Otalgia
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39364.643275.47 (Published 31 January 2008) Cite this as: BMJ 2008;336:276All rapid responses
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Impacted teeth, i.e. teeth which have failed to fully erupt through
the gums, are not in themselves symptomatic.
Impacted teeth can develop an infection where the crown is partially
covered by gum. This is called pericoronitis and pain from this source
would only be referred to the ear very rarely. More often pericoronitis
causes pain and swelling in the mouth, on the gum, around the crown of the
tooth.
If the impacted tooth becomes carious and the pulp becomes inflamed
(pulpitis), this 'toothache' is poorly localised and can be referred to
the ear.
If the pulp of an impacted tooth dies, an abscess can form below the
root of the tooth. The pain from a dental abscess is usually well
localised to the tooth and the jaw around its roots.
Impacted teeth that are completely unerupted only cause problems if
they develop associated pathology such as a cyst and this cyst becomes
infected.
So we think listing impacted teeth in the list of causes of otalgia
is a distraction. Pulpitis from any tooth is the most likely dental cause
of pain referred to the ear.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
The article by Siddiq and Samra has attracted criticism from general
practitioners due to its lack of primary care focus. As hospital based
doctors we also wish to highlight problems with the paper that could have
significant ramifications if left uncorrected.
Trigeminal neuralgia is
included as a cause of otalgia. In this condition pain characteristically
lancinates across the face and although there is often a trigger point
anterior to the ear, ear pain is not typically seen. ,P>Otalgia is, however,
a characteristic feature of Glossopharyngeal neuralgia which is not
included in the list of causes. Glossopharyngeal neuralgia is associated
with a high rate of underlying structural abnormality including
malignancies around or invading the carotid sheath making it important to
differentiate from Trigeminal neuralgia which has a benign cause in most
cases. Additionally Glossopharyngeal neuralgia can cause significant
bradycardia and even assystole via facilitation of cardioinhibitory
reflexes. This cardioinihibition can prove fatal if not recognised but is
treatable, often requiring a pacemaker. The patient presenting with the
combination of otalgia and new onset collapses should be treated as a
medical emergency. The other serious neurological consideration of otalgia
is lateral sinus thrombosis which is also omitted from the list of
differential diagnoses. This condition may have other associated features
such as generalised headache, seizure or focal neurology and is commonly
misdiagnosed.
Competing interests:
None declared
Competing interests: No competing interests
An excellent article till the "autopilot" setting went on for otitis
media and the unthinking practice of 15 years ago dents the evidence based
publications since.
Yes I am sure there is probably someone the secondary care author has seen
with a really nasty complication , its GP's see the nonresponders
(repeatedly!!!) and deal with the antibiotic related diarrhoea.
Was there a primary care reviewer or is this article so "out" of fashion
its now "hot" again?
Competing interests:
None declared
Competing interests: No competing interests
Arrgh. Come on BMJ you can do better. Antibiotics are not indicated
in 90% of
otitis media and aciclovir is no better than placebo in Bell's Palsy
(Sullivan and
others 2007; yes published in the BMJ).
Decongestants do not help with barotrauma.
More annoyingly it does not offer some really useful short cuts to
help with ear
pain:
Wiggling the pinna is sore in otitis externa, not otitis media
(sometimes difficult
to differenciate if the EAM is full of debri.
Getting the patient to "pop" there ears is a useful way of seeing if the
pain is
middle ear in origin.
A negative Rinne test is helpful when diagnosing otitis media (how can
they have
otitis media with an air filled middle ear?).
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
The 10-minute consultation format is a deeply floored concept at the
best of
times. This week's paper has by-passed the radar (1), raising questions
about
editorial rigor. I assume that the format is aimed at primary care
professionals - who else would be interested? If so why have Siddiq and
Samra produced a classical secondary care treatise without reference to
the
reality of primary care ENT practice. There is no sense of the frequency
or
incidence of symptoms in this article, instead we are presented with a
list that
gives no sense of perspective. As every practitioner knows, most
consultations with otalgia are the result of self-limiting viral
infections. By far
the majority of the remaining cases of otalgia, are often without physical
signs, and are either from the oro-pharynx, or from the eustachian tube
(this
latter, not even worthy of a mention by our esteemed colleagues).
When I read articles in your publication, I expect stimulation and
new
perspectives, not disinformation. Editors please take note.
Jim Hardy
(1) MA Siddiq, MJ Samra. 10-Minute Consultation. BMJ: 2 February
2008. Vol
336
Competing interests:
None declared
Competing interests: No competing interests
I was surprised to read that the author recommends antibiotics as a
first line treatment for acute otitis media. Many of my primary care
colleagues perceive acute otitis media as a minor self limiting illness.
If I would give use antibiotics, especially Augmentin, as first line then
this would clearly contribute to bacterial resistance and a higher rate
Clostridium Difficile Colitis in the community.
I cannot believe this article has been peer reviewed by a General
Practitioner and I would suggest that 10 minute consultations about common
complaints in primary care are being peer reviewed by someone working in
primary care.
Competing interests:
None declared
Competing interests: No competing interests
This is an informative article but I was very disappointed to see the
instruction to prescribe antibiotics to all cases of acute otitis media.
This is in contradiction to guidance published elsewhere
http://cks.library.nhs.uk/otitis_media_acute/view_whole_guidance
This indicates that antibiotics should not be prescribed for the majority
of cases. Educating patients, in particular parents of small children,
that all earache does not need to be seen by a GP or out of hours doctor
has significant workload implications. In addition, at a time when we are
encouraged to rationalise our use of antibiotics, following this advice
would, in most quarters, be seen as overprescribing.
Competing interests:
None declared
Competing interests: No competing interests
Otalgia In Adults And children
Sir,
What are the common conditions of otalgia which a family
physician will encounter in his day to day practice? What should be done
first witout prescribing antibiotics?
When the patient is to be referred for expert opinion?
Competing interests:
None declared
Competing interests: No competing interests