Rensink, Michael J. MD
Dr. Rensink is a member of ENT Associates of San Diego, and has been a practicing ENT specialist for more than 35 years.
Special thanks to MedRx for use of a video otoscope to capture figures 1 and 2 in this article.
A 16-year-old athletic girl in excellent health complained of pain in her right ear. She had no problems with hearing, balance, or tinnitus. She denied cotton swab use, cleaning her ear with a hair pin, or other unsafe ear habits.
She swims weekly at school in a pool (treated water), and does not surf or swim in the ocean (untreated water). She had problems with her ears as a child, and uses over-the-counter ear plugs when she swims. Her last ear infection was more than five years ago.
Figure. Michael J. R...Image Tools
Inspection of her ear, nose, and throat were unremarkable expect for the small, round, reddish-brown spot on her right eardrum shown in figure 1 and the irritated zone in her lower ear canal shown in figure 2. The patient does not wear hearing aids or nose plugs. I palpated the irritated zone in her ear canal. This tissue was sensitive, but she was certain that this area was not responsible for her ear pain. I examined the red spot on the upper portion of the tympanic membrane with pneumatic massage under a microscope. The patient did not report tenderness or irritation with this procedure, and the visual and palpation inspection of the tissue in the ear canal was unremarkable.
What is your diagnosis? See next page.
Diagnosis: Temporomandibular Disorder
By Michael J. Rensink, MD
An otolaryngologist often encounters complaints of ear pain. The most common cause of ear pain is an inflammation of the temporomandibular joint, also known as TMJ. (Figure 3.) This patient's diagnosis was temporomandibular disorder (TMD). The irritation in the ear canal was caused by the ear plugs she used for swimming, and the red spot on her eardrum was a red herring.
This case illustrates an important point: Irritations, indents in the ear canal's tissues, and funny-looking spots can lead away from an accurate diagnosis. A red herring is an important concept in medicine because it can hinder the proper course of action.
A patient who complains about ear pain is a challenge that dispensing audiologists face. The audiologist needs to inspect the ear for a pressure point and zones of irritation if the patient is wearing newly fitted hearing aids. Most audiology practices are equipped with otoscopes and light bars used to insert ear dams. These tools can be used to palpate an irritation zone in the outer part of the ear canal cautiously. The area may be red and inflamed if a hearing aid is creating excessive pressure on tissues in the ear canal. Sometimes, as in this patient, irritation is prevalent in more than one spot, and these points must be inspected to determine the tissue's status. Most patients will let you know it hurts if you touch an irritation point that is significantly troublesome.
Most problematic spots on the eardrum affect its status. A spot might be a bubble of fluid in the middle ear, in which case the patient's hearing would be affected. A spot might also be a tiny opening in the eardrum, in which case the tympanogram and relative physical volume measurement would be changed. The spot is probably innocuous if you do multiple comprehensive tests and find no effect. I studied this spot carefully under the microscope and with audiometric tests, and found no evidence of pathology. Having ruled out the abrasion in the canal and the red spot on the eardrum as problematic, I turned my attention to the most likely diagnosis, TMD.
The patient enjoyed chewing gum, and noticed an exacerbation of pain the longer she chewed. She also noticed significant ear pain when she chewed hard candies. Excellent information booklets are available on TMJ and TMD. More than 50 percent of those who report ear pain to an otolaryngologist have TMJ. The pain may be felt in front of the ear in the joint, but it can occur anywhere around the ear. People sometimes experience TMJ after visiting the dentist, especially when the jaw is held open during dental work.
TMJ becomes aggravated with stress and tension. Stress can lead the patient to grind and clench his teeth clenching, which is called bruxism. Treatment for TMJ includes but is not limited to eating soft food, applying heat, exercising the jaw, avoiding chewing gum, chewing food on both sides of the mouth, anti-inflammatory medication, and using a night guard or custom dental splint. Surgery for TMJ should be a last resort.
All patients reporting continuous ear pain need to be examined by an ENT to rule out serious pathology. I once had a patient whose only complaint was ear pain, and she had cancer of the larynx. Ear pain sounds like a simple problem, but must be thoroughly evaluated.
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