in improving secondary otalgia and tinnitus in TMD patients. Thus, further RCTs with a higher level of evidence and more representative samples should be conducted to better understand the effects of TMD therapy on otologic complains.

Epidemiology and risk factors for extension of necrotizing otitis externa.

PURPOSE: Necrotizing otitis externa (OEN) is an aggressive and morbid infection of the external acoustic meatus. What are the risk factors for OEN extension? METHODS: French monocentric retrospective study (2004-2021), including patients with OEN defined by the association of an inflamed EAM, a positive nuclear imaging, the presence of a bacteriological sample and the failure of a well-followed local and/or general antibiotic treatment. OEN was extensive if it was associated with vascular or neurological deficits, if nuclear imaging fixation and/or bone lysis extended beyond the tympanic bone. RESULTS: Our population (n = 39) was male (74%), type 2 diabetic (72%), aged 75.2 years and pseudomonas aeruginosa was found in 88% of cases. Complications for 43% of patients were extensive fixation on nuclear imaging, for 21% of them the presence of extensive bone lysis, for 13% the appearance of facial palsy, for 5.3% the presence hypoglossal nerve palsy and for 2.5% the presence of thrombophlebitis or other nerves palsies. 59% of our population had extensive OEN. The diagnosis of the extensive OEN was made 22 days later (p = 0.04). The clinical presentation was falsely reassuring due to easier identification of the tympanic membrane (70% vs 46%, p = 0.17) but associated with periauricular oedema (42% vs 0%), bone exposure (16% vs 0%) and a temporomandibular joint pain (41% vs 12%). CONCLUSION: Delayed treatment of OEN, identification of clinical bone lysis, especially when the tympanic membrane is easily visualized, and the presence of unbalanced diabetes are potential risk factors for extension of OEN.

Case Report: Inflamed Jacobson nerve: an uncommon cause of persisting otalgia after an acute otitis media.

Introduction: Otalgia can have multiple causes. Mostly otalgia is caused by a tubal dysfunction or an acute middle ear infection. This case describes a patient with an inflammation of the Jacobson's nerve causing severe persistent otalgia after an acute otitis media. The patients complaints completely disappeared after neurolysis of the Jacobson's nerve. Case presentation: We describe a case of a 21-year-old female caucasian patient with acute otitis media and persistent intractable otalgia. Infection was first successfully controlled by antibiotics. But the patient reported a persistent otalgia not responding to analgetics. We performed a CT scan, which exhibited a regular aerated middle ear finding, and a diagnostic tympanoscopy to examine the middle ear structures particularly the tympanic Jacobson's nerve as a possible cause for persistent pain. The following neurolysis of Jacobson's nerve under general anaesthesia led to a resolution of otalgia. Conclusion: An inflamed tympanic Jacobson's nerve is a rare observation and a persisting otalgia after an acute otitis media not responding to conservative treatment can be treated by a neurolysis.

Review article: Otalgia as presenting symptom of myocardial infarction.

OBJECTIVE: There are many etiologies for otalgia, most of which are benign conditions. However, it can also be the initial symptom for life threatening emergencies such as a myocardial infarction (MI). This case report and review of literature describes diagnosis of MI with the initial primary complaint of unilateral otalgia. PATIENT: A 77-year-old female with intermittent left-sided otalgia with exertion for many years that recently worsened. In the clinic, she had a normal otologic exam and denied any other associated symptoms. The following day, her symptoms progressed to otalgia radiating down her arm and dyspnea on exertion. After progression of symptoms, a nuclear stress test was performed revealing a large and severe apical infarct. INTERVENTIONS: Diagnosis of referred otalgia from a cardiac source. She had subsequent medical management of cardiac risk factors and treatment of angina. RESULTS: Resolution of otalgia with medical management for coronary artery disease (CAD) after treatment of unstable angina. CONCLUSIONS: Otologists should be aware of the atypical presentations of angina because a missed diagnosis is potentially fatal. Otalgia, either unilateral or bilateral, may be the only presenting symptom of underlying cardiac ischemia and a high index of suspicion is needed for early diagnosis. Patients with otalgia related to exertion, no abnormal findings on otoscopic examinations, and significant risk factors for cardiac disease should undergo systematic evaluation including a cardiac rule out.

Association of anatomical features of the petrotympanic fissure and presence of foramen of Huschke with otalgia and tinnitus.

The petrotympanic fissure (PTF) and foramen of Huschke (FH) are anatomical structures in the temporal bone that can connect the temporomandibular joint (TMJ) and the ear. The purpose of this retrospective study was to investigate the association between PTF morphology and otalgia and tinnitus, as well as the prevalence of the FH and otological symptoms, using cone beam computed tomography (CBCT). CBCT images from 114 patients presenting with symptoms of a temporomandibular disorder were examined retrospectively. The PTF was classified into three subtypes (open, semi-open, closed) and the presence of the FH was identified. Symptoms of otalgia and tinnitus were obtained from the patient files. The FH was observed in 12.3% of patients examined, and in 12.0% of those with otalgia and 18.9% of those with tinnitus. There was no significant association between the PTF subtypes or the presence of the FH and otalgia or tinnitus (all P > 0.05). The PTF subtype and presence of the FH alone do not appear to contribute to otalgia or tinnitus in patients with temporomandibular disorders.

Subtypes of temporomandibular disorders in patients diagnosed with otalgia: observational study / Subtipos de desordem temporomandibular em pacientes diagnosticados com otalgia: estudo observacional

ABSTRACT BACKGROUND AND OBJECTIVES: Temporomandibular disorder (TMD) has complex symptoms that involve the orofacial region, such as otalgia. Considering the difficult differential diagnoses for associating otological symptoms with TMD. The aim of this study was to verify the diagnosis of TMD in patients with otalgia. METHODS: This is a cross-sectional and descriptive study, where 75 patients diagnosed with otalgia were evaluated. The European Academy of Craniomandibular Disorders's (EACD) screening questionnaire was initially applied, and those who answered affirmatively to at least one question were evaluated by the Research Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), with a final sample of 50 patients. Data were tabulated and ANOVA verified whether there was a statistical difference between TMD subtypes classified by DC/TMD, considering confidence intervals with 95% significance. RESULTS: The mean age of the participants was 39.9±14.1 years, with a predominance of females (76%) (p<0.0001). Among those diagnosed with TMD, females also predominated, with a higher percentage in all evaluated subtypes, with emphasis on arthralgia (82%) and myofascial pain with limited opening (81.8%), followed by myofascial pain (74%) and disc displacement with reduction (72.7%). When observing the distribution of TMD subtypes between genders, there was a predominance of myofascial pain in males (75%) and females (68%), but no statistical significance was observed in this variable and in the others studied. CONCLUSION: Patients with otalgia had one or more TMD subtypes, and the myofascial subtype TMD was the most prevalent among study participants.

RESUMO JUSTIFICATIVA E OBJETIVOS: A disfunção temporomandibular (DTM) possui sintomas complexos que envolvem a região orofacial, como a otalgia. Considerando os difíceis diagnósticos diferenciais para associar sintomas otológicos com DTM. O objetivo deste estudo foi verificar o diagnóstico de DTM em pacientes com otalgia. MÉTODOS: Este é um estudo transversal e descritivo, com uma avaliação de 75 pacientes diagnosticados com otalgia. O questionário de triagem da Academia Europeia de Disfunções Craniomandibulares (EACD) foi aplicado inicialmente, e aqueles que responderam afirmativamente a pelo menos uma questão foram avaliados pelo Critério Diagnóstico de Pesquisa para Disfunções Temporomandibulares (DC/TMD), com amostra final de 50 pacientes. Os dados foram tabulados e por meio da ANOVA foi verificado se havia diferença estatística entre os subtipos de DTM classificados pelo DC/TMD, considerando intervalos de confiança com 95% de significância. RESULTADOS: A idade média dos participantes foi de 39,9±14,1 anos. Além disso, predominou-se o sexo feminino (76%) (p<0,0001), com maior percentual em todos os subtipos avaliados, destacando-se a artralgia (82%) e a dor miofascial com limitação de abertura (81,8%), seguida da dor miofascial (74%) e deslocamento de disco com redução (72,7%). Quando observada a distribuição dos subtipos de DTM entre os sexos, notou-se predominância de dor miofascial no sexo masculino (75%) e feminino (68%), mas não foi observada significância estatística nessa variável e nas demais estudadas. CONCLUSÃO: Os pacientes com otalgia manifestaram mais de um dos subtipos de DTM, sendo o subtipo de dor miofascial o mais prevalente entre os participantes do estudo.

Temporomandibular treatments are significantly efficient in improving otologic symptoms.

Symptoms of temporomandibular disorders (TMD) could be present as otologic symptoms like earache and dizziness in some patients. In most cases, these symptoms are not recognized because otolaryngologists fail to diagnose TMD as a source of the problem. This investigation was conducted to evaluate the effect of TMD treatments on the otologic symptoms which after taking history and clinical examinations seemed to be related to TMD. In the present study, the patients who were complaining of otalgia, ear fullness, tinnitus, hearing loss, and dizziness were evaluated by an ear fellow. Forty patients who had no known otologic or other primary causes to explain their symptoms, were referred to the orofacial pain clinic with the possible diagnosis of TMD. If the diagnosis was confirmed by an orofacial pain specialist, a combination of TMD treatments was administered to each case and the patients were followed up. The results showed that following implementation of treatment protocols for TMD, more than 50% of the patients reported complete or partial recovery in the second follow-up (p < 0.05). The most common otologic symptom of the referred cases was earache, and the most common associated complaint was neck pain. All the patients had one or more parafunctional habits. This study showed that TMD treatments were significantly efficient in improving otologic symptoms partially or completely and the authors concluded that for the patients with otolaryngologic unexplained symptoms, an overhaul examination is needed to assess TMD as a possible cause of the patient complaint. It is recommended that in cases with unexplained otologic symptoms, otolaryngologists care more about the neck trigger points (TP) and ask about the patient's parafunctional habits. Otolaryngologists and dentists need to be aware of the risk of developing otologic symptoms caused by these habits or cervical TPs.

Imatinib associated temporal bone osteonecrosis.

Tyrosine kinase inhibitors have substantially improved survival in patients with gastrointestinal stromal tumors (GIST) and chronic myeloid leukemia (CML). We report the first association between long-term imatinib use and temporal bone osteonecrosis, highlighting the importance of prompt ENT evaluation of such patients with new otological symptoms.

A Case Report of Refractory Postherpetic Neuralgia After Ramsay Hunt Syndrome Treated With Tympanic Nerve Neurectomy.

Ramsay Hunt syndrome is a facial nerve palsy that arises from herpes zoster infection. In rare cases, postherpetic neuralgia is a complication following Ramsay Hunt syndrome. Pain management to address postherpetic neuralgia includes facial nerve blocks, medications such as gabapentin, carbamazepine and botulinum toxin injections, and pulsed radiofrequency. Despite the reported benefits for patients with glossopharyngeal nerve pain, neurectomy as a treatment has rarely been described. A 45-year-old patient visited our ENT clinic for chronic right-sided facial, ear, and jaw pain that persisted for 9 years following the development of Ramsay Hunt syndrome. She trialed multiple medications including gabapentin, carbamazepine, and botulinum toxin injections with minimal relief to her symptoms. The patient underwent a diagnostic myringotomy with topical application of lidocaine to the tympanic nerve. This resulted in temporary relief of her pain until the effects of the lidocaine subsided. The patient was subsequently offered lysis of the right tympanic nerve for more definitive management. The patient experienced significant pain reduction after the right tympanic neurectomy procedure. Chronic postherpetic neuralgia following Ramsay Hunt syndrome can cause significant impairment in a patient's quality of life. For patients with ear pain refractory to conservative management, a tympanic neurectomy can be considered.

An Overview of Acute Otitis Externa.

Acute otitis externa, cellulitis of the external auditory canal, is most frequently due to bacteria. Patients may present with otalgia, aural fullness, hearing loss, and otorrhea. Its diagnosis is a clinical one. Treatment is focused on analgesia, treating the underlying infection and preventing recurrence.

A Case of Unilateral Otologic Symptoms as Initial Manifestations of Granulomatosis With Polyangiitis.

Granulomatosis with polyangiitis (GPA) is a chronic and systematic autoimmune condition characterized by granuloma formation and necrotizing vasculitis of small to medium-sized vessels. GPA initially presents itself as respiratory and renal symptoms. Although temporal bone involvement is not uncommon, an otologic disorder is rarely the initial symptom. We present a case of a 36-year-old man who presented with unilateral ear pain, hearing loss, and facial palsy. After a series of diagnostics and temporal bone and chest imaging, he was diagnosed with GPA with multiorgan involvement. Cyclophosphamide and methylprednisolone relieved the patient's ear pain and partially improved his hearing, facial palsy, and overall clinical condition. Although uncommon, systemic GPA may cause initial otologic symptoms and should not be dismissed as a possible cause of an otologic disease resistant to standard therapy.