Syndrome differentiation of diseases of the ear
By Dr. Kenneth Wang
Differentiating otalgia
Otalgia is the commonly-seen symptom of many otic diseases. Its syndrome differentiation mainly lies in the severity of otalgia. When pathogenic wind invades externally, the pathogenic factor will accumulate and block the ear, mostly causing mild otalgia at the early stage; prolonged otalgia may result from loss of nourishment of meridians due to asthenia of the spleen and kidney, or obstruction of the ear due to blood stasis; when fire and heat of the liver and gallbladder rise to scorch the ear, severe otalgia will occur in most cases.
Primary otalgia
Primary otalgia, namely pain due to otopathies, is commonly seen in clinic. It is subdivided into the following four types according to its sites of onset,
Pain in auricle
It is due to traumas such as bite by insects and injury by blow. It is caused by cold injury. The patient has a history of otic cold injury. The disease is due to auricualr perichondritis and local red swelling, fever and pain which mostly occur after the auricular skin is injured. The disease results from otic herpes  zoster, with possible small blisters and thick wall clustering on auricles.
Before the appearance of  herpes zoster, there existed instant severe pain, mostly stabbing pain.
Pain in the external auditory canal
It is due to the foreign object obstructing the external auditory canal, mostly seen in children. The disease results from boil, inflammation, mostly with local redness and swelling. The disease is caused by ceruminal impaction, mostly with onset after water enters the auditory canal.
Pain in the drum membrane
It is due to acute myringitis, with congestion in the drum membrane, which is one manifestation otitis media. The disease results from myringitis bullosa,
with severe pain and larger blisters on the drum membrane, the pain of which is relieved after the ulceration of the blisters. The disease is caused by chronic granular myringitis, with mild pain and otic pyorrhea while no perforation exists on the drum membrane in general. The pain is due to trauma of the drum membrane, with rupture of the drum membrane, instaneous pain as well as the subsequent tinnitus and other foreign body sensations.
Pain in the middle ear
It is due to secretory otitis media, with more obvious sensation of distension and obliteration inside the ear. The disease results from suppurative otitis media,with congestion or perforation and pyorrhea of the drum membrane. The pain is due to aero-otitis media, with invagination or rupture of the drum membrane and the patient has a history of taking a plane. The illness is caused by malignant tumor with prolonged pain which worsens progressively, with pus intermingled with blood.
 Nervous otalgia
Nervous otalgia is due to nervous lesion which is not commonly seen in clinic. It is characterized by severe and transient pain with the manifestations in local parts like burning sensation, electric shock and tearing pain. The disease is mainly caused by pathological changes of the brancles of the trigeminal nerve and glossopharyngeal nerve such as auriculotemporal neuralgia and tympanic neuralgia.
Reflex otalgia
Reflex otalgia is also called referred otalgia. Because of the distribution of the trigeminal nerve, glossopharyngeal nerve, etc. in the ear, pathological changes of the other organs where these nerves distribute will give rise to referred otalgia. These pathological changes mainly include:
Pathological changes of the oral cavity
 Like pulpitis.
Pathological changes of the nose
Like inflammation of the posterior ethmoid sinuses and sphenoiditis.
Pathological changes of the pharynx
Like tonsillitis.
Other pathological changes
Like temporomandibular arthralgia, bronchial pathological and pulmonary pathological changes.
Differentiating pus
In the case of pyorrhea, the colour, quality and odour of the pus should be differentiated.
Colour
Pus with white colour belongs to cold, dampness and asthenia; pus with yellow colour to heat.
Quality
Thick pus pertains to heat, of which the sticky one coming out of the middle ear with more mucus can form a line and of which the unsticky one flowing out of the external ear can not form a line. Clear, thin and profuse pus mostly belongs to cold and dampness; clear, thin and scanty one to excessive fire due to yin deficiency, or is the sign that suppurative inflammation will heal; pus with the substance like bean dregs is cholesteatoma, mostly pertaining to hyperactivity of the liver fire.
Smell
Pus free from odour or with slight odour is common inflammation, mostly belonging to dampness due to asthenia of the spleen; pus with strange odour is possibly chop esteatoma or malignant tumour, mostly pertaining to dampness and heat of the liver and gallbladder.
Differentiating tinnitus and deafness
Tinnitus
Loud tinnitus with booming sound belongs to sthenia mostly with heat; tinnitus with low sound occurring only at night and disappearing at daytime to asthenia, mostly qi deficiency of the spleen or yin deficiency of the kidney.Â
Deafness
Fulminating deafness with dysphoria worsened when the patient hears noises pertains to sthenia, mostly due to blood stasis because of qi stagnation, or liver fire; prolonged deafness without dysphoria when the patient hears noises to asthenia, mostly asthenia of the kidney and spleen.
Differentiating vertigo
Vertigo with sudden onset, dizziness, headache or fullness of head belongs to hyperactivity of the liver yang;vertigo with nausea, vomiting with Sputum and saliva,pale and greasy fur to turbid phlegm obstructing middle energizer; vertigo with general fatigue worsened when the patient stands up from the seat and when the patient is standing mostly to asthenia of the kidney or spleen.
Differentiating the drum membrane
The normal drum membrane is translucent like the pearl color. Its forms with pathological changes are as follows.
Congestion
Mild congestion mostly belongs to the wind and heat syndrome; severe congestion to the fire and heat of the liver and gallbladder.
Perforation
It is mostly seen in suppurative tympanitis. In the case of sudden onset, it mostly belongs to the liver fire;at the chronic stage, it mostly belongs to asthenia of the spleen.
Invagination
It is mostly seen in secretory tympanitis. At the primary stage, it mostly belongs to pathogenic wind invading the lung; prolonged invagination mostly belongs to blood stasis due to qi stagnation.
Hydrops
If the doctor can see the fluid level through the drum membrane, or liquid intermingled with bubbles in the tympanic cavity, the fact indicates hydrops. Hydrops is mostly seen in the case of secretory tympanitis. At the early stage, it is retention of turbid phlegm due to pathogenic wind invading the lung; in the case of prolonged hydrops, it belongs to retention of phlegm and dampness due to qi deficiency of the spleen, or obstruction due to phlegm intermingled with blood stasis.
Blue colour
This is mostly seen in the case of retention of blood in the tympanic cavity due to trauma, hemopathy, idiopathic hemo-tympanium, etc. or bulb of jugular vein
sticking out into the tympanic cavity. The pathogenesis mostly belongs to blood stasis due to qi stagnation.
