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Earache occurs from otologic causes (involving the external or middle ear) or from nonotologic causes referred to the ear from remote disease processes (see Table 1: Approach to the Patient With Ear Problems: Causes of Earache  ). With chronic pain (eg, > 2 to 3 wk), a tumor must be considered, particularly in older patients.
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Table 1
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Causes of Earache
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Location
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Condition
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History
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Physical Examination
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Otologic Causes
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Middle ear or mastoid process
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Otitis media, acute otitis media, chronic otitis media
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Preceding URI
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Bulging, red tympanic membrane
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Acute barotitis media (barotrauma)
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Rapid change in air pressure as in air travel or scuba diving
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Hemorrhage on or behind the tympanic membrane
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Acute eustachian tube obstruction
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Gurgling, crackling, or popping noises, with or without nasal congestion
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Unilateral conductive hearing loss and decreased tympanic membrane mobility
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Acute mastoiditis
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Fever, postauricular pain, otorrhea. Previous URI, incompletely or inadequately treated otitis media
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Fever, postauricular swelling and tenderness to palpitation. Sometimes, downward or lateral pinna displacement, edema of posterior portion of external canal
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External ear
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Otitis externa
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Earache localized to the canal, particularly in a swimmer, diabetic, or patient with seborrheic dermatitis
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Erythematous, edematous ear canal; exquisite tenderness with movement of the tragus, and thick white otorrhea
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Bullous myringitis
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Sudden pain, sometimes history of herpes
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Small blebs on the tympanic membrane, sometimes herpetic lesions adjacent to tragus
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Cerumen, impacted or foreign body
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Vague pain accompanied by hearing loss and without other symptoms
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Visualization
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Nonotologic Causes
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Cancer
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Nasopharynx, pharynx, tonsil, base of tongue, larynx
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Often tobacco and/or alcohol use
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Varies; sometimes unilateral or remitting middle ear effusion
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Infection
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Tonsillopharyngitis, peritonsillar, or other oropharyngeal abscess
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Pain with swallowing
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Pharyngeal erythema and sometimes swelling
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Neurologic
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Neuralgia (trigeminal, sphenopalatine, glossopharyngeal, geniculate)
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Severe, lancinating pain episodes
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None
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Other
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Post-tonsillectomy or adenoidectomy
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History of surgery
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Varies
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Temporomandibular joint disorder
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Pain with jaw movement
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Lack of smooth temporomandibular joint movement; trismus
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Eustachian tube obstruction inhibits equilibration between middle ear pressure and atmospheric pressure, causing pain with change in ambient pressure. Otitis media produces painful inflammation of the mucous membrane and pain from increased middle ear pressure, with bulging of the tympanic membrane.
Evaluation
History and physical
examination:
If results of an ear examination are normal, a source of referred pain is sought in areas innervated by cranial nerves responsible for sensation in the external and middle ear (5th, 9th, and 10th). Specific areas include the nose, paranasal sinuses, nasopharynx, teeth, gingiva, temporomandibular joint, mandible, parotid glands, tongue, palatine tonsils, pharynx, larynx, trachea, and esophagus.
Testing:
Otologic causes are usually diagnosed during otoscopic examination. Depending on clinical findings, nonotologic causes may require testing, including audiometry; vestibular function testing; dental films; CT of the head, temporal bone, neck, and sinuses; and MRI.
Treatment
Underlying causes are treated. Pain may be treated with oral analgesics (eg, NSAIDs, acetaminophen ). Patients with temporomandibular disorder should see a dentist experienced in its treatment and should avoid chewing gum and hard foods when experiencing symptoms.
Earache is often caused by trauma resulting from ear irrigations. Patients should not perform ear irrigations unless instructed by a physician to do so, and then only gently. An oral irrigator should never be used to irrigate the ear.
Last full review/revision November 2005
Content last modified November 2005
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