Neuropathic Otalgia: Rare and Treatable Ear Pains

Objective: To present two rare and commonly misdiagnosed causes of treatable neuralgic ear pain. Background: Ear pain (otalgia) is a common yet complex complaint which can be multifactorial in etiology. Receiving sensation from four cranial nerves (V, VII, IX and X), the upper cervical plexus and cervical sympathetic fibers, understanding the etiology of neuropathic otalgia – particularly greater auricular neuralgia and nervus intermedius neuralgia remains a difficult task in the clinical setting. Though the two present similarly, confirming the diagnosis is crucial in providing appropriate treatment. Design/Methods: We report 2 cases of neuropathic otalgia: First, a 55-year old female presented with severe, isolated right ear pain lasting 2 months involving the right mandibular angle and right carotid angle. Prior to neurologic evaluation, patient was misdiagnosed with otitis externa and treated with antibiotics with no improvement. Her initial work-up included contrasted MRI acoustic which was unremarkable. Her exam revealed exquisite tenderness over the right greater auricular nerve and lesser occipital nerve. In contrast, a 42-year-old male presented with post-traumatic right ear pain following a work-related accident with known skull fractures, subarachnoid and subdural hematomas 6 years prior to neurologic evaluation. Described as severe, stabbing, deep ear pain lasting for several seconds up to 1 minute with periods of remission lasting for months, concern for secondary nervus intermedius neuralgia prompted further evaluation with MRI acoustic and cervical spine. Results: Our first patient had dramatic improvement in her pain with greater auricular and lesser occipital nerve blocks, confirming the diagnosis of greater auricular neuralgia. Our second patient sought reassurance alone and declined any treatment with carbamazepine and gabapentin but continues to be monitored as an outpatient. Conclusions: Recognizing distinct clinical features based on pain characteristics, duration, and distribution of ear pain is an important diagnostic and therapeutic tool to identify uncommon causes of debilitating yet treatable ear pain