Ear Pain: Diagnosing Common and Uncommon Causes

 

Otalgia (ear pain) is a common presentation in the primary care setting with many diverse causes. Pain that originates from the ear is called primary otalgia, and the most common causes are otitis media and otitis externa. Examination of the ear usually reveals abnormal findings in patients with primary otalgia. Pain that originates outside the ear is called secondary otalgia, and the etiology can be difficult to establish because of the complex innervation of the ear. The most common causes of secondary otalgia include temporomandibular joint syndrome and dental infections. Primary otalgia is more common in children, whereas secondary otalgia is more common in adults. History and physical examination usually lead to the underlying cause; however, if the diagnosis is not immediately clear, a trial of symptomatic treatment, imaging studies, and consultation may be reasonable options. Otalgia may be the only presenting symptom in several serious conditions, such as temporal arteritis and malignant neoplasms. When risk factors for malignancy are present (e.g., smoking, alcohol use, diabetes mellitus, age 50 years or older), computed tomography, magnetic resonance imaging, or otolaryngology consultation may be warranted.

Patients with otalgia (ear pain) commonly present to their primary care physician. Pain that originates from the ear is known as primary otalgia, whereas pain that originates outside the ear is secondary otalgia. A comprehensive history and physical examination are essential to determine the etiology of primary or secondary otalgia.

Primary otalgia is more common in children, whereas secondary otalgia is more common in adults.1,2 The etiology of primary otalgia, which is usually identified on examination of the ear, is typically otitis externa or otitis media.3 The etiology of secondary otalgia is more complex because the nerves innervating the ear have a shared distribution to include the head, neck, chest, and abdomen2,4 (Figure 1). The ear is innervated by several sensory nerves. The auricle is affected by cranial nerves V, VII, X, C2, and C3; the external auditory meatus and canal by cranial nerves V, VII, and X; the tympanic membrane by cranial nerves VII, IX, and X; and the middle ear by cranial nerves V, VII, and IX. Irritation of any portion of these nerves can result in otalgia.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The diagnosis of acute otitis media requires moderate to severe bulging of the tympanic membrane, new onset of otorrhea not caused by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema.

C

9

Magnetic resonance imaging and referral for nasolaryngoscopy are recommended in the setting of otalgia with normal ear examination findings and symptoms of or risk factors for tumor. Laboratory evaluation with a complete blood count and erythrocyte sedimentation rate can be helpful.

C

2, 14

Patients 50 years and older with otalgia and a normal ear examination should be evaluated for temporal arteritis.

C

14


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The diagnosis of acute otitis media requires moderate to severe bulging of the tympanic membrane, new onset of otorrhea not caused by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema.

C

9

Magnetic resonance imaging and referral for nasolaryngoscopy are recommended in the setting of otalgia with normal ear examination findings and symptoms of or risk factors for tumor. Laboratory evaluation with a complete blood count and erythrocyte sedimentation rate can be helpful.

C

2, 14

Patients 50 years and older with otalgia and a normal ear examination should be evaluated for temporal arteritis.

C

14


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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FIGURE 1.

Sensory distribution of the nerves innervating the ear. (A) Trigeminal nerve (V): face, sinuses, teeth. (B) Facial nerve (VII): anterior two-thirds of the tongue, soft palate. (C) Glossopharyngeal nerve (IX): posterior one-third of the tongue, tonsils, pharynx, middle ears. (D) Vagus nerve (X): heart, lungs, trachea, bronchi, larynx, pharynx, gastr

The Authors

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JOHN SCOTT EARWOOD, MD, is assistant program director of the Family Medicine Residency Program at Dwight D. Eisenhower Army Medical Center, Fort Gordon, Ga., and assistant professor of family medicine at the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine, Bethesda, Md....

TYLER SHERROD ROGERS, MD, is a faculty member in the Family Medicine Residency Program at Dwight D. Eisenhower Army Medical Center. At the time the article was submitted, Dr. Rogers was chief resident of the Family Medicine Residency Program at Dwight D. Eisenhower Army Medical Center.

NICHOLAS ALAN RATHJEN, DO, is chief resident of the Family Medicine Residency Program at Dwight D. Eisenhower Army Medical Center.

Address correspondence to John Scott Earwood, MD, Dwight D. Eisenhower Army Medical Center, 300 Hospital Dr., Fort Gordon, GA 30905 (e-mail: john.s.earwood.civ@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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