Medical Excellence - Issue 2

Red Ear Syndrome Precipitated by a Dietary Trigger: A Case Report Chung Chi Chan 1,2* , Susmita Ghosh 3 Introduction Red ear syndrome (RES) is a rare condition characterized by epi- sodic erythema of the ear accompanied by burning sensation or otalgia. One or, less commonly, both ears may be affected, and erythema may extend beyond the ear to the face. Symptoms may be spontaneous or triggered by touch, exertion, heat or cold, stress, neck movements, sneezing, coughing, chewing and/or brushing of hair [1]. Recognition of this condition is important but difficult because of its rarity. Case Presentation A 22-year-old Caucasian woman who was a student presented to our neuro-otology clinic on two separate occasions five years apart. Her initial symptoms were a six-month history of inter- mittent right-sided tinnitus and bilateral hyperacusis (abnor- mal sound sensitivity arising from within the auditory system to normal or moderate-level ambient noise which would not trouble other people). She also reported right ear fullness and significant difficulty hearing in background noise when stressed. *Correspondence: chung.chan@nhs.net 1 Department of Audiovestibular Medicine, St Ann’s Hospital, St Ann’s Road, London N15 3TH, UK 2 Department of Adult Audiovestibular Medicine, Royal National Throat, Nose and Ear Hospital, 330 Grays Inn Road, London WC1X 8DA, UK 3 Department of Audiovestibular Medicine, Platt Bridge Health Centre, Rivington Drive, Bickershaw, Wigan WN2 5NG, UK Abstract Introduction: Red ear syndrome is a rare condition characterized by episodic attacks of erythema of the ear accompanied by burning ear pain. Symptoms are brought on by touch, exertion, heat or cold, stress, neck movements and washing or brushing of hair. Diagnosis and treatment of this condition are challenging. The case we report here involves a woman whose symptoms were brought on by a dietary trigger: orange juice as well as stress, causing significant physical and psychological morbidity. Avoidance of triggers resulted in symptomatic improvement. Case presentation: A 22-year-old Caucasian woman who was a student presented twice to our department with evolving symptoms, the first time with hyperacusis (abnormal sound sensitivity arising from within the auditory system to sounds of moderate volume), intermittent right tinnitus and subjective hearing difficulties. She presented five years later with highly distressing episodes of erythematous ears, which were associated with burning pain around the ear and temporal areas, and intolerance to noise. After keeping a symptom diary, she identified orange juice and stress as triggers of her symptoms. No local head and neck pathology was present. Investigations and imaging were negative. Avoidance of triggers led to great symptomatic improvement. To the best of our knowledge, dietary triggers have not previously been reported as a trigger for this syndrome. This case shows a direct temporal link to a dietary trigger and supports a primary pathogenesis. Recognition and management of primary headache disorder and simple dietary and lifestyle changes brought about symptomatic relief. Conclusion: Red ear syndrome is a little-known clinical syndrome of unknown etiology and management. To the best of our knowledge, our present case report is the first to describe primary red ear syndrome triggered by orange juice. Clinical benefit derived from avoidance of this trigger, which is already known to precipitate migraines, gives some insight into the pathogenesis of red ear syndrome. Keywords: Dietary trigger, Erythema, Lifestyle modifications, Migraine, Red ear syndrome Issue-2  |  1 MEDICAL EXCELLENCE