Etiology	History	Physical examination	Additional information
Common causes
Barotrauma	Pain starts while scuba diving or while flying in an airplane; patient may have experienced a recent blast injury	Tympanic membrane can show middle ear hemorrhage	Prevent with use of topical nasal decongestants or autoinflation
Eustachian tube dysfunction	Symptoms of pressure dysregulation	Tympanic membrane retraction or positive tympanographic findings	Also associated with aural fullness and intermittent symptoms7
Foreign object	Commonly insects, small toys, peanuts; most common in children	Foreign object visible in ear canal	May require general anesthesia to remove
Otitis externa	Recent swimming with history of discharge	Pain with pulling on external ear; discharge may be present	More common in summer
Otitis media	Recent upper respiratory tract infection; children may pull on ears	Red, inflamed, cloudy tympanic membrane	Most common cause of ear pain
Uncommon causes
Cellulitis of auricle	Preceding insect bite, scratch, or piercing; rapid progression	Earlobe usually involved	Must treat aggressively; parenteral antibiotics may be required
Cholesteatoma	Sense of fullness	A pearly mass may be visible through the tympanic membrane; often infected with visible squamous material	May be asymptomatic early, but generally associated with hearing loss and otorrhea
Granulomatosis with polyangiitis (Wegener granulomatosis)	Arthralgia, hearing loss, myalgias, oral ulcers, otorrhea, and rhinorrhea	Often with chronic otitis media or serous otitis	Consider testing for antineutrophil cytoplasmic autoantibodies
Malignant otitis externa	Retroauricular pain; often associated with diabetes mellitus and immunocompromised state; consider in persons with no improvement in otitis externa	Granulation tissue may be present in the external auditory canal Lower cranial neuropathies (VII, X, XI, XII)	Easy to miss with subtle findings; technetium bone scan can be used to determine the extent of disease
Mastoiditis	Recent otitis media that is typically chronic but may be acute	Tender edematous mastoids	Uncommon, but prevalence is increased in children with decreased access to health care
Ramsay Hunt syndrome (herpes zoster oticus)	Pain can be present before lesions develop; may be associated with hearing loss, vertigo, or tinnitus	Vesicular rash on auricle or ear canal with possible palsy of cranial nerve VII	Can also involve cranial nerves V, IX, and X; pain can occur without eruption
Relapsing polychondritis	Recurrent swelling of the auricle; hearing loss	Earlobe is typically not involved because it has no cartilage	Noninfectious; other cartilaginous sites (trachea, nose, bronchi) can be affected
Trauma	Blunt trauma, frostbite, burns	Evidence of the trauma	Most common is laceration of the auricle
Tumors or infected cysts	Pain usually well localized to auricle or ear canal	Similar presentation to chronic otitis media or externa but nonresponsive to therapy	May be confused with chronic inflammation; if nonresponsive to therapy, timely otolaryngology referral is advised
Viral myringitis	Similar presentation to acute otitis media	Tympanic membrane red but not bulging; hemorrhagic bullae of tympanic membrane and ear canals are typical	Bullous myringitis is not pathognomonic of viral meningitis, but commonly presents in that fashion