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David M. Kaylie

, MS, MD, Duke University Medical Center

Last full review/revision Mar 2021| Content last modified Mar 2021
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Earache may occur in isolation or along with discharge or, rarely, hearing loss.

Pathophysiology of Earache

Ear 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 of Earache

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 Some Causes of Earache).

With acute pain, the most common causes are

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

Also with chronic pain, a tumor must be considered, particularly in older patients and if the pain is associated with ear drainage. People with diabetes or chronic kidney disease 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.


Some Causes of Earache


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 examination alone

Significant pain

History of rapid change in air pressure (eg, air travel, scuba diving)

Often hemorrhage on or behind TM

Clinical examination alone

Recent history of otitis media

May have otorrhea, redness, and tenderness over mastoid process

Sometimes clinical examination alone

Sometimes CT

Otitis media (acute or chronic)

Significant pain, often URI symptoms

Bulging, red TM

More common among children

Possible discharge if eardrum perforated

Clinical examination alone

External ear

Visible on otoscopy

Clinical examination alone

Usually history of attempts at ear cleaning

Canal lesion visible on otoscopy

Clinical 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

Sometimes clinical examination alone

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

Sometimes clinical examination alone

Sometimes strep culture

Neuralgia (trigeminal, sphenopalatine, glossopharyngeal, geniculate)

Random, brief, severe, lancinating pain

Clinical examination alone

Pain worsens with jaw movement, lack of smooth TMJ movement

Clinical examination alone

* Some degree of conductive hearing loss is common in many middle and external ear disorders.

† Clinical examination is always done but is mentioned in this column only when that can be the sole means of diagnosis.

‡ Common feature is normal ear examination.

TM = tympanic membrane; TMJ = temporomandibular joint; URI = upper respiratory infection.

Evaluation of Earache


History of present illness should assess the location, duration, and severity of ear 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

Patients 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 pinna is gently tugged; significant pain exacerbation with tugging suggests otitis externa. The ear canal should be examined for redness, discharge, swelling, 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 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 or chronic kidney disease

  • 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 Some Causes of Earache). For example, patients with chronic eustachian tube dysfunction have abnormalities of the TM, typically a retraction pocket.

Patients 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 minutes) 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.


Most cases are clear after history and physical examination. Depending on clinical findings, nonotologic causes may require testing (see table Some Causes of Earache). Patients with a normal ear examination, particularly with chronic or recurrent pain, may warrant evaluation with an MRI to rule out cancer.

Treatment of Earache

Underlying disorders in patients with ear pain are treated.

Pain is treated with oral analgesics; usually a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen 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; oral antibiotics are not used unless part or all of the pinna is erythematous, suggesting spread of infection. Topical analgesics (eg, antipyrine-benzocaine 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 patients claim 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.

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