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Ear Pain: Diagnosing Common and Uncommon Causes

Stacie Ann Kasper, DO
Jeffrey D. Quinlan, MD

American Family Physician. 2026;114(3):238-247.

Author Disclosure: No relevant financial relationships.

Otalgia, or ear pain, is a common reason for primary care visits. It is categorized as primary (ie, originating from the ear) or secondary (ie, referred from nonotologic sources). A systematic approach guides appropriate management and identifies red flags. Acute otitis media, otitis externa, and eustachian tube dysfunction are common causes of primary otalgia. Temporomandibular joint disorders, dental pathology, and cervical spine pathology are common causes of secondary otalgia. Evaluation should include a focused history and physical examination, with further assessment for concerning or persistent findings. Treatment of benign cases includes targeted therapy for infections or structural abnormalities. Recognizing red flags, such as persistent, severe, or unilateral symptoms, is critical for identifying serious causes.

Otalgia, or ear pain, is a common reason for primary care visits.1–6 Otalgia is categorized as primary (ie, originating from the ear) or secondary (ie, referred from nonotologic sources).3,4,7–9 Primary otalgia is more common in children; secondary otalgia is more common in adults.10,11 A focused history and physical examination remain the cornerstones of evaluation.12,13

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments
A systematic approach to diagnosing secondary otalgia should include evaluation for temporomandibular disorders, dental pathology, cervical spine pathology, and cranial neuralgias; malignancy should be considered.8,17,18CConsensus, usual practice, expert opinion, disease-oriented evidence, and case series for studies of diagnosis, treatment, prevention, or screening
In children, sudden-onset moderate or severe bulging of the tympanic membrane should prompt diagnosis of acute otitis media, but it should not be diagnosed if pneumatic otoscopy or tympanometry does not show middle ear effusion.24CClinical practice guideline based on disease-oriented evidence
Diagnosis of temporomandibular joint disorder requires pain that involves the jaw, temple, or both and varies with jaw movement.49CClinical practice guideline based on disease-oriented evidence

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 https://www.aafp.org/afpsort.

HISTORY

Pain can be characterized by location, quality (eg, dull, sore, throbbing, sharp, neuropathic), radiation to surrounding sites, severity, and course (eg, onset, duration, recurrence).4,9 Clinicians should document the duration and laterality of otalgia and whether otalgia is constant or episodic because unilateral symptoms or persistent pain may suggest a more serious underlying etiology.9 Associated otologic symptoms (eg, hearing loss, tinnitus, ear fullness, vertigo, discharge, trauma) should be assessed.9,13 Absence of these associated symptoms indicates that secondary causes are more likely.4 Systemic symptoms (eg, fever or malaise, dysphagia, odynophagia, weight loss) may indicate more serious causes, such as cancer.4,14 History of otologic surgery should be noted.9,13

Recent swimming, water exposure, ear canal instrumentation, air travel, or scuba diving may suggest external canal disorders or barotrauma.12,15,16 Comorbidities (eg, diabetes, immunosuppression) increase the risk of atypical and severe infections.16 Dental symptoms, jaw pain, or temporomandibular joint (TMJ) clicking suggests odontogenic or TMJ disorder.3,7,17,18 In adults with unexplained unilateral otalgia, a history of tobacco and alcohol use and human papillomavirus exposure should be obtained.4,14,19–22 History of these may indicate risk of oropharyngeal malignancy, which can be associated with referred ear pain.14,19–22 In children, additional social history should include day care attendance, breastfeeding, exposure to tobacco products, immunization status, and family history of ear problems.23

STACIE ANN KASPER, DO, is a clinical assistant professor in the Department of Family and Community Medicine at the University of Iowa Carver College of Medicine, Iowa City.

JEFFREY D. QUINLAN, MD, FAAFP, is a professor and chair in the Department of Family and Community Medicine at the University of Iowa, Iowa City.

Address correspondence to Stacie Ann Kasper, DO, at stacie-kasper@uiowa.edu.

Author Disclosure: No relevant financial relationships.

  1. 1.Shaikh N, Conway SJ, Kovačević J, et al. Development and validation of an automated classifier to diagnose acute otitis media in children. JAMA Pediatr. 2024;178(4):401-407.
  2. 2.Kozin ED, Sethi RK, Remenschneider AK, et al. Epidemiology of otologic diagnoses in United States emergency departments. Laryngoscope. 2015;125(8):1926-1933.
  3. 3.Norris CD, Koontz NA. Secondary otalgia: referred pain pathways and pathologies. AJNR Am J Neuroradiol. 2020;41(12):2188-2198.
  4. 4.Ramazani F, Szalay-Anderson C, Batista AV, et al. Referred otalgia: common causes and evidence-based strategies for assessment and management. Can Fam Physician. 2023;69(11):757-761.
  5. 5.Fife TD, Tourkevich R. Tinnitus, hyperacusis, otalgia, and hearing loss. Continuum (Minneap Minn). 2021;27(2):491-525.
  6. 6.Shaikh N. Otitis media in young children. N Engl J Med. 2025;392(14):1418-1426.
  7. 7.Jaber JJ, Leonetti JP, Lawrason AE, et al. Cervical spine causes for referred otalgia. Otolaryngol Head Neck Surg. 2008;138(4):479-485.
  8. 8.Fenton JE, Uzomefuna V, O'Rourke C, et al. Applying the Ts of referred otalgia to a cohort of 226 patients. Clin Otolaryngol. 2018;43(3):937-940.
  9. 9.Hwa TP, Brant JA. Evaluation and management of otalgia. Med Clin North Am. 2021;105(5):813-826.
  10. 10.Earwood JS, Rogers TS, Rathjen NA. Ear pain: diagnosing common and uncommon causes. Am Fam Physician. 2018;97(1):20-27.
  11. 11.Neilan RE, Roland PS. Otalgia. Med Clin North Am. 2010;94(5):961-971.
  12. 12.Bustamante J, Tran T, Rodriguez CR. Otitides: acute and chronic otitis media and externa. Prim Care. 2025;52(1):1-14.
  13. 13.Majumdar S, Wu K, Bateman ND, et al. Diagnosis and management of otalgia in children. Arch Dis Child Educ Pract Ed. 2009;94(2):33-36.
  14. 14.Pynnonen MA, Gillespie MB, Roman B, et al. Clinical practice guideline: evaluation of the neck mass in adults executive summary. Otolaryngol Head Neck Surg. 2017;157(3):355-371.
  15. 15.Buchanan BJ, Hoagland J, Fischer PR. Pseudoephedrine and air travel– associated ear pain in children. Arch Pediatr Adolesc Med. 1999;153(5):466-468.
  16. 16.Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150:S1-S24.
  17. 17.Hernández-Nuño de la Rosa MF, Keith DA, Siegel NS, et al. Is there an association between otologic symptoms and temporomandibular disorders? An evidence-based review. J Am Dent Assoc. 2022;153(11):1096-1103.
  18. 18.Scrivani SJ, Keith DA, Kaban LB. Temporomandibular disorders. N Engl J Med. 2008;359(25):2693-2705.
  19. 19.Benson E, Li R, Eisele D, et al. The clinical impact of HPV tumor status upon head and neck squamous cell carcinomas. Oral Oncol. 2014;50(6):565-574.
  20. 20.Chaturvedi AK, Engels EA, Pfeiffer RM, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011;29(32):4294-4301.
  21. 21.Pytynia KB, Dahlstrom KR, Sturgis EM. Epidemiology of HPV-associated oropharyngeal cancer. Oral Oncol. 2014;50(5):380-386.
  22. 22.Mody MD, Rocco JW, Yom SS, et al. Head and neck cancer. Lancet. 2021;398(10318):2289-2299.
  23. 23.Paul CR, Frohna JG. Acute otitis media. Pediatr Rev. 2025;46(3):139-147.
  24. 24.Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999.
  25. 25.Kaur R, Morris M, Pichichero ME. Epidemiology of acute otitis media in the postpneumococcal conjugate vaccine era. Pediatrics. 2017;140(3):e20170101.
  26. 26.Dykewicz MS, Wallace DV, Amrol DJ, et al.; Joint Task Force on Practice Parameters; Workgroup contributors. Rhinitis 2020: a practice parameter update. J Allergy Clin Immunol. 2020;146(4):721-767.
  27. 27.Kleinman K, Psoter KJ, Nyhan A, et al. Evaluation of digital otoscopy in pediatric patients: a prospective randomized controlled clinical trial. Am J Emerg Med. 2021;46:150-155.
  28. 28.Habib AR, Kajbafzadeh M, Hasan Z, et al. Artificial intelligence to classify ear disease from otoscopy: a systematic review and meta-analysis. Clin Otolaryngol. 2022;47(3):401-413.
  29. 29.Suresh K, Wu MP, Benboujja F, et al. AI model versus clinician otoscopy in the operative setting for otitis media diagnosis. Otolaryngol Head Neck Surg. 2024;170(6):1598-1601.
  30. 30.Hoberman A, Paradise JL, Rockette HE, et al. Shortened antimicrobial treatment for acute otitis media in young children. N Engl J Med. 2016;375(25):2446-2456.
  31. 31.Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: otitis media with effusion (update). Otolaryngol Head Neck Surg. 2016;154:S1-S41.
  32. 32.Harmes KM, Blackwood RA, Burrows HL, et al. Otitis media: diagnosis and treatment. Am Fam Physician. 2013;88(7):435-440.
  33. 33.Venkatesan NN, Pine HS, Underbrink M. Laryngopharyngeal reflux disease in children. Pediatr Clin North Am. 2013;60(4):865-878.
  34. 34.Falk N, Joseph R, Dieujuste M. Lymphadenopathy: evaluation and differential diagnosis. Am Fam Physician. 2025;112(3):286-293.
  35. 35.Wilbur J, Tran VL, Doobay MF. Evaluation of neck masses in adults. Am Fam Physician. 2026;113(2):156-165.
  36. 36.Kotikoski MJ, Palmu AAI, Puhakka HJ. The symptoms and clinical course of acute bullous myringitis in children less than two years of age. Int J Pediatr Otorhinolaryngol. 2003;67(2):165-172.
  37. 37.Mills RP. Management of otitis media with effusion in adults. J Laryngol Otol. 2025;139(5):383-388.
  38. 38.Poe D, Anand V, Dean M, et al. Balloon dilation of the eustachian tube for dilatory dysfunction: a randomized controlled trial. Laryngoscope. 2018;128(5):1200-1206.
  39. 39.Chao JH, Kunkov S, Reyes LB, et al. Comparison of two approaches to observation therapy for acute otitis media in the emergency department. Pediatrics. 2008;121(5):e1352-e1356.
  40. 40.Hoberman A, Paradise JL, Rockette HE, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med. 2011;364(2):105-115.
  41. 41.Jackson EA, Geer K. Acute otitis externa: rapid evidence review. Am Fam Physician. 2023;107(2):145-151.
  42. 42.Smetana GW, Shmerling RH. Does this patient have temporal arteritis?. JAMA. 2002;287(1):92-101.
  43. 43.Agarwal M, Juliano AF, Hagiwara M, et al.; Expert Panel on Neurological Imaging. ACR Appropriateness Criteria® inflammatory ear disease. J Am Coll Radiol. 2025;22(5):S300-S318.
  44. 44.Gaddey HL, Wright MT, Nelson TN. Otitis media: rapid evidence review. Am Fam Physician. 2019;100(6):350-356.
  45. 45.Jeon Y, Lee H. Ramsay Hunt syndrome. J Dent Anesth Pain Med. 2018;18(6):333-337.
  46. 46.Zhang Y, Yang F, He Y, et al. Otitis media with effusion in adults during the SARS-CoV-2 epidemic. Sci Prog. 2024;107(1):368504241231659.
  47. 47.Uscategui T, Dorée C, Chamberlain IJ, et al. Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database Syst Rev. 2008(4):CD006851.
  48. 48.Uscategui T, Doree C, Chamberlain IJ, et al. Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults.. Cochrane Database Syst Rev. 2008(3):CD006852.
  49. 49.Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache. 2014;28(1):6-27.
  50. 50.Finnikin S, Mitchell-Innes A. Recurrent otalgia in adults. BMJ. 2016;354:i3917.
  51. 51.Di Credico G, Polesel J, Dal Maso L, et al. Alcohol drinking and head and neck cancer risk: the joint effect of intensity and duration. Br J Cancer. 2020;123(9):1456-1463.
  52. 52.Ely JW, Hansen MR, Clark EC. Diagnosis of ear pain. Am Fam Physician. 2008;77(5):621-628.
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