Also known as localized ear pain, it is a common symptom seen in the general practice of otolaryngology.
Most of the common causes of earache are benign conditions that can be effectively treated with routine treatment.
However, there are more adverse diagnoses that must be considered in some cases. Unfortunately, there is no simple algorithm for evaluating earache.
To understand earache and its causes and complications, a brief appreciation of the anatomy is required.
The main anatomical structures of the external ear ( atrium ) are the helix, the earlobe, the cartilage, the external auditory canal and the canal and the lateral tympanic membrane.
The middle ear is made up of the medial tympanic membrane and the ossicles, and connects through the Eustachian tube to the posterior nasopharynx.
The nerve supply for sensation in the ear comes from several cranial nerves, including the trigeminal nerve, the facial nerve, the glossopharyngeal nerve, and the vagus nerve, as well as the cervical plexus.
In the ear, pain fibers in nerve endings are stimulated by distension of the skin due to swelling or compression of bone or cartilaginous structures.
These same nerves also provide multiple structures for the head and neck, and therefore make earache a complex symptom given the possibility of referred pain.
Causes of earache
The etiology of earache can be broadly divided into primary and secondary causes.
The main causes are those that originate in the ear and are a direct cause of pain through stimulation of the nociceptor fibers .
Secondary causes are those that the patient feels originated in the ear, but are in fact derived from other sources and require a higher index of suspicion to determine the precise aeitiology.
Also, primary earache appears to be more common in children and secondary earache is more common in adults.
- Trauma and foreign bodies.
- Impacted earwax.
- Otologic neoplasms.
Secondary ear pain
- Inflammation and dental infection.
- Temporomandibular joint disorders.
- Trigeminal neuralgia.
- Head and neck cancer 14.
- Eagle Syndrome 15.
- Arteritis temporal.
The main causes of earache are often benign and present as simple cases to the experienced GP.
Infection, trauma, foreign bodies, and impacted earwax are the common conditions generally diagnosed at otoscopy.
Primary neoplasms of the ear are rare and are generally clearly identified when they occur in the atrium and originate in the periauricular region.
Cancers of the temporal bone and external auditory canal are even rarer, often only diagnosed when more advanced signs appear, but should be considered in a patient with earache and chronic discharge from the ear.
Skull-base osteomyelitis (or malignant external otitis) should always be considered in immunosuppressed or diabetic patients with severe earache and a history of external otitis.
Organisms generally responsible include Pseudomonas but can also be fungi.
The pain is often described as severe and throbbing in nature radiating to the jaw.
As the disease progresses, it causes cranial nerve palsy, initially involving the facial nerve (VII), then the hypoglossal nerve (XII), and the vagus nerve (X).
Granulation tissue is usually seen on the floor of the ear canal.
This should be biopsied by an ear, nose and throat surgeon as the differential diagnosis is squamous cell carcinoma of the temporal bone.
Herpes zoster oticus viral infection (Ramsay Hunt syndrome) presents with pain, vesicles involving the external pinna, external auditory meatus, and facial nerve palsy.
If the cause is not obvious, they are considered secondary causes of earache.
Odontogenic causes are an extremely common cause of referred earache.
These causes occur in up to 63% of cases and include inflammation and infection of dental structures, particularly associated with the posterior teeth.
Temporomandibular joint disorders are another important cause of secondary earache and some patients may present with other otologic symptoms such as tinnitus and vertigo.
The pain of TMJ disorders reflects the joint or muscles associated with jaw movement.
Therefore, exacerbation of pain associated with chewing may indicate the source of the pain.
A brief examination of the teeth and jaw can allow the beginning of basic management and avoid excessive investigation.
Trigeminal neuralgia can also present with earache.
This diagnosis is generally clear; however, when the patient describes one-sided attacks of pain that start abruptly, last up to two minutes, and are extremely excruciating.
It is reported that neuralgia can occur in other cranial nerves and the consistent feature is that pain must follow the distribution of the nerve.
All head and neck cancers, usually squamous cell carcinomas, should be considered a secondary cause of earache in patients who have a normal otology history and examination.
Of particular importance are neoplasms in the oropharyngeal region such as the soft palate, the posterior wall of the pharynx, the palatine tonsil, or the base of the tongue, which can present with deep and intense earache.
Patients with cancers in this region may have additional symptoms of dysphagia, odynophagia, and sore throat, or may be otherwise asymptomatic.
Risk factors include chronic alcohol use and exposure to tobacco.
Cervical lymphadenopathy is a common examination finding as these cancers often present in advanced stages.
Examination of the oropharynx by direct inspection and palpation, as well as the neck, is critical since earlier diagnosis will allow a better chance of curative treatment.
A complete examination of the oropharynx requires nasal endoscopy by an otolaryngologist, and therefore unexplained earache should be referred early.
Eagle syndrome may be secondary to a calcified stylohyoid ligament, which can be palpated in the tonsillar fossa.
Symptoms of earache
The symptoms associated with earache depend on the underlying cause.
Symptoms that can occur with external otitis include redness of the ear, swelling of the ear, tenderness in the ear, and discharge from the ear canal.
Additional symptoms that can occur with otitis media include fever, nasal congestion, hearing loss, dizziness, and vertigo, a feeling that the room is spinning.
An earache from an ear infection can be especially troublesome for children and babies.
Symptoms of earache include:
- Babies seem hot and fussy.
- Children pulling or rubbing their ear.
- A high temperature, more than 38 degrees ºC.
- Poor feeding in babies or loss of appetite in children.
- Sleep problems and restlessness at night.
- Cough and runny nose.
- Hearing problems
- Balance problems.
The most serious symptoms are:
- Associated oropharyngeal symptoms such as dysphagia , dysphonia, odynophagia, hemoptysis, weight loss, which may suggest head and neck cancer.
- Sudden or progressive hearing loss.
- Eye symptoms (loss of vision, black spots).
The severity of earache alone is unlikely to reflect the severity of the etiology.
A complete otology history is essential to determine if the cause is primary, and therefore a history should be routine in a patient with earache.
In addition to a thorough pain review, symptoms of otorrhea, hearing loss, vertigo, auditory fullness, and tinnitus should be explored.
For some patients, this minimal history is all that is required to make a correct diagnosis and begin prompt treatment.
The course of time will further support the possible cause of the disease.
In general, shorter time frames suggest a primary or benign cause and longer time frames suggest a secondary cause.
If the cause is not almost immediately apparent, look for associated symptoms from the other anatomical regions supplied by the same nerves that innervate the ear.
There are symptoms associated with the oral cavity, including dental history, oropharyngeal symptoms, including a history of tonsil infections, and sinus and nasal passage symptoms.
The examination should be history-driven, but should generally begin with a general inspection of the outer ear, including the preauricular and postauricular regions, as well as otoscopic examination of the auditory canal and visualization of the tympanic membrane.
If there is an abnormal finding in the ear, the examination should always progress to examination of the cranial nerves to assess complications.
A patient with a bulging tympanic membrane that is erythematous is a key finding in acute otitis media.
Purulent discharge from the ear canal probably reflects external otitis.
Alternatively, it may represent perforated suppurative otitis media, which can sometimes be difficult to differentiate.
Pain when inserting the otoscope is a reliable sign that the cause is external otitis.
Acute mastoiditis is a complication of acute otitis media and a clinical diagnosis with key findings including postauricular swelling and erythema, tenderness, and protrusion of the atrium.
Obliteration of the postauricular sulcus and possible swelling involving the postero-superior external meatus can also be observed.
If the ear and otoscopic examinations do not reveal a clear cause of earache, a full examination of the head and neck with the cranial nerve should be performed given the possibility of referred pain.
This part of the examination should include inspection and palpation of the oral cavity and oropharynx with concentration of the teeth, the temporomandibular joint, the tongue, the soft palate, the posterior wall of the pharynx, and the tonsils.
All dentures must be removed to facilitate a proper examination.
Opening and closing the mouth may reveal lockjaw as well as audible or palpable crackles suggestive of a temporomandibular joint abnormality.
The anterior nasal cavities can also be inspected with good lighting.
Complete palpation of the neck in all regions for masses or lymphadenopathy is important for the diagnosis of metastatic disease.
Lateral palpation over the temporomandibular joint can reveal dysfunction and pain directly in these joints.
Little investigation is required at the first check-up of the patient with earache, as the history and examination are usually sufficient to begin the appropriate first-line treatment for common conditions.
However, in primary ear pain that is not direct, or in the case of secondary ear pain, investigations should be considered.
Ear swabs should be done only for recurrent or chronic otitis externa.
Hearing tests should always be considered for patients with associated hearing loss, especially if this does not improve with proper treatment of the suspected cause of earache.
Imaging is done when a patient is considered to be at high risk for malignancy; therefore, the radiologist may be the first to identify the source of the referred earache.
Outpatient referral is indicated in patients with persistent or unexplained earache without an apparent cause and a normal examination.
A flexible nasal endoscopy can be performed by an otolaryngologist to exclude a lesion that may be squamous cell cancer not visible to the GP.
It is difficult to identify the correct region and modality when performing an imaging investigation based solely on earache, and a specialized review may be required before any imaging is performed.
Consider referral to a dental or maxillofacial specialist if symptoms appear to be odontogenic in origin.
If the suspected diagnosis does not respond to usual treatment within the normal time frame, reconsider the diagnosis.
Treatment for earache
Treatment for earache will depend on the underlying cause.
You can include over-the-counter pain relievers such as aspirin or ibuprofen (Advil, Motrin) for pain and fever.
Treatment may also include warm compresses, acetaminophen (Tylenol), other non-steroidal anti-inflammatory drugs, or a short course of narcotic pain relievers.
Treatment for otitis media may include oral antibiotics, while treatment for external otitis requires antibiotic ear drops.
Your doctor may prescribe antibiotics for ear infections, although some research suggests that antibiotics may not always be an effective treatment.
A pharmacist may recommend over-the-counter eye drops for quick pain relief at home.
Olive oil, as well as a few ear drops, can also help loosen the match.
But if an ear infection is suspected, avoid getting the inside of the ear wet.
In most cases, the earache goes away without any treatment, but if it doesn’t go away or is accompanied by other more serious symptoms, you should see your doctor.
Evaluation for beneficial drug treatment or surgery cannot be established without a comprehensive medical examination and associated tests.
Avoidance of medical evaluation for earache or any other condition related to impaired hearing or balance is not recommended, and may result in permanent hearing loss.
While relatively common for short periods, prolonged earache can be a sign of a serious medical condition.