Earache: A Merck Manual of Patient Symptoms podcast

Earache may occur in isolation or along with discharge or, rarely, hearing loss.

Pathophysiology

Pain may come from a process within the ear itself or may be referred to the ear from a nearby nonotologic disorder.

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 (TM) as well as pain from increased middle ear pressure (causing bulging of the TM).

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). 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 from a middle ear pressure gradient.

Etiology

Earache 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 1: Approach to the Patient With Ear Problems: Some Causes of Earache).

With acute pain, the most common causes are

• Middle ear infection
• External ear infection

With chronic pain (> 2 to 3 wk), the most common causes are

• TMJ dysfunction
• Chronic eustachian tube dysfunction
• Chronic otitis externa

Also with chronic pain, a tumor must be considered, particularly in elderly patients and if the pain is associated with ear drainage. People with diabetes or in other immunocompromised states may develop a particularly severe form of external otitis termed malignant or necrotizing external otitis. In this situation, if abnormal soft tissue is found on examination of the ear canal, the tissue must be biopsied to rule out cancer.

TMJ dysfunction is a common cause of earache in patients with a normal ear examination.

Table 1
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Some Causes of Earache Cause Suggestive Findings* Diagnostic Approach Middle ear Acute eustachian tube obstruction Less severe discomfort Gurgling, crackling, or popping noises, with or without nasal congestion TM not red but mobility decreased Unilateral conductive hearing loss Clinical evaluation Barotrauma Significant pain History of rapid change in air pressure (eg, air travel, scuba diving) Often hemorrhage on or behind TM Clinical evaluation Mastoiditis Recent history of otitis media May have otorrhea, redness, and tenderness over mastoid process Clinical evaluation Sometimes CT to monitor extent and complications Otitis media (acute or chronic) Significant pain, often URI symptoms Bulging, red TM More common among children Possible discharge if eardrum perforated Clinical evaluation External ear Impacted cerumen or foreign body Visible on otoscopy Clinical evaluation Local trauma Usually history of attempts at ear cleaning Canal lesion visible on otoscopy Clinical evaluation 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 Clinical evaluation CT of temporal bone if malignant external otitis 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 Clinical evaluation Sometimes strep culture Neuralgia (trigeminal, sphenopalatine, glossopharyngeal, geniculate) Random, brief, severe, lancinating pain Clinical evaluation TMJ disorders Pain worsens with jaw movement, lack of smooth TMJ movement Clinical evaluation *Some degree of conductive hearing loss is common in many middle and external ear disorders. †Common feature is normal ear examination. TM = tympanic membrane; TMJ = temporomandibular joint. Some Causes of Earache Cause Suggestive Findings* Diagnostic Approach Middle ear Acute eustachian tube obstruction Less severe discomfort Gurgling, crackling, or popping noises, with or without nasal congestion TM not red but mobility decreased Unilateral conductive hearing loss Clinical evaluation Barotrauma Significant pain History of rapid change in air pressure (eg, air travel, scuba diving) Often hemorrhage on or behind TM Clinical evaluation Mastoiditis Recent history of otitis media May have otorrhea, redness, and tenderness over mastoid process Clinical evaluation Sometimes CT to monitor extent and complications Otitis media (acute or chronic) Significant pain, often URI symptoms Bulging, red TM More common among children Possible discharge if eardrum perforated Clinical evaluation External ear Impacted cerumen or foreign body Visible on otoscopy Clinical evaluation Local trauma Usually history of attempts at ear cleaning Canal lesion visible on otoscopy Clinical evaluation 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 Clinical evaluation CT of temporal bone if malignant external otitis 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 Clinical evaluation Sometimes strep culture Neuralgia (trigeminal, sphenopalatine, glossopharyngeal, geniculate) Random, brief, severe, lancinating pain Clinical evaluation TMJ disorders Pain worsens with jaw movement, lack of smooth TMJ movement Clinical evaluation *Some degree of conductive hearing loss is common in many middle and external ear disorders. †Common feature is normal ear examination. TM = tympanic membrane; TMJ = temporomandibular joint.

Evaluation

History: History of present illness should assess the location, duration, and severity of pain and whether it is constant or intermittent. If intermittent, it is important to determine whether it 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.

Physical examination: Vital signs 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 ear canal should be examined for redness, discharge, cerumen or foreign body, and any other lesions. The TM should be examined for redness, perforation, and signs of middle ear fluid collection (eg, bulging, distortion, change in normal light reflex). A brief bedside test of hearing (see Hearing Loss: Evaluation of Hearing Loss) should be conducted.

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.

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
• 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

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 etiology (see Table 1: Approach to the Patient With Ear Problems: Some Causes of Earache). For example, those with chronic eustachian tube dysfunction have abnormalities of the TM, typically a retraction pocket.

Those with a normal ear examination may have a visible oropharyngeal cause, such as tonsillitis or peritonsillar abscess. Ear pain due to neuralgia has a classic manifestation as brief (usually seconds, always < 2 min) episodes of extremely severe, sharp pain. Chronic ear pain without abnormality on ear examination might be due to a TMJ disorder, but patients should have a thorough head and neck examination (including fiberoptic examination) to rule out cancer.

Testing: Most cases are clear after history and physical examination. Depending on clinical findings, nonotologic causes may require testing (see Table 1: Approach to the Patient With Ear Problems: Some Causes of Earache). Those with a normal ear examination, particularly with chronic or recurrent pain, may warrant evaluation with an MRI to rule out cancer.

Treatment

Underlying disorders are treated.

Pain is treated with oral analgesics; usually an NSAID or acetaminophenSome Trade Names
GENAPAP
TYLENOL
VALORIN
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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. Topical analgesics (eg, antipyrine-benzocaineSome Trade Names
AMERICAINE
ANBESOL
HURRICAINE
ORAJEL BABY TEETHING
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combinations) are generally not very effective but can be used on a limited basis.

Patients should be instructed to avoid digging in their ears with any objects (no matter how soft the objects are or how careful the patient claims to be). 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.

Last full review/revision January 2009 by Debara L. Tucci, MD, MS

Content last modified February 2012