Case Study: Refractory Unilateral Otalgia in a Patient with Long-Standing GERD

Case at a Glance

A 32-year-old female with a history of gastroesophageal reflux disease (GERD) since early childhood presented with a five-year history of constant, right-sided ear pain. An extensive workup, including imaging and specialist consultations, failed to identify a primary otologic, neurologic, or temporomandibular cause, suggesting a diagnosis of referred otalgia.

Patient's Story

The patient is a 32-year-old female with a five-year history of persistent pain localized deep within her right ear. She describes the pain as a strong, constant ache punctuated by occasional, sharp stabbing sensations. The pain is partially relieved by ibuprofen but is not influenced by triggers such as loud noises, head movement, or swallowing. The patient has a significant past medical history of GERD, diagnosed via a barium swallow study at the age of four.

Initial Assessment

Initial evaluation by primary care and otolaryngology (ENT) focused on common causes of ear pain. Physical examination of the external auditory canal and tympanic membrane was unremarkable. There was no evidence of infection, inflammation, cerumen impaction, or a foreign body. Audiometry testing confirmed normal hearing bilaterally. The patient denied any sensation of aural fullness, pressure, or popping, which made primary eustachian tube dysfunction less likely.

The Diagnostic Journey

Given the absence of primary ear pathology, the differential diagnosis was expanded to include referred pain sources. The patient was evaluated for temporomandibular joint (TMJ) dysfunction and trigeminal neuralgia. An MRI of the head was performed, which showed no evidence of TMJ derangement or vascular compression of the trigeminal nerve. Therapeutic trials with a mouth guard, cyclobenzaprine (Flexeril), and Botox injections provided no relief, further arguing against a musculoskeletal or primary neuropathic etiology.

The patient also reported experiencing a globus sensation and a feeling of tightness in her throat, which had previously been attributed to anxiety. She expressed concern that these throat symptoms might be linked to her ear pain and her history of GERD. During a review of her MRI scans, the patient herself identified an area at the base of the tongue and epiglottis that she perceived as abnormal, prompting further consideration of a pharyngeal or laryngeal cause for her symptoms.

Final Diagnosis

This case represents a diagnostic challenge. With primary otologic, neurologic, and temporomandibular disorders effectively ruled out, a diagnosis of referred otalgia is most likely. Given the patient's long-standing history of GERD and concomitant symptoms of globus and throat tightness, referred otalgia secondary to laryngopharyngeal reflux (LPR) is the leading suspected diagnosis. The glossopharyngeal nerve (CN IX) and vagus nerve (CN X) provide sensory innervation to both the pharynx and parts of the ear, providing a clear neurologic pathway for this referred pain pattern.

Treatment Plan

Current management consists of as-needed ibuprofen for symptomatic control. The recommended treatment plan is to initiate an aggressive trial of anti-reflux therapy. This includes a high-dose proton pump inhibitor (PPI) administered twice daily for a period of 8-12 weeks, along with lifestyle and dietary modifications (e.g., avoiding trigger foods, elevating the head of the bed). A referral for direct fiberoptic laryngoscopy is also warranted to visually assess the larynx and pharynx for signs of inflammation, irritation, or other pathology consistent with LPR.

Outcome and Follow-up

The patient is awaiting follow-up with her ENT specialist to discuss the potential diagnosis of LPR-induced otalgia and to proceed with the proposed treatment plan and further diagnostic investigations. The primary measure of therapeutic success will be the reduction or resolution of her chronic ear pain in response to aggressive acid suppression therapy. The case underscores the importance of considering LPR in the differential diagnosis of chronic, unexplained otalgia.