A 59-year-old man comes to the office with a 3-month history of persistent right ear pain. He has tried to control the pain with acetaminophen and ibuprofen but with no improvement. He has no other medical issues. He works as a welder and has smoked a pack of cigarettes daily for 40 years and drinks a case of beer each weekend. Vital signs are within normal limits. Right ear examination shows a normal external ear, normal external auditory canal, and a clear tympanic membrane with no middle ear fluid. Palpation of the temporomandibular joint elicits no tenderness or crepitus. His left ear examination shows no abnormalities. Oral cavity examination shows poor dentition, but there are no ulcers. The tonsils are not enlarged, and posterior pharyngeal wall is nonerythematous. There is a nontender 2-cm lymph node on the right side of his neck. Which of the following is the best next step in management of this patient?

Question

A 59-year-old man comes to the office with a 3-month history of persistent right ear pain.  He has tried to control the pain with acetaminophen and ibuprofen but with no improvement.  He has no other medical issues.  He works as a welder and has smoked a pack of cigarettes daily for 40 years and drinks a case of beer each weekend.  Vital signs are within normal limits.  Right ear examination shows a normal external ear, normal external auditory canal, and a clear tympanic membrane with no middle ear fluid.  Palpation of the temporomandibular joint elicits no tenderness or crepitus.  His left ear examination shows no abnormalities.  Oral cavity examination shows poor dentition, but there are no ulcers.  The tonsils are not enlarged, and posterior pharyngeal wall is nonerythematous.  There is a nontender 2-cm lymph node on the right side of his neck.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d8bf_d4bc_bc81_e75011c36f5a_MD0003_00 Otalgia in the setting of a normal ear examination is likely referred pain (pain perceived at a different site than its true origin). The most common causes of referred otalgia are dental disease and temporomandibular joint disorders. However, referred otalgia is commonly a presenting symptom of mucosal head and neck squamous cell carcinoma (HNSCC), especially in an older patient with a history of smoking, alcohol use, occupational exposure to welding fumes, and cervical lymphadenopathy. Referred pain frequently occurs when nerves travel in close proximity, especially if their cell bodies are located in the same ganglia or they synapse in the same location. In this case, the glossopharyngeal nerve (CN IX), which has afferent fibers innervating the base of the tongue, also has a branch that provides afferent sensory input from the external auditory canal; all of these afferent fibers converge in a ganglion just prior to entering the jugular foramen. Similarly, the vagus nerve (CN X), which innervates parts of the larynx and hypopharynx, also provides sensory innervation to the external auditory canal. Therefore, referred otalgia can be due to a tumor at the base of the tongue or from the larynx/hypopharynx. Flexible laryngopharyngoscopy would likely identify the primary tumor site. (Choice A) An audiogram is used to evaluate hearing loss. Although many etiologies of hearing loss present with a normal ear examination, ear pain, especially in a patient with HNSCC risk factors, is concerning for malignancy. (Choice C) MRI scan of the brain can assess for vestibular schwannoma (acoustic neuroma), which can cause hearing loss, dizziness, and tinnitus but would not cause referred otalgia. Referred otalgia is almost never due to central causes. (Choice D) Although a normal ear examination is reassuring that there is no primary etiology of otalgia (eg, otitis externa, otitis media), referred otalgia can be the presenting symptom of many diverse, insidious pathologies and therefore must be further evaluated. (Choices E and F) Tympanometry can assess for eustachian tube dysfunction, which can cause ear pain but would also cause hearing loss, feeling of fullness, and tympanic membrane retraction or middle ear effusion; tympanostomy tube placement can be considered in patients who do not respond to medical management (eg, decongestants). Tube placement is also indicated in some children with recurrent otitis media. Educational objective: In a patient with risk factors for malignancy, ear pain with a normal ear examination may be referred from the base of the tongue or hypopharynx/larynx. Associated cervical adenopathy makes head and neck squamous cell carcinoma the most likely diagnosis. References: Clinical differences in types of otalgia. (http://www.ncbi.nlm.nih.gov/pubmed/26185789) Survival trends in hypopharyngeal cancer: a population-based review. (http://www.ncbi.nlm.nih.gov/pubmed/25220657) Diagnosis of ear pain. (http://www.ncbi.nlm.nih.gov/pubmed/18350760)

A 59-Year-Old Man Comes to the Office with a 3-Month