Middle ear

Acute eustachian tube obstruction

Usually mild discomfort

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

TM not red but mobility decreased

Unilateral conductive hearing loss

Clinical examination alone

Sometimes audiogram

Barotrauma

Significant pain

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

Often hemorrhage on or behind TM

Clinical examination alone

Sometimes audiogram

Mastoiditis

Recent history of otitis media

May have otorrhea, redness, and tenderness over mastoid process

Clinical examination alone

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

Sometimes audiogram

External ear

Impacted cerumen or foreign body

Visible on otoscopy

Clinical examination alone

Local trauma

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

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

Clinical examination alone

Sometimes strep culture

Neuralgia (trigeminal, sphenopalatine, glossopharyngeal, geniculate)

Random, brief, severe, lancinating pain

Clinical examination alone

TMJ disorders

Pain worsens with jaw movement, lack of smooth TMJ movement

Clinical examination alone