Abstract
Acute coronary syndrome usually presents with retrosternal chest pain, nausea, vomiting, sweating, and jaw and arm pain. Some patients only present with neck, epigastric, or ear discomfort. A 47-year-old male with a history of hypertension and coronary artery disease presented to the emergency department complaining of bilateral otalgia. He never felt chest pain, jaw pain, nausea, diaphoresis, or shortness of breath. He had a history of 2 acute coronary events and had a stress test 2 months prior to admission, which was unremarkable. The initial electrocardiography was sinus rhythm with Q-waves in the inferior leads and nonspecific ST changes in the lateral leads. His troponin on admission was normal but subsequently elevated to 20.00 mg/mL after 24 hours. He underwent left heart catheterization, which found significant occlusive disease of the second and fourth obtuse marginal branches and 2 drug-eluting stents were placed. His ear pain resolved soon after cardiac catheterization. The pathophysiology of this referred pain is thought to be related to the neuroanatomy of the nerves innervating the heart and ear. The auricular nerve branch of the vagus nerve supplies the inner portion of the external ear. Only a few cases with the complaint of otalgia have been reported. Patients were older, more frequently women, and with diabetes or heart failure. Clinicians should be aware of the atypical presentation of angina that may be life-threatening cardiac ischemia. Ear pain and fullness could be the sole presenting symptom in a patient with acute coronary syndrome.
Highlights
Heart disease is the leading cause of death in the United States and around the world.[1]
acute coronary syndrome (ACS) is a spectrum of heart diseases that include ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, and unstable angina.[2]
Otalgia is reported as a possible presentation of ACS in the 2014 American Heart Association guidelines for management of non-ST-elevation myocardial infarction.[2]
Summary
Heart disease is the leading cause of death in the United States and around the world.[1]. A 47-year-old male with a past medical history of hypertension and coronary artery disease presented to the emergency department complaining of bilateral otalgia. Pertinent negatives include no chest pain, shortness of breath, nausea, vomiting, diaphoresis, dizziness, tinnitus, hearing loss, fevers, or chills His past medical history was significant for 2 non-ST-elevation myocardial infarctions 6 and 10 years prior to admission that required 3 coronary stents, which he did not know any additional information about. The initial EKG showed sinus rhythm with Q-waves in the inferior leads and nonspecific ST changes in the lateral leads (Figure 1) He was admitted to the hospital for observation given his significant history of coronary artery disease. His ear fullness and otalgia improved immediately after the angioplasty and completely resolved the following day
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