The Radiology of Referred Otalgia

Primary and referred otalgia pathways of the mandibular nerve (V3). Cranial nerve V is the most frequent pathway for referred otalgia via the auriculotemporal branch of the trigeminal nerve. Reprinted with permission from the American Journal of Clinical Oncology (2003;26:e157–62).

TMJ. Coronal reformatted CT scan demonstrates severe erosion and irregularity involving the head of the left condylar process. TMJ disease has been well documented to be associated with referred otalgia via the auriculotemporal and masseteric branches of V3.

Parotid malignancy. Positron-emission tomography image demonstrates abnormal hypermetabolic activity involving the left prestyloid parapharyngeal region. The corresponding anatomic images demonstrate a calcified mass within the deep lobe of the parotid gland. The parotid branches of the auriculotemporal nerve mediate referred otalgia.

Primary and referred otalgia pathways of the facial nerve (VII). Cranial nerve VII produces referred otalgia via the auricular branch of the facial nerve. Bell palsy can present as ear pain, antecedent to facial paralysis. Reprinted with permission from the American Journal of Clinical Oncology (2003;26:e157–62).

Sphenoid sinusitis. T2-weighted image demonstrates mucosal thickening in the left sphenoid sinus. The greater superficial petrosal nerve supplies afferents to this region.

Nasal spur. Coronal CT with bone algorithm demonstrates a nasal spur that touches the adjacent concha. Referred otalgia may be eliminated during the ENT examination via placement of a cocaine solution over the spur.

Primary and referred otalgia pathways of the glossopharyngeal nerve (IX). Cranial nerve IX mediates otalgia via the tympanic nerve of Jacobson. Reprinted with permission from the American Journal of Clinical Oncology (2003;26:e157–62).

Squamous cell carcinoma of the nasopharynx. Axial CT scan with contrast demonstrates an abnormal soft-tissue mass with relatively uniform contrast enhancement filling the left lateral fossa of Rosenmueller, affecting the pharyngeal plexus of cranial nerve IX.

Peritonsillar abscess. Axial CT scan with contrast demonstrates a right inferior peritonsillar abscess in association with edematous change in the adjacent right parapharyngeal space irritating the pharyngeal plexus (cranial nerve IX).

Retropharyngeal adenitis. Axial CT scan demonstrates suppurative adenitis involving the right retropharyngeal space, which can affect the pharyngeal plexus and produce referred otalgia.

Eagle syndrome. A 30-year-old man with otalgia. Plain film demonstrates a thickened and elongated styloid process, which can irritate the tonsillar bed via the tonsillar branch of cranial nerve IX. Patients classically have reproduction of pain on transoral palpation of the tonsils.

Primary and referred otalgia pathways of the vagus nerve (X). Cranial nerve X is involved with otalgia via the auricular nerve of Arnold. Reprinted with permission from the American Journal of Clinical Oncology (2003;26:e157–62)

Supraglottic squamous cell carcinoma. Positron-emission tomography/CT scan demonstrates an enhancing exophytic supraglottic mass arising from the posterior wall of the larynx. This area is innervated by the internal branch of the superior laryngeal nerve and can result in otalgia when irritated.