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++

Probability diagnosis

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Otitis media (viral or bacterial)

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Otitis externa

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Boils and furuncles of canal

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TMJ arthralgia

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Eustachian tube dysfunction

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Serious disorders not to be missed

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Neoplasia of external ear

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Cancer of other sites (e.g. tongue, throat)

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Herpes zoster (Ramsay—Hunt syndrome)

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Acute mastoiditis

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Cholesteatoma

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Necrotising otitis externa

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Pitfalls (often missed)

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Foreign bodies in ear

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Hard ear wax

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Trauma including barotrauma

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Dental abscess

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Referred pain: neck, throat (e.g. tonsillitis)

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Unerupted wisdom tooth and other dental causes

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TMJ arthralgia

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Chondrodermatitis nodularis helicus

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Facial neuralgias, esp. glossopharyngeal

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Post tonsillectomy:

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  • from the wound

  • from TMJ due to mouth gag

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Masquerades checklist

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Depression

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Spinal dysfunction (cervical)

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Is the patient trying to tell me something?

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Unlikely, but always possible with pain. More likely in children. Consider factitious pain.

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Key history

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Assess the site of pain and radiation, details of the onset of pain, nature of the pain, aggravating or reliving factors and associated features such as vertigo, tinnitus, sore throat and irritation of the external ear. Ask about trauma, especially the use of a cotton bud to clean the ear.

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Key examination

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  • The external ear with manipulation of the ear

  • Check helix for chondrodermatitis nodularis helicus

  • Palpate the face and neck to include the parotid glands, regional lymph nodes and skin and temporomandibular joint (TMJ)

  • Inspect both empty ear canals and tympanic membrane (TM) with the auroscope using the largest possible earpiece

  • Look for causes of referred pain: cervical spine, nose, postnasal space and mouth including teeth

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Key investigations

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Seldom necessary.

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  • Consider hearing tests, audiometry

  • Any ear discharge for MC but swabs of no value if the TM is intact

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Diagnostic tips

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  • The pain of otitis media may be masked by fever in babies and young children.

  • If an adult presents with ear pain but normal auroscopy, examine possible referral sites, namely TMJ, mouth, throat, teeth and cervical spine.

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