Earache (otalgia) and referred pain


  • Otalgia (ear pain) is common.  The source of pain, however, is not always the ear.  It is estimated that around a third of ear pain is secondary.  The most common cause of secondary ear pain is dental (38% of these patients).
    • Usually, if the ear is the source, examination of the ear will be abnormal.
    • If the ear is not the source and examination is normal, then it can often be difficult to identify the source as innervation of the ear comes from multiple nerves supplying a number of other structures


  • Pain
    • Duration, Progression (including timing e.g. constant/intermittent) and Location of pain (ask the patient to point to it if possible); and radiation
    • Nature of pain
    • Aggravating factors (e.g. chewing, coughing, head movements, palpation etc)
    • Relieving factors (e.g. popping ears)
    • Any initial incident/trauma e.g cotton bud use, head trauma etc
  • Associated symptoms
    • Redness
    • Ds- Deafness; Dizziness; Din-din; Discharge (+discomfort)
    • Systemic- fever, malaise, cough, weight loss etc
  • PMHx
    • Otological history
    • General- including diabetes
      • Recent URTIs
    • Drugs
  • Family Hx
  • Social History
    • Particularly smoking/alcohol (in >50yo, this may be important risk factor for cancer) 
    • Ask about the use of cotton swabs
    • Ask about recent air travel, diving or swimming

Examination of the ear

see here

  • Also examine the throat, oral cavity, TMJ and neck

Differential Diagnosis

  • Ear pain: Abnormal Examination
    • Otitis Media
      • Recent URTI; red/cloudy tympanic membrane
    • Otitis Externa
      • Recent swimming; white discharge; Pain on palpation of the ear; swollen/red external canal
    • Foreign Body
    • Cholesteatoma
    • Barotrauma
      • Pain may be acute onset with change of altitude; TM haemorrhage/ serous/haemorrhagic middle ear fluid
    • Rarer causes include
      • Malignant (necrotising) Otitis Externa
      • Ramsay Hunt Syndrome (Herpes Zoster)
      • Auricular Cellulitis/Chondritis/perichondritis (and relapsing polychondritis)
      • Trauma
      • Mastoiditis
      • Tumours
      • Infected cysts
      • Wegener’s Granulomatosis
      • Viral myringitis
  • Ear pain: normal examination
    • TMJ syndrome
      • Pain/crepitus with talking chewing, tender TMJ, restricted ROM
    • Dental causes
    • Pharygitis/Tonsillitis
    • Cervical Spine Arthritis
    • Other rarer causes:
      • Tumours
      • Neuralgias (e.g. trigeminal)
      • Bell’s Palsy
      • Temporal (Giant cell) Arteritis
      • Oral Ulcers

Referred Pain

  • Theauriculo-temporal branchof trigeminal nerve (CN V)
    • Carious teeth, impacted molars; dental disease etc; TMJD; tongue pain
  • The tympanic branch of the glossopharangeal nerve (CN IX)
    • Tonsillectomy; tonsillitis/quinsy; carcinoma of the base of the tongue/tonsil; glosso-pharyngeal neuralgia
    • Pharyngitis
  • The sensory branch of the facial nerve (CN VII)
    • Herpes zoster
  • The auricular branch of the vagus nerve (CN X)
    • Carcinoma of the larynx, piriform fossa or post cricoid cancer
  • The great auricular nerve (C2-3) or lesser occipital nerve (C2)
    • Cervical spondylosis/stenosis

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