Some Causes of Otalgia

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

Barotrauma

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

Mastoiditis

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

Otitis media (acute or chronic)

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

Impacted cerumen or foreign body

Visible on otoscopy

History and physical examination alone

Local trauma

Usually history of attempts at ear cleaning

Canal lesion visible on otoscopy

History and physical examination alone

Otitis externa (acute or chronic)

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

TMJ disorders

Pain worsens with jaw movement, lack of smooth TMJ movement

History and physical examination alone