Red ear syndrome and lesser occipital nerve block

IntroductionRed ear syndrome (RES) is a rare condition characterized by episodes of burning pain and redness of the external ear. Its pathophysiology remains unclear, and both peripheral mechanisms, involving the upper cervical roots, and central mechanisms, involving the trigeminal autonomic reflex, have been proposed.Case reportWe report a 44-year-old man with a 3-year history of left ear pain and redness, occurring five times per week and lasting more than 60 minutes, sometimes triggered by touching the tragus. He also had migraine ipsilateral to the red ear, but the red ear attacks did not occur during the migraine attacks. There were no cranial autonomic symptoms, and neurological and otorhinolaryngological examinations, including magnetic resonance imaging, were normal. On examination, there was tenderness over the lesser occipital nerve, and its anesthetic blockade led to the complete disappearance of symptoms for ten days. He was then treated with amitriptyline 25 mg/day, with excellent response, and is currently asymptomatic. We also review the literature on the mechanisms, differential diagnosis and treatment of RES.ConclusionThe response to the lesser occipital nerve blockade suggests that upper cervical afferents, possibly through convergence in the trigeminocervical complex, may contribute to RES in selected patients. Tenderness over the upper cervical nerves should be investigated in patients with RES, and peripheral nerve blocks deserve further study in this condition.