Otalgia may occur in isolation or along with discharge or hearing loss.
Pathophysiology of Otalgia
Ear pain may come from a process within the ear itself or may be referred to the ear from a nearby nonotologic source.
Pain from the ear itself may result from a pressure gradient between the middle ear and outside air, from local inflammation, or both. A middle ear pressure gradient usually involves eustachian tube obstruction, which inhibits equilibration between middle ear pressure and atmospheric pressure and also allows fluid to accumulate in the middle ear. Otitis media causes painful inflammation of the tympanic membrane as well as pain from increased middle ear pressure (causing bulging of the tympanic membrane).
Referred pain can result from disorders in areas innervated by cranial nerves responsible for sensation in the external and middle ear (5th, 9th, and 10th nerves). Specific areas include the nose, paranasal sinuses, nasopharynx, teeth, gingiva, temporomandibular joint (TMJ), mandible, parotid glands, tongue, palatine tonsils, pharynx, larynx, trachea, and esophagus. Disorders in these areas sometimes also obstruct the eustachian tube, causing pain due to a middle ear pressure gradient. Isolated ear pain is a common manifestation of migraines (1). More than two-thirds of patients presenting to a specialty ear clinic with ear pain and a normal ear examination meet diagnostic criteria for migraines established by the International Classification of Headache Disorders (2). In these cases, ear pain improves when migraines are treated (3).
Pathophysiology references
1. Lempert T, Olesen J, Furman J, et al. Vestibular migraine: diagnostic criteria. J Vestib Res 2012;22(4):167-172. doi:10.3233/VES-2012-0453
2. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018;38(1):1-211. doi:10.1177/0333102417738202
3. Sussman S, Zimmerman Z, Chishom T, Reid L, Seyyedi M. Migraine-Associated Otalgia: An Underappreciated Entity. J Audiol Otol 2022;26(2):90-96. doi:10.7874/jao.2021.00465
Etiology of Otalgia
Otalgia results from otologic causes (involving the middle ear or external ear) or from nonotologic causes referred to the ear from nearby disease processes (see table Some Causes of Otalgia).
With acute pain, the most common causes are
With chronic pain (> 2 to 3 weeks), the most common causes are
Chronic eustachian tube dysfunction
Also with chronic pain, a tumor must be considered, particularly in older patients and if the pain is associated with ear drainage or any bleeding from the ear canal. People with diabetes or chronic kidney disease or in other immunocompromised states may develop a particularly severe form of otitis externa called necrotizing otitis externa (previously called malignant otitis externa). In this situation, if abnormal soft tissue is found on examination of the ear canal, the tissue must be biopsied to exclude cancer.
TMJ dysfunction and migraine are common causes of otalgia in patients with a normal ear examination.
Some Causes of Otalgia
Cause | Suggestive Findings* | Diagnostic Approach |
|---|---|---|
Middle ear | ||
Acute eustachian tube obstruction | Usually mild discomfort often described as fullness Gurgling, crackling, or popping noises, with or without nasal congestion, especially during yawning or swallowing TM not red but mobility decreased or appears retracted Unilateral conductive hearing loss | History and physical examination Sometimes audiogram |
Significant pain History of rapid change in air pressure (eg, air travel, scuba diving) Often hemorrhage on or behind TM | History and physical examination Audiogram if hearing loss reported | |
Recent history of otitis media May have otorrhea, redness, and tenderness or fluctuance over mastoid bone behind the ear | History and physical examination CT with contrast | |
Significant pain, often URI symptoms Bulging TM More common among children Possible discharge if TM perforated Perceived hearing loss almost always present due to fluid behind TM Sometimes loss of "light reflex" or color of TM; however, neither are sensitive nor specific for excluding otitis media | History and physical examination Sometimes audiogram | |
External ear | ||
Visible on otoscopy | History and physical examination alone | |
Usually history of attempts at ear cleaning Canal lesion visible on otoscopy | History and physical examination alone | |
Itching and pain (more itching and only mild discomfort in chronic otitis externa) Often history of swimming or recurrent water exposure Sometimes foul-smelling discharge Canal red, swollen; purulent debris TM normal but often not visible if canal edema is present | History and physical examination CT of temporal bone if necrotizing otitis externa suspected | |
Nonotologic causes† | ||
Cancer (nasopharynx, tonsils, base of tongue, larynx) | Chronic discomfort Often long history of tobacco or alcohol use Sometimes middle ear effusion, cervical lymphadenopathy Usually in older patients | Gadolinium-enhanced MRI Biopsy of visible lesions |
Infection (tonsils, peritonsillar abscess) | Pain with swallowing Visible pharyngeal erythema Bulging if abscess | History and physical examination Sometimes culture for streptococci |
Migraine | History of migraine with normal otoscopy and physical examination Symptoms worsened by typical migraine triggers (eg, stress, sleep deprivation) | History and physical examination alone |
Neuralgia (trigeminal, sphenopalatine, glossopharyngeal, geniculate) | Random, brief, severe, lancinating pain | History and physical examination MRI to exclude vascular compression of nerve |
Pain worsens with jaw movement, lack of smooth TMJ movement | History and physical examination alone | |
* Some degree of conductive hearing loss is common in many middle and external ear disorders. | ||
† Common feature is normal ear examination. | ||
CT= computed tomography; MRI = magnetic resonance imaging; TM = tympanic membrane; TMJ = temporomandibular joint; URI = upper respiratory infection. | ||
Evaluation of Otalgia
History
History of present illness should assess the location, duration, and severity of ear pain and whether it is constant or intermittent. If intermittent, it is important to determine whether pain is random or occurs mainly with swallowing or jaw movement. Important associated symptoms include ear drainage, hearing loss, and sore throat. The patient should be asked about any attempts at cleaning the ear canal (eg, with cotton swab) or other recent instrumentation, foreign bodies, recent air travel or scuba diving, and swimming or other recurrent water exposure to ears.
Review of systems should ask about symptoms of chronic illness, such as weight loss and fevers.
Past medical history should ask about known diabetes or other immunocompromised state, previous ear disorders (particularly infections), and amount and duration of tobacco and alcohol use. Patients should also be asked about prior otologic history (eg, prior ear discharge, hearing loss, tinnitus) and otologic surgery (eg, tympanostomy tubes during childhood).
Physical examination
Patients should be checked for fever.
Examination focuses on the ears, nose, and throat.
The pinna and area over the mastoid process should be inspected for redness and swelling. The pinna is gently tugged; significant pain exacerbation with tugging suggests otitis externa. The ear canal should be examined for redness, discharge, swelling, cerumen or foreign body, and any other lesions. The tympanic membrane should be examined for redness, perforation, and signs of middle ear fluid collection (eg, bulging, distortion).
A brief bedside test of hearing should be conducted, including the Weber and Rinne tests using a 512-Hz tuning fork. If a tuning fork is not available, the patient can be asked to hum at a low frequency. If the humming is heard louder in the affected ear, this suggests that the patient has conductive hearing loss, such as that due to a middle ear effusion or inflammation of the tympanic membrane. If the humming is heard louder in the unaffected ear, this suggests a sensorineural hearing loss in the affected ear at the frequency of humming (about 200 Hz).
The throat should be examined for erythema, tonsillar exudate, peritonsillar swelling, and any mucosal lesions suggesting cancer.
TMJ function should be assessed by palpation of the joints on opening and closing of the mouth, and notation should be made of trismus or evidence of bruxism such as wearing down of teeth.
The neck should be palpated for lymphadenopathy. In-office fiberoptic examination of the pharynx and larynx should be considered, particularly if no cause for the pain is identified on routine examination and if nonotologic symptoms such as hoarseness, difficulty swallowing, or nasal obstruction are reported.
Red flags
The following findings are of particular concern:
Diabetes or immunocompromised state or chronic kidney disease
Redness and fluctuance over mastoid and protrusion of auricle
Severe swelling at external auditory canal meatus
Chronic pain, especially if associated with other head/neck symptoms
Pain that wakes the patient from sleep
Interpretation of findings
An important differentiator is whether the ear examination is normal; middle and external ear disorders cause abnormal physical findings, which, when combined with history, usually suggest an otogenic etiology (see table Some Causes of Otalgia). For example, patients with chronic eustachian tube dysfunction have abnormalities of the tympanic membrane, typically a retraction pocket.
Patients with a normal ear examination may have a visible oropharyngeal cause, such as tonsillitis or peritonsillar abscess. Ear pain due to neuralgia (such as trigeminal neuralgia, or much less commonly, glossopharyngeal neuralgia) has a classic manifestation as brief (usually seconds, always < 2 minutes) episodes of extremely severe, sharp pain. Chronic ear pain without abnormality on ear examination might be due to a TMJ disorder or migraine, but patients should have a thorough head and neck examination (including fiberoptic examination) to exclude cancer.
Testing
Most cases are clear after history and physical examination. Depending on clinical findings, nonotologic causes may require testing (see table Some Causes of Otalgia). Patients with a normal ear examination, particularly with chronic, nocturnal, or recurrent pain, may warrant evaluation with an MRI of the base of skull to exclude cancer.
Treatment of Otalgia
Underlying disorders in patients with ear pain are treated.
Pain is treated with oral analgesics; usually a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen is adequate, but sometimes a brief course of an oral opioid is necessary, particularly for cases of severe otitis externa. In cases of severe otitis externa, effective treatment requires suction of debris from the ear canal and insertion of a wick to allow for delivery of antibiotic ear drops to the infected tissue. Oral antibiotics are not used unless part or all of the pinna is erythematous, suggesting spread of infection. Oral antibiotics also may be used for patients who are immunocompromised (eg, patients with diabetes or end-stage renal disease). Topical analgesics are generally not very effective and are not routinely recommended.
Patients should be instructed to avoid digging in their ears with any objects (no matter how soft the objects are or how careful patients claim to be). Patients with otitis externa should keep their ears dry. Also, patients should not irrigate their ears unless instructed by a physician to do so, and then only gently. An oral irrigator should never be used to irrigate the ear.
Key Points
Most cases are due to infection of the middle or external ear.
History and physical examination are usually adequate for diagnosis.
Nonotologic causes should be considered when ear examination is normal.
