Original Article

Pain Presentation in Otorhinolaryngological Practice in a Tertiary Health Care Center

Adegbiji WA,¹ Aremu SK²

1. Department of Ear, Nose and Throat, Ekiti State Teaching Hospital, Ado-Ekiti. Ekiti State, Nigeria

2. ENT Department, College of Medicine and Health Sciences, Afe Babalola University, Ado- Ekiti. Ekiti State, Nigeria

ABSTRACT

Background and aims: Otorhinolaryngological, head and neck pain is one of the most common reasons for consultation in ear, nose and throat practices. This present study aimed at determining the otorhinolaryngology, head and neck pain prevalence, sociodemographic features, clinical presentation and prehospital treatment among patients presenting in our centre. Materials and methods: This was a hospital-based prospective cross-sectional study of patients presenting with otorhinolaryngological, head and pain. Sociodemographic features of the patients and detailed clinical features of the pain were collected and recorded in special forms. Data obtained were collated and analyzed using SPSS version 18.0. Results: The prevalence of otorhinolaryngology and head and neck pain was 27.6%. Among the patients, 42.4% were males with female to male ratio of 1.4:1. Commonest site of pain was 37.3% ear. Other were 23.3% head and 14.6% throat. Trauma caused 29.6% of pain and infection was 59.7%. Commonly associated symptoms were 31.7% hearing loss, 31.4% catarrh, 23.4% odynophagia and 42.4% fever. Most patients 51.7% presented between 1 week and 3 months duration of pain while 30.4% presented at more than 3 months. Recurrent pain accounted for 63.1% while primary pain accounted for 91.1%. The majority 91.3% of the patients were referred and the main source of referral was 53.9%, general practitioners. Majority 71.9% presented in the outpatient clinic followed by the emergency ward 25.8%. Regarding prior treatment before presentation, 95.7% had analgesics 71.4% were on antibiotics, 84.2% were on herbal medication and 4.2% had a traditional surgery. Conclusion: Otorhinolaryngology, head and neck pain was a common presentation in our centre. It must be considered as one of the differential diagnosis of head and neck pain.  Most of the patients presented late at the outpatient clinic with recurrent pain. The major source of referral was from general practitioners. The majority of the patients were wrongly treated.

Keywords: 

Ear-Nose-Throat 

Pain 

Prevalence 

Treatment 

Corresponding Author

Dr. Shuaib Kayode Aremu      

ENT Department, College of Medicine and Health Sciences,

Afe Babalola University, Ado- Ekiti.

Ekiti State, Nigeria

Email: aremusk@abuad.edu.ng

Phone: +2348033583842

Fax: +2348033583842

Postal Code: 371101

INTRODUCTION 

Otorhinolaryngological, head and neck pain is a subjective unpleasant discomfort sensation which is secondary to potentially damaged tissue ¹. This pain is a broad concept which comprises of ear, nose, and throat with other head and neck organs ². 

Pain is a symptom, not a disease and a very frequent reason for a patient's referral for an otorhinolaryngologist consultation. It is very common among patients attendance at the clinic and most of the pain is primarily ear, nose, throat, head and neck origin ^3-5. Otorhinolaryngology, head and neck pain influence patients’ quality of life ^6,7. These include frequent consultation, absenteeism, disruption of sleep, reduced social contacts and reduced efficiency ⁸.

Pathology leading to pain ranges from trauma, and inflammation to neoplastic disorders ^9-12. Traumatic conditions could be foreign body impaction, iatrogenic, burn, blunt or open injuries. Inflammatory disorders may be infections or reactions as in allergies. Neoplastic disorders are mainly from malignancies but benign neoplasia may cause pressure pain. 

Response to these painful symptoms depends on pathology and patients’ perception.  It further depends on factors such as sex, age, self-medication, sociocultural background and treatment interventions ^13,14. 

Clinical manifestation depends on the organs of origin which include the nose, paranasal sinuses, ear, pharynx, larynx, salivary glands and others in single or in combination. This also depends on the severity and stages of the disease.

Information on otorhinolaryngology pain is vital for the future design of health care, preventive and management strategies. There is a paucity of studies available on the pattern and impact of otorhinolaryngology, and head and neck pain on patients ^15,16.  However, there is none from this area of the country. This present study aimed at determining the otorhinolaryngology, head and neck pain prevalence, sociodemographic features, clinical presentation and prehospital treatment among patients presenting in our centre. 

MATERIALS AND METHODS 

This was a hospital-based prospective cross-sectional study of patients presenting with otorhinolaryngological, head and pain in ear, nose and throat department of Ekiti state university teaching hospital, Ado Ekiti, Nigeria. The study was carried out over a period of one year (between August 2018 and July 2019). 

Patients presenting with pain during the period of the study were recruited after obtaining consent to participate in the study. 

Sociodemographic features of the patients and clinical history of the pain were collected and recorded in special forms. The data collected included the location of the pain, severity, duration, precipitating factor, aggregating factor, relieving factor and other characteristics of ear, nose and throat pain. A history of associated ear, nose and throat symptoms was obtained. All the patients were examined to arrive at a diagnosis of pain and these were documented. Patients’ confidentiality was assured, anonymity and preserved.

Data obtained were collated and analyzed using SPSS version 18.0. Summary statistics were used in form of the frequency table, percentages, pie charts and bar charts to express the outcome. 

Ethical clearance for this study was sought and obtained from the ethical committee of the hospital. 

RESULTS 

A total of 2,682 patients were seen in the ear, nose and throat department during the period of the study, out of which 739 patients presented with different otorhinolaryngology, and head and neck pain. Thus, the prevalence of otorhinolaryngology, and head and neck pain was 27.6%. 

Table 1 Age group distribution among the patients

Otorhinolaryngology, head and neck pain is a common presentation in all the studied age groups. The peak value was 209 (28.3%) in the age group (1-10) years while the least value was 47 (6.4%) in the age group >60 years. This is illustrated in table 1. 

Among the patients, 313 (42.4%) were males while 426 (57.6%) were females with female to male ratio of 1.4:1. Urban dwellers accounted for 398 (53.9%) while rural dwellers accounted for 341 (46.1%). Christian faith in 654 (88.5%) was commoner than the Muslim faith in 85 (11.5%). Most of the patient’s education levels were secondary, primary and post-secondary in 261 (35.3%), 224 (30.3%) and 152 (20.6%) respectively. The majority of 298 (40.3%) of the patients were students/apprentices others were 179 (24.2%) civil servants and 91 (12.3%) businesses. On marital status, single were commonest by 339 (45.9%) followed by 243 (32.9%) married and 108 (14.6%) divorced. This is shown in table 2. 

Table 2 Sociodemographic features among the patients

Table 3 Anatomical distribution of pain among patients

Commonest site of pain was 276 (37.3%) ear. Right ear pain and left ear pain accounted 128 (17.3%) and 101 (13.7%) respectively. Other location of otorhinolaryngology, head and neck pain were 172 (23.3%) head, 108 (14.6%) throat and 86 (11.6%) neck. This is demonstrated in table 3. 

Trauma caused 219 (29.6%) pain of which foreign body impaction, road traffic accident accounted for 147 (19.9%) and 51 (6.9%) respectively. Pain from infection was observed in 441 (59.7%). 

Figure 1 Aetiological distribution among the patients  

Table 4 Associated symptoms among the patients

Figure 2 Duration of pain prior to presentation 

Common otorhinolaryngology, head and neck infections were 162 (219%) rhinosinusitis, 146 (19.8%) otitis external, 47 (6.4%) otitis media, 38 (5.1%) tonsillitis and 14 (1.9%) pharyngitis. Neoplasm caused pain in 57 (7.7%) with sinonasal tumour and cervical lymphadenopathy in 21 (2.8%) and 16 (2.2%) respectively. Other causes of pain accounted for 22 (3.0%) of which the commonest cause was neuralgia in 13 (1.8%). This is shown in figure 1. 

Table 5 Characteristics of pain among patients

Figure 3 Sources of the patients 

The commonest associated otological symptom was hearing loss in 234 (31.7%) others included 186 (25.2%) with itchy ears. Associated rhinologic symptoms were catarrh and nasal blockage in 232 (31.4%) and 199 (26.9%) respectively. Associated throat symptoms were 173 (23.4%) odynophagia, and 154 (20.8%). The commonest constitutional symptom was 313 (42.4%) fever. This is demonstrated in table 4. 

Most of the patients 382 (51.7%) presented to the ear, nose and throat department between 1 week and 3 months duration of pain. Other duration of pain prior to presentation was 225 (30.4%) at more than 3 months and 132 (17.9%) within 1 week. This is demonstrated in figure 2. 

Table 6 Prior treatment among the patients.

Regarding the nature of pain, recurrent pain in 466 (63.1%) was commoner than a single episode of pain in 273 (36.9%). Primary pain accounted for 673 (91.1%) while referred (secondary) pain accounted for 136 (18.4%). This is illustrated in table 5. 

The majority of 675 (91.3%) of the patients were referred. The main sources of referral were 398 (53.9%) general practitioners, 164 (22.2%) paediatricians and 92 (12.4%) casualty officers. There was 64 (8.7%) self-reported patient. This is shown in figure 3. 

On presentation of pain in otorhinolaryngology, head and neck, the majority 531 (71.9%) presented in the outpatient clinic. Other presentations were in the emergency ward and admissions ward in 191 (25.8%) and 17 (2.3%) respectively. As demonstrated in figure 4. 

Regarding prior treatment before presentation, 707 (95.7%) had analgesics and 528 (71.4%) patients were on antibiotics. Also, 622 (84.2%) were on herbal medication. Traditional surgery in different forms was performed in 31 (4.2%). This is illustrated in table 6. 

DISCUSSION 

The study of pain in otorhinolaryngology and head and neck practices is uncommon in developing countries. Pain is a symptom, not a diagnosis. Pain in the patient must be fully assessed clinically to rule out the aetiology and arrived at a definitive diagnosis. Pain is one of the commonest reasons for patients seeking medical consultation worldwide. 

The prevalence of pain in otorhinolaryngology, head and neck in this study was 27.6%. This observed prevalence is very high.¹⁷ High prevalence of infection and trauma predisposes to the high prevalence of pain in this study compared to a lower incidence of the neoplastic disorder in this study. Furthermore, the prevalence of otorhinolaryngology, and head and neck pain varies from place to place and depends on the age groups under study.¹⁸ The high prevalence may be due to the high preponderance of children with low pain thresholds. Pain threshold is low in females who are commoner than males in this study. 

In this study, otorhinolaryngology, and head and neck pain are more common among females than males.  Body hygiene and caring in females are more common than in males. In the process of their general body hygiene head, orifices are usually injured and infected. ¹⁹ Females seek attention to ill health intervention and general care from such injuries and infections more than males. The majority of the patients with otorhinolaryngology, and head and neck pain were urban dwellers compared to rural dwellers. Urban dwellers are more accessible to tertiary healthcare facilities. The location of our centre is very close, lower cost of transport and easier for a family member to accompany the patients to the hospital. Other sociodemographic features, religion, patient/parent occupation and education do not have much effect on otorhinolaryngology, and head and neck pain. 

The commonest cause of otorhinolaryngology, head and neck pain was earache which was due to frequent ear picking by the patient or their parents. Ear cleaning is to get rid of ear wax, soothe itchy ears and part of ear play in children.²⁰ This may be referred to as primary otalgia. The headache was due to pathology in the head and neck region. Most otorhinolaryngology headaches are secondary to sinonasal diseases. This is mostly mistaken by other clinicians to be caused by intracranial pathology like a brain tumour.²¹ Throat is the entrance to the aerodigestive tract and it is more prone to different physical and infective assaults. Tonsillitis and pharyngitis are common with pain as major complaints. Neck pain is usually secondary to throat diseases like infection, foreign body impaction and abscesses. Facial pain is commoner with sinonasal disease or orofacial disorder in our practice. Nasal pain is not uncommon it is usually secondary to trauma or nasal vestibular infection such as furunculosis as noted in most of our patients. 

The commonest trauma leading to otorhinolaryngology, head and neck pain is foreign body impaction in the ear, nose and throat. The pain is usually worsened by unskilled hand attempted removal using inappropriate instruments in our patient. This is followed by trauma from road traffic injuries and assault while head and neck burn is not common here. Infective pain is commonly otitis externa, otitis media, acute rhinosinusitis, acute tonsillitis, acute pharyngitis and cervical adenitis. These results from acute inflammation of the tissue. Destructive and expansion of the head and neck tumour leads to pain. Commonly observed tumours in our study were sinonasal tumours, pharyngeal and laryngeal tumours while aural neoplasms are not common. 

More commonly, diagnoses of otorhinolaryngology, and head and neck pain are missed when clinicians concentrate on constitutional symptoms like fever and malaise. Disorders like malaria and typhoid fever are treated and most present late. ²¹ Pain location and associated symptoms greatly assisted in the diagnosis of the otorhinolaryngology, and head and neck pain. Otology pain is accompanied by hearing impairment, discharging ear and itching. Rhinologic pain is associated with catarrh, nasal blockage and sneezing. Associated with throat and neck pain were sore throat, odynophagia and hoarseness in our patient. Wrong diagnosis of headache with a brain tumour has exposed some patients to expensive and unwarranted irradiation like skull x-ray, brain CT scan and MRI.

Based on the duration before presentation at the ear, nose and throat department, our observation is similar to reports from other developing countries.¹⁷ Most of the patients delay their visit to the specialist and usually present with complicated cases or when the pain becomes unbearable. Most of our patients presented after one week or month. This is due mainly to poor perception of causes and treatment of diseases, bad attitude to health care, unskilled self-intervention, lack of funds, attempted foreign body removal, herbal medication, thought the pain/disease will disappear with or without treatment, medications were most time self-prescribed or by untrained hand ²² Some patients’ referral were usually delayed and untimely. 

Otorhinolaryngology, head and neck pain are mainly recurrent and it is commoner than a single episode. This is because most cases are infectious and are poorly managed by untrained personnel. Sources of pain in this study are mainly primary with the associated wrong technique of foreign body removal and poor treatment of ear, nose and throat infections are common.²²Referral otorhinolaryngology, head and neck pain were mostly not known and nonspecialists mostly miss the diagnosis and institute inappropriate treatment. 

The majority of the patients in this study were referred with very few patients as self-reported cases.²⁰ Main referrals were from primary contacts like general practitioners, paediatricians and casualty officers. Most of the referrals were delayed or wrongly to the outpatient clinics. In this study, most patients with otorhinolaryngology, and head and neck pain were first seen in our outpatient clinic. Few were referred to be seen in the emergency department.²² This may be due to patient abuse of analgesics which mask the pain at presentation to the primary care. 

Most of the patients with otorhinolaryngology, and head and neck pain were on medication prior to presentation at the ear, nose and throat department. The most worrisome is the fact that almost all of the patients were on analgesics and antibiotics. Some were on narcotics depending on the degree of the pain with prescriptions by non-health professionals. These practices could lead to drug addiction, the emergence of resistant strains of microorganisms and poor treatment of head and neck cancers resulting in late presentation with high mortality and morbidity.¹⁷ There was prior administration of herbs of different types with unknown chemical composition and dosage. This may be very dangerous to the vital organs in the body. A different form of traditional surgery was observed in this study of which the major ones were traditional uvulectomy and scarification. This leads to anaemia and wound infection from poor technique and non-sterile instruments. 

CONCLUSION 

Pain presentation in otorhinolaryngology, and head and neck practice was a common symptom in our centre. Most of the patients presented late with recurrent pain. The majority of the patients were wrongly treated with analgesics and antibiotics. Early presentation and referral are encouraged while abuse of drugs should be discouraged.

Funding

There was no financial support. It is a self-sponsored research study. 

Competing interests

All the authors declare that there were no competing interests.

Funding: By the authors only. No grants received

Conflicts of interest: None

Acknowledgements

The authors wish to acknowledge the management of Afe Babalola University for its immense support and also be grateful to Ekiti State University Teaching Hospital, the staff and all the patients who participated in this study. 

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