Ear Pain – Causes, Symptoms, Diagnosis, Treatment

Ear Pain is also known as earache, is a pain in the ear. Primary ear pain is pain that originates from the ear. Secondary ear pain is a type of referred pain, meaning that the source of the pain differs from the location where the pain is felt.^[rx][rx]

Otalgia or ear pain, in or about the external ear and temporal bone may occur from multiple causes, many of which are remote from the ear itself. Otorrhea, or ear drainage, indicates inflammation of the external or middle ear or both. The Otorrhea may be clear, sanguineous, mucoid, or purulent.

Otalgia (ear pain) divides into two broad categories: primary and secondary otalgia. Primary otalgia is ear pain that arises directly from pathology within the inner, middle, or external ear.  Secondary or referred otalgia is ear pain that occurs from pathology located outside the ear. A complex neural network innervates the ear as a result of complex embryologic development. The ear shares this neural network with other organs, which leads to numerous potential causes of referred ear pain.[rx]

Cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), X (vagus), and branches from the cervical plexus (C2 and C3) all innervate the ear.[rx][rx]

• The auricle is innervated by cranial nerves V, VII, X, C2, and C3.
• The ear canal is innervated by cranial nerves V, VII, and X.
• The tympanic membrane is innervated by cranial nerves VII, IX, and X.
• The middle ear is innervated by cranial nerves V, VII, and IX.

Cranial nerves V, VII, IX, X, C2, and C3 also innervate organs outside of the ear, leading to numerous potential causes of referred ear pain. 

• Cranial nerve V (trigeminal) – is composed of the ophthalmic (V1), maxillary (V2), and mandibular (V3) branches.  It provides sensory innervation for the face, sinuses, palate, and teeth.  The auriculotemporal branch of cranial nerve V innervates the temporomandibular joint (TMJ). This branch is most commonly implicated in temporomandibular joint disease. Dental and TMJ pathology are common secondary causes of otalgia.
• Cranial nerve VII (facial) – innervates the anterior two-thirds of the tongue, sublingual, and submandibular salivary glands.  It also innervates the muscles of facial expression.
• Cranial nerve IX (glossopharyngeal) – innervates the posterior third of the tongue, carotid body, and oropharynx.
• Cranial nerve X (vagus) – innervates the sinuses, thyroid gland, pharynx, and larynx.  The superior laryngeal branch of the vagus nerve innervates the vocal cords.  It also innervates distant organs such as the heart, lung, and parts of the gastrointestinal tract.
• C2 and C3 –  which are branches of the cervical plexus, innervate the back of the head, sternocleidomastoid, and cervical paraspinal muscles.

Types of Ear Pain

Otalgia classifies into primary versus secondary or referred causes. The differential diagnosis is extensive and receives more detailed coverage below. Thus, a comprehensive and systematic approach to otalgia is essential.

• Primary otalgia classifies into infectious, mechanical, neoplastic, and inflammatory causes.
• Secondary otalgia is best classified based on organ systems. More proximal causes of the head and neck include dental and temporomandibular pathology. Distant etiologies include cardiac, gastrointestinal, and lung pathology.

Pathophysiology

Primary otalgia occurs most commonly from infection. Acute otitis media (AOM) ranks as the number one cause of primary otalgia in children. The disease is typically associated with an upper respiratory tract infection that causes congestion and swelling of the eustachian tube. Between the middle ear and the eustachian tube, there is a narrowing of the eustachian tube called the bony-cartilaginous junction or isthmus.  The swelling of the eustachian tube at this location can prevent the middle ear drainage. This collection of middle ear secretions can initially generate an effusion, leading to obstruction and potential bacterial growth.[rx] In adults, chronic otitis media is the most common primary disease. Its pathophysiology is the same as AOM and can result from upper respiratory infections or allergic rhinitis. Infections can also directly affect the auricle or ear canal in perichondritis or otitis externa, respectively. If the infection spreads to adjacent bone, it can cause petrous apicitis, mastoiditis, or malignant otitis externa.

Secondary or referred otalgia occurs as a result of the complex cranial nerve network that innervates the ear.  These cranial nerves have a shared connection between the ear and organs outside of the ear.  One theoretical mechanism of referred otalgia is the convergence-projection theory, which states that these nerves converge onto a shared neural pathway.[rx] Given the extent of different organs that share innervation pathways with the ear, secondary otalgia can arise from many different organs.

Causes of Ear Pain

External ear

Many conditions involving the external ear will be visible to the naked eye.  Because the external ear is the most exposed portion of the ear, it is vulnerable to trauma or environmental exposures.^[rx]  Blunt trauma, such as a blow to the ear, can result in a hematoma, or collection of blood between the cartilage and perichondrium of the ear. This type of injury is particularly common in contact sports such as wrestling and boxing.^[rx] Environmental injuries include sunburn, frostbite, or contact dermatitis.^[rx]

Less common causes of external ear pain include

• Auricular Cellulitis – a superficial infection of the ear that may be precipitated by trauma, an insect bite, or ear piercing
• Perichondritis – infection of the perichondrium, or fascia surrounding the ear cartilage, which can develop as a complication of untreated auricular cellulitis. It is important to identify and treat perichondritis with antibiotics to avoid permanent ear deformities.
• Relapsing polychondritis – a systemic inflammatory condition involving cartilage in many parts of the body, but often including the cartilage of both ears. The severity and prognosis of the disease vary widely.^[rx]

Otitis externa

Otitis externa, also known as “swimmer’s ear”, is a cellulitis of the external ear canal. In North America, 98% of cases are caused by bacteria, and the most common causative organisms are Pseudomonas and Staph aureus.^[rx] Risk factors include exposure to excessive moisture (e.g. from swimming or a warm climate) and disruption of the protective cerumen barrier, which can result from aggressive ear cleaning or placing objects in the ear.^[rx]

Malignant otitis externa is a rare and potentially life-threatening complication of otitis externa in which the infection spreads from the ear canal into the surrounding skull base, hence becoming osteomyelitis. It occurs largely in diabetic patients.^[rx] It is very rare in children, though can be seen in immunocompromised children and adults.^[rx] Pseudomonas is the most common causative organism.^[rx] 

Mechanical obstruction

• Earwax impaction – results in 12 million medical visits annually in the United States.^[rx] Cerumen impaction may cause ear pain, but it can also prevent thorough examination of the ear and identification of an alternate source of pain.
• Foreign body – commonly include insects or small objects like beads^[rx]

Less common

• Herpes zoster – the varicella-zoster virus can reactivate in an area that includes the ear. Reactivation can produce pain and visible vesicles within the ear canal and, when combined with facial paralysis due to facial nerve involvement, is called Ramsay Hunt syndrome.^[rx]
• Tumors – the most common ear canal tumor is squamous cell carcinoma. Symptoms can resemble those of otitis externa, and cancer should be considered if the symptoms are not improving on appropriate treatment.^[rx]

Middle and inner ear

Acute otitis media

Acute otitis media is an infection of the middle ear. More than 80% of children experience at least one episode of otitis media by age 3 years.^[rx] Acute otitis media is also most common in these first 3 years of life, though older children may also experience it.^[rx] The most common causative bacteria are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.^[rx] Otitis media often occurs with or following cold symptoms.^[rx] The diagnosis is made by the combination of symptoms and examination of the tympanic membrane for redness, bulging, and/or a middle ear effusion (collection of fluid within the middle ear).^[rx]

Complications of otitis media include hearing loss, facial nerve paralysis, or extension of infection to surrounding anatomic structures, including:^[rx]

• Mastoiditis – infection of the air cells in the mastoid process, the area of the skull located right behind the ear^[rx]
• Petrositis – infection of the petrous portion of the temporal bone
• Labyrinthitis
• Meningitis
• Subdural abscess
• Brain abscess

Trauma

• Barotrauma – results from changes in atmospheric pressure that occur when descending in a plane or deep diving.  As atmospheric pressure increases with descent, the eustachian tube collapses due to pressure within the middle ear is less than the external pressure, which causes pain. In severe cases, middle ear hemorrhage or tympanic membrane rupture can result.^[rx]
• Tympanic membrane rupture – disruption of the eardrum. This can be caused by a blow to the ear, blast injury, barotrauma, or direct penetration of the tympanic membrane by an object entering the ear.^[5]

Referred ear pain

A variety of conditions can cause irritation of one of the nerves that provide sensation to the ear.

Conditions causing irritation the trigeminal nerve (cranial nerve V):^[rx]

• Temporomandibular joint syndrome – inflammation or abnormal movements of the joint between the jaw and skull. These disorders are most common in women of childbearing age, and are uncommon in children younger than 10 years old.^[rx]
• Myofascial pain syndrome – pain in the muscles involved in chewing. There may be certain parts of the muscles or tendons (connective tissue connecting the muscles to bones) that are especially painful when pressed^[rx]
• Trigeminal neuralgia – attacks of shooting pain down the face that may be triggered by touching the face or temperature changes^[rx]
• Dental pain from cavities or an abscess
• Oral cavity carcinoma

Conditions causing irritation of the facial nerve (cranial nerve VII) or glossopharyngeal nerve (cranial nerve IX)

• Tonsillitis – infection/inflammation of the tonsils
• Post-tonsillectomy – pain following surgical removal of the tonsils
• Pharyngitis – infection/inflammation of the throat
• Sinusitis
• Parotitis – inflammation of the parotid gland, the salivary gland right in front of the ear
• Carcinoma of the oropharynx – (base of tongue, soft palate, pharyngeal wall, tonsils)

Conditions causing irritation of the vagus nerve (cranial nerve X)

• GERD
• Myocardial ischemia (inadequate oxygen supply to the heart muscle)

Conditions causing irritation of cervical nerves C2-C3:^[rx][rx]

• Cervical spine trauma, arthritis – (joint inflammation), or tumor
• Temporal arteritis – an autoimmune disorder leading to inflammation of the temporal artery, a large artery in the head. This condition tends to occur in adults older than 50.^[rx]

Diagnosis of Ear Pain

History and Physical

• A comprehensive history and physical examination are vital to evaluate otalgia. The clinician must consider both primary and secondary causes.  History should include the following:

Red flags associated with otalgia include[rx]

• Dysphagia, odynophagia, dysphonia, or hemoptysis
• Loss of vision or black spots
• Unintended weight loss

Risk factors for a serious diagnosis, such as malignancy include [rx][rx]

• History of smoking
• History of alcohol use (approximately 3.5 or more drinks per day)
• Immunosuppressed state, i.e., diabetes mellitus

Key features on history include

• Shorter time-frames suggest more benign causes.  Longer time-frames suggest a secondary cause.[rx]
• Ear pain lasting over four weeks is more suspicious for malignancy, especially if in the presence of risk factors and normal otoscopy.[rx][rx]
• Ear fullness rather than ear pain may be more associated with cholesteatomas.
• Sharp, lancinating pain is more indicative of neuralgia or neuropathy.
• Malignancy tends to cause unilateral symptoms.[rx]
• Ear pain exacerbated by swallowing is suggestive of glossopharyngeal neuralgia.[rx]
• Of note, 1 case series noted “the otalgia point,” located at the apex of the jugulodigastric region.  The case series included 32 patients who pointed to this location, who also had normal physical examinations, tympanogram, and age-appropriate audiograms. This point was found to correlate more with symptom relief after either myringotomy or nasal steroid usage.[rx]

The following associated symptoms could indicate the following referred origins:

• Sinus congestion – chronic rhinosinusitis
• Toothaches – dental pathology
• Hoarseness – vocal cord condition
• Heartburn – gastroesophageal reflux
• Chest pain – coronary artery disease
• Shortness of breath– lung disease
• Upper back pain – cervical disc disease or myofascial pain
• Headache, diplopia, malaise, jaw claudication, diplopia – temporal arteritis

It is also possible for patients to experience otalgia during the early postoperative phase of tonsillectomies.

Physical examination should include the following:

• Ear examination to identify signs of infection or other signs of primary etiologies. It may also reveal vesicular lesions, which can be found in herpes zoster oticus infection (Ramsay Hunt syndrome if it occurs with facial paralysis).
• Nasal examination to identify inflamed nasal mucosa or nasal polyps. It may reveal chronic rhinosinusitis.
• Oral cavity examination to identify dental caries, loose fillings, aphthous ulcers, abnormal growths, or abscesses.  Intra-oral palpation may also detect an elongated styloid process, which can occur in Eagle syndrome.[rx]
• Temporomandibular joint examination to identify temporalis, lateral/medial pterygoid, or masseter muscle tenderness. It may reveal trigger points or TMJ syndrome.
• Head examination to identify parotid or other salivary gland pathologies. It may reveal salivary gland tumors or sialadenitis. Tenderness along the temporal artery may reveal temporal arteritis.
• Neck examination to identify lymphadenopathy or thyroid gland pathology. It may reveal thyroiditis or lymph node malignancies.
• Cervical spine examination to identify cervical spine and related musculoskeletal exam pathology. It may reveal myofascial pain or cervical degenerative disc disease.
• Cranial nerve full examination to identify cranial nerve neuropathies. It may reveal trigeminal, glossopharyngeal, geniculate, sphenopalatine, occipital, vagal neuralgia, or Ramsay Hunt syndrome.[rx][rx]
• Cervical spine, cardiac, pulmonary, or abdominal physical examinations to identify referred pain from distant organ systems from the ear.

Evaluation

The first step in evaluating otalgia includes a comprehensive history and physical examination. Evaluation should exclude red flags and risk factors for a serious diagnosis.

• If found, then head & neck CT and MRI, panendoscopy, including nasolaryngoscopy and direct visualization of the upper aerodigestive tract, can be ordered. Gastrointestinal red flags should prompt a barium swallow or referral to gastroenterology for esophagogastroduodenoscopy (EGD).
• Chest pain and cardiac risk factors should prompt a full cardiac work-up. Clinical signs of temporal arteritis should prompt an ESR. An ESR greater than 50mm per hour indicates the need for an urgent referral to ophthalmology and otolaryngology.[rx]
• The pain tends to be more severe than in uncomplicated otitis externa, and laboratory studies often reveal elevated inflammatory markers (ESR and/or CRP). The infection may extend to cranial nerves, or rarely to the meninges or brain. Examination of the ear canal may reveal granulation tissue in the inferior canal. It is treated with several weeks of IV and oral antibiotics, usually fluoroquinolones.^[rx]
• The next step should include an assessment of primary otalgia. Evaluation beyond a comprehensive history and physical examination is rarely necessary for primary otalgia. Acute otitis media is the most common cause of primary otalgia. Pneumo-otoscopy will reveal opacification, bulging, and immobility of the tympanic membrane.  Eustachian tube dysfunction is another common cause of otalgia. Tympanometry will reveal abnormalities such as negative pressure within the middle ear. The Eustachian Tube Dysfunction Questionnaire (EDTQ-7) can also be an option in the primary care setting.[rx] Audiometry could be a consideration if hearing loss is also present.
• If the ear exam is normal and without an obvious cause of otalgia, then the next step is to perform a comprehensive evaluation for secondary causes. Clinical assessment should guide the need for lab or imaging studies.  Dental and the temporomandibular joint are common sources of secondary or referred otalgia.
• Orthopantogram can provide a fast and easy way to give a panoramic view of the lower jaw and teeth. Imaging studies are not routinely required to evaluate temporomandibular joint disorder. CT imaging of the temporal bone may be used to assess for petrous capacities. CT and MRI imaging can also evaluate malignant otitis externa. MRI of the cranial nerves can be ordered to evaluate cranial neuropathy. A complete blood count (CBC) can help screen for infection.

If the patient has not red flags, no risk factors for a serious diagnosis such as malignancy, no clinical signs of referred otalgia, then it is reasonable to trial non-steroidal analgesics such as ibuprofen or acetaminophen. If symptoms persist for over four weeks, then specialty referral and all of the above studies can be re-considered.[rx]

Treatment

Treatment of otalgia is dependent on the diagnosis. This section will review the salient points. Infections cause most primary otalgia and are treated with antibiotics, while mechanical receive treatment with decongestants, nasal steroids, or myringotomy. Secondary causes include a wide variety of diagnoses. One notable management point is the need for urgent referral and steroid treatment for temporal arteritis, a rare cause of secondary otalgia. Therapy otherwise addresses the underlying medical condition, such as malignancy, dental caries, temporomandibular joint disease, coronary artery disease, or gastroesophageal reflux. Patients who have an unremarkable clinical evaluation and no red flags or risk factors for serious disease can be treated conservatively with analgesics and re-evaluated in 4 weeks.

Antibiotics

Otitis externa is often treated with office suctioning of debris under a microscope and

• the application of antibiotic drops (ciprofloxacin, tobramycin, neomycin, polymyxin B), with or without hydrocortisone in various combinations. Frequently, a small wick or sponge is placed in the ear canal to help maintain patency of the canal and allow the facile application of the medications.
• For otitis media, oral antibiotic treatment is directed at eradicating H. influenzae, M. catarrhalis, S. pneumonia, and S. aureus with amoxicillin or erythromycin as for sinusitis. The benefit is notable for children 2 years or younger with bilateral otitis and for older children with otitis plus otorrhea, whereas other patients can be observed without antibiotics.

Some of the causes of ear pain that are typically treated with either topical or systemic antibiotics include

• Uncomplicated acute bacterial otitis externa (AOE).^[rx][rx] For symptoms that are not responsive to treatment within 10 days, a physician should evaluate for necrotizing external otitis.^[rx]
• Acute otitis media (AOM) self-resolves within 24–48 hours in 80% of cases. If it does not self-resolve, AOM thought to be caused by bacteria is treated with systemic antibiotics. If symptoms do not respond to a week of treatment, a physician should evaluate for mastoiditis.^[rx]
• Acute folliculitis.^[rx]
• Auricular cellulitis.^[rx]
• Suppurative otitis media.^[rx] There is also a risk for tympanic membrane rupture.^[rx]
• Perichondritis. An otorhinolaryngologist should also evaluate it and if a foreign body is present in the cartilage, this foreign body should be removed.^[rx] If there is cartilage involvement, then more advanced care with hospitalization is needed.^[rx]
• Sinusitis can cause secondary ear pain. Treating the underlying sinusitis will treat the ear pain. ^[rx]

Some bacterial infections may require a more advanced treatment with evaluation by otorhinolaryngology, IV antibiotics, and hospital admission.

• Necrotizing external otitis is potentially fatal and should be evaluated by an otorhinolaryngologist with admission to the hospital and IV antibiotics.
• Acute mastoiditis is treated with admission to the hospital, otorhinolaryngology consultation and empiric IV antibiotics.^[rx][rx]Cases with intracranial involvement are treated with a mastoidectomy with myringotomy.^[rx][rx]
• Chondritis.^[rx][rx]

Procedures

Some causes of ear pain require procedural management alone, by a health professional, or in addition to antibiotic therapy.

• Keratosis obturans is treated with removal of impacted desquamated keratin debris in the ear canal.^[rx]
• Chronic perichondritis and chondritis that continue to be symptomatic despite appropriate antibiotic management may require surgical debridement.^[rx] Surgical drainage could be required.^[rx]
• Bullous myringitis leads to the development of bullae on the tympanic membrane that can be punctured to give pain relief.^[rx]
• Foreign bodies in the ear canal can cause pain and be treated with careful removal.^[rx]
• An infected sebaceous cyst is treated with incision and drainage of the cysts, oral antibiotics, and otorhinolaryngology assessment.^[rx]

Other

Given the variety of causes of ear pain, some causes require treatment other than antibiotics and procedures.

• Relapsing polychondritis – is an autoimmune disease treated with immunomodulating medications (medications that help modulate the immune system).^[rx]
• Temporomandibular joint dysfunction – can lead to secondary ear pain and can be initially treated with a soft food diet, NSAIDs, application of a heat pack, massage of the local area, and a referral to a dentist.^[rx][rx]
• Myofascial pain syndromes – are initially treated with NSAIDs and physical therapy. Local anesthetic injection into the muscle trigger point can be considered in severe cases.^[rx]
• Glossopharyngeal neuralgia – is treated with carbamazepine.^[rx]

Surgery

• Most perforations of an eardrum caused by trauma heal without surgical intervention, but if an eardrum perforation persists for more than about 3 months, surgical closure and the use of tympanoplasty with or without mastoidectomy can be contemplated.
• Chronic draining perforations, especially if located in the posterior superior quadrant of the tympanic membrane, may require tympanomastoid surgery.

References