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Earache +ir-!Ak

by Debara L. Tucci, MD, MS

Earache (otalogia) usually occurs in only one ear. Some people also have ear discharge (see see Otorrhea) or, rarely, hearing loss (see see Hearing Loss).

Causes

Pain may be due to a disorder within the ear itself or a disorder in a nearby body part that shares the same nerves to the brain as the ear. Such body parts include the nose, sinuses, throat, and temporomandibular joint (TMJ).

With acute pain (pain for less than 2 weeks), the most common causes are

  • Middle ear infection (otitis media)

  • External ear infection (otitis externa)

  • Sudden pressure change (barotrauma)

Middle and external ear infections cause painful inflammation. A middle ear infection also causes a build up of pressure behind the eardrum (tympanic membrane [TM]). This build up of pressure is painful and also causes the eardrum to bulge. After the eardrum bulges, it occasionally bursts and releases a small amount of pus from the ear. Rarely, a middle ear infection spreads to the mastoid bone behind the ear (causing mastoiditis—see see Mastoiditis).

People with diabetes and those who have a compromised immune system (due to HIV infection or chemotherapy for cancer) may develop a particularly severe form of external otitis termed malignant or necrotizing external otitis.

Pressure changes during airplane flights and underwater diving can cause ear pain. Such ear pain occurs when the tube that connects the middle ear and the back of the nose (eustachian tube) is blocked or fails to function normally. The blockage or dysfunction keeps pressure in the middle ear from equalizing with outside pressure. The pressure difference pushes or pulls on the eardrum, causing pain. Pressure changes can also cause the TM to rupture.

With chronic pain (pain for more than 2 to 3 weeks), the most common causes are

A less common cause of chronic pain is cancer, mainly in older people.

Evaluation

The following information can help people decide when a doctor's evaluation is needed and help them know what to expect during the evaluation.

Warning signs

In people with earache, certain symptoms and characteristics are cause for concern:

  • Diabetes or a compromised immune system

  • Redness and swelling behind the ear

  • Severe swelling at the opening of the ear canal

  • Fluid draining from the ear

  • Chronic pain, especially in people who have other head/neck symptoms (such as hoarseness, difficulty swallowing, or nasal obstruction)


When to see a doctor

People with warning signs or ear discharge should see a doctor as soon as possible, unless the only warning sign is chronic pain. Then, a delay of a week or so is not harmful. People with acute pain should see a doctor within a few days (or sooner if pain is severe).


What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination that is focused on the ears, nose, and throat. What they find during the history and physical examination often suggests a cause of the earache and the tests that may need to be done (see Some Causes and Features of Earache).

In addition to the presence of warning signs, an important feature is whether the ear examination is normal. Middle and external ear disorders cause abnormalities, which, when combined with the person's symptoms and other medical history, usually suggest a cause (see Some Causes and Features of Earache).

People with a normal ear examination may have a visible cause, such as tonsillitis, for their ear pain. If no abnormalities are found during the ear examination but the person has chronic pain, doctors suspect the ear pain might be due to a TMJ disorder. However, people should have a thorough head and neck examination (including fiberoptic examination) to rule out cancer or a tumor in the nasal passages and upper throat (nasopharynx).

Some Causes and Features of Earache

Cause

Common Features*

Tests

Middle ear

Acute eustachian tube obstruction (for example, due to a cold or allergies)

Mild to moderate discomfort

Gurgling, crackling, or popping noises, with or without nasal congestion

Decreased hearing in affected ear

A doctor's examination

Pressure changes (barotrauma)

Severe pain

History of recent rapid change in air pressure (such as air travel or scuba diving)

Often blood visible on or behind eardrum

A doctor's examination

Mastoiditis

Recent middle ear infection

Redness and tenderness behind the ear

Often fever and/or ear discharge

A doctor's examination

Sometimes CT scan

Otitis media (acute or chronic)

Severe pain, often with cold symptoms

Bulging, red eardrum

More common among children

Sometimes ear discharge

A doctor's examination

Infectious myringitis (eardrum infection)

Severe pain

Inflamed eardrum

Small blisters on surface of eardrum

A doctor's examination

Herpes zoster oticus

Severe pain

Blisters or pustules on the outer ear

May be accompanied by hearing loss or facial weakness

A doctor's examination

External ear

Impacted wax or foreign object

Visible during a doctor's examination

Foreign objects almost always in children

A doctor's examination

Injury

Usually in people who were attempting to clean their ear

Visible during a doctor's examination

A doctor's examination

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

Red, swollen external ear canal filled with pus-like material

A doctor's examination

CT scan if malignant external otitis suspected

Causes due to structures near the ear

Cancer of the throat, tonsils, base of tongue, voice box (larynx), or nasal passages and upper throat (nasopharynx)

Chronic discomfort

Often long history of tobacco and/or alcohol use

Sometimes enlarged, nontender lymph nodes in the neck

Usually in older people

Gadolinium-enhanced MRI

Removal and examination (biopsy) of visible lesions

Infection (tonsils, peritonsillar abscess)

Pain much worse with swallowing

Visible redness of throat and/or tonsils

A doctor's examination

Neuralgia (inflamed nerve)

Very severe, frequent, sharp pains lasting less than 1 second

A doctor's examination

TMJ disorders

Pain worsens with jaw movement

Lack of smooth TMJ movement

A doctor's examination

*Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present.

Many people with middle and external ear disorders have some hearing loss.

A common feature is a normal ear examination.

CT = computed tomography; MRI = magnetic resonance imaging; TMJ = temporomandibular joint.


Testing

Most often, the doctor's examination provides a diagnosis, and tests are not needed. However, people with a normal ear examination, particularly those with chronic or recurrent pain, may need tests to look for cancer. Such tests usually include examination of the nose, throat, and voice box (larynx) with a flexible viewing scope (endoscope) and magnetic resonance imaging (MRI) of the head and neck.


Treatment

The best way to treat earache is to treat the underlying disorder.

People may take a pain-relieving drug by mouth. Usually a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen is adequate. However, some people, particularly those who have a severe external ear infection, need to take an opioid such as oxycodone or hydrocodone for a few days. For a severe external ear infection, doctors also often suction pus or other discharge from the ear canal and insert a small foam wick. The wick can be soaked with antibiotic and/or corticosteroid ear drops.

Ear drops that contain pain relievers (such as antipyrine/benzocaine combinations) are generally not very effective but can be used for a few days. These drops (and any other ear drops, such as those to remove earwax) should not be used by people who might have a perforated eardrum, so a doctor should be consulted before drops are used.

People should avoid digging in their ears with any objects (no matter how soft the object or how careful people think they are). Also, people should not try to flush out their ears unless instructed by a doctor to do so, and then only gently. An oral irrigator (such as used for teeth cleaning) should never be used in the ear.

Key Points

  • Most earaches are due to infection of the middle or external ear.

  • A doctor's examination is usually all that is needed for diagnosis.

  • If the ear appears normal during the examination, doctors look for a disorder in the structures near the ear.

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  • ANBESOL
  • TYLENOL
  • OXYCONTIN