Inferior ST-Elevation Myocardial Infarction (STEMI) Presenting as Left Otalgia: A Case Report

Diabetic populations are predisposed to atypical, or sometimes silent, responses to myocardial ischemia. This is often the result of chronic neuropathy involving the nociceptive sympathetic pathways of the heart that converge at the T1-T4/5 spinal columns. When these signals are blunted, ischemic pain signals may be delivered via the "Arnold's nerve," the auricular branch of the vagus that innervates the external auditory canal.  A 70-year-old woman with a history of type 2 diabetes (diagnosed 14 years before presentation), hypertension, hyperlipidemia, and chronic obstructive pulmonary disease presented to the urgent care for a 24-hour history of left ear pain. Following a negative otoscopic exam, she was advised to apply warm compresses and use Tylenol. The subsequent day, she developed intractable nausea, vomiting, and generalized weakness. Emergency medical services were notified and en route identified an acute inferior ST-elevation myocardial infarction (STEMI) via 12-lead electrocardiogram. Emergent left heart catheterization revealed total right coronary artery occlusion, which resolved after deployment of two drug-eluting stents. Her symptoms of left ear pain and nausea resolved postintervention, and she was discharged the following day. This case thus underscores an exceedingly rare but critical anginal equivalent in diabetics, left otalgia.