Otalgia

Aka: Otalgia, Ear Pain

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II. Physiology

  1. Ear shares sensory fibers from head, neck and chest
    1. Trigeminal Nerve (CN 5)
      1. V3 branch innervates anterior and superior External Ear
    2. Cervical nerves (C2 and C3)
      1. C2 innervates posterior and inferior External Ear
    3. Facial Nerve (CN 7)
      1. Innervates posterior ear canal and parts of Tympanic Membrane
    4. Glossopharyngeal Nerve (CN 9)
      1. Innervates middle ear
    5. Vagus Nerve (CN 10)
      1. Innervates middle ear
  2. Primary Ear Pain sources
    1. Auricle (CN 5, 7, 10 and C2-3)
    2. External auditory canal (CN 5,7, 10)
    3. Tympanic Membrane (CN 7, 9, 10)
    4. Middle Ear (CN 5, 7, 9)

III. History

  1. Pain location, quality, duration and radiation
  2. Palliative and provocative factors
  3. Prior episodes of Ear Pain
  4. Associated symptoms suggestive of primary Otalgia
    1. Otorrhea
    2. Tympanic Membrane fullness
    3. Vertigo
    4. Hearing Loss
    5. Continuous and progressive Ear Pain
  5. Associated symptoms suggestive of secondary Otalgia
    1. Pain worse with chewing
    2. Dental procedures
    3. Sinusitis
    4. Gastroesophageal Reflux
    5. Hearing Loss absent
    6. Intermittent Ear Pain
    7. Temporomandibular Joint Dysfunction
  6. Exposures
    1. Daycare attendance
    2. Recent swimming or water exposure
    3. Ear canal instrumentation or procedures
    4. Ear Barotrauma (e.g. recent air travel, Scuba Diving)
  7. Other Risks
    1. Diabetes Mellitus
    2. Immunosuppression
    3. Tobacco Abuse
    4. Alcohol Abuse

IV. History: Red Flags to suggest secondary cause (esp. persistent symptoms)

  1. Age over 50 years (malignancy, Temporal Arteritis)
  2. Tobacco use (malignancy, vascular disease)
  3. Cardiac Risk Factors (Coronary Artery Disease, thoracic aneurysm)

V. Exam

  1. External Ear exam
    1. Auricle
    2. Periauricular area
    3. Tragus tenderness or pinna traction pain (Otitis Externa)
    4. Mastoid region tenderness (Mastoiditis)
  2. Otoscopy
    1. External auditory canal (e.g. edema, discharge, foreign bodies)
    2. Tympanic Membrane (e.g. erythema, bulging, retraction, perforation)
  3. Mouth Exam
    1. Dental Infection or Dental Pain
    2. Pharyngitis
  4. Nasal Exam
    1. Paranasal Sinus tenderness
    2. Inflamed nasal mucosa
    3. Nasal Polyps
  5. Other regional exam
    1. Head and Neck Lymphadenopathy
    2. Temporomandibular Joint exam
    3. Cervical Spine exam (for referred cervical radicular pain)
    4. Hearing Exam
    5. Tuning Fork Test (when indicated for Hearing Loss)

VI. Causes: Primary Ear Conditions (50-60% of Otalgia cases)

  1. Common
    1. Cerumen Impaction
    2. Ear Canal Foreign Body
    3. Otitis Externa
    4. Suppurative Otitis Media
    5. Serous Otitis Media
    6. Eustachian Tube Dysfunction (often with Upper Respiratory Infection)
    7. Ear Barotrauma
  2. Uncommon: Urgent
    1. Malignant Otitis Externa (esp. age >60 years, Immunocompromised, Diabetes Mellitus)
    2. Ramsay Hunt Syndrome (Herpes Zoster Oticus)
    3. Cholesteatoma
    4. Mastoiditis
    5. Cellulitis (auricle)
  3. Uncommon: Other
    1. Relapsing Polychondritis
    2. Ear Trauma
    3. Granulomatosis with Polyangiitis (previously known as Wegener's Granulomatosis)
      1. Associated with frequent Serous Otitis Media and Chronic Otitis Media
      2. Also associated with Hearing Loss, Oral Ulcers, Otorrhea, Rhinorrhea

VII. Causes: Secondary, Referred Pain (40-50% of Otalgia cases)

  1. Common
    1. Dental causes (38%) such as Dental Caries, Periodontal Abscess
    2. Temporomandibular Joint Disorders (35%)
    3. Cervical Spine disorders (8%) or Myofascial Pain
    4. Parotitis
    5. Pharyngitis
  2. Uncommon: Urgent
    1. See Neck Masses in Adults (including head and neck malignancy)
    2. See Neck Masses in Children
    3. Temporal Arteritis
    4. Carotidynia
    5. Angina Pectoris or Acute Coronary Syndrome
    6. Thoracic aneurysym
  3. Uncommon: Other
    1. Bell's Palsy (esp. retroauricular pain)
    2. Eagle's Syndrome (palpable styloid process elongation)
      1. Associated with recurrent globus Sensation, Dysphagia, throat pain and Otalgia
    3. Gastroesophageal Reflux
    4. Oral Aphthous Ulcers
    5. Periauricular or cervical adenitis
    6. Sialolithiasis
    7. Sinusitis
    8. Thyroiditis (rare cause of isolated Otalgia)
    9. Trigeminal Neuralgia and other regional Neuropathy (5%)

VIII. Evaluation: Secondary Ear Pain (no primary ear source identified)

  1. Malignancy risk factors (age >50, Tobacco Abuse, Alcohol Abuse, weight loss)
    1. Nasolaryngoscopy
    2. CT or MRI imaging
    3. Otolaryngology
  2. Temporal Arteritis (age >50, Jaw Claudication, Polymyalgia Rheumatica)
    1. Erythrocyte Sedimentation Rate (>50 mm/h)
  3. Suspected thoracic source (e.g. Coronary Artery Disease)
    1. Electrocardiogram
    2. Chest XRay
    3. Evaluate for Coronary Artery Disease, thoracic aorta
  4. Temporomandibular Joint Dysfunction or dental source
    1. Symptomatic management (NSAIDs, soft diet)
    2. Dental referral (or Temporomandibular Joint clinic)

IX. Management

  1. Treat underlying cause
  2. Systemic Analgesics (e.g. Acetaminophen, Ibuprofen)
  3. Topical Anesthetics (if no TM Rupture)
    1. Aurodex (Benzocaine and Antipyrine)
      1. Not available in U.S. as of 2016
      2. Risk of Contact Dermatitis (use with caution)
      3. Risk of methhemoglobinemia (do not use under age 2 years)
      4. Avoid Auralgan (expensive trade name replacement) without improved efficacy

X. References

  1. Earwood (2018) Am Fam Physician 97(1): 20-7 [PubMed]
  2. Ely (2008) Am Fam Physician 77:621-8 [PubMed]
  3. Kasper (2026) Am Fam Physician 114(3): 238-47 [PubMed]
  4. Kuttila (2004) J Orofac Pain 18:226-34 [PubMed]
  5. Shah (2003) Otolaryngol Clin North Am 36: 1137-51 [PubMed]

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