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Ear pain

Ear pain, also known as earache or otalgia, can be classified into primary ear pain, originating from the ear itself, and secondary ear pain, which is referred pain from another anatomical structure. Most ear pain causes are non-life-threatening, with infections and injuries being the most common primary causes. Secondary ear pain can result from conditions like temporomandibular joint syndrome or throat inflammation. Diagnosis typically involves a detailed history and physical examination, with imaging reserved for cases with red flags such as hearing loss or unexplained weight loss.

Signs and Symptoms

Ear pain may affect one or both ears and can be accompanied by symptoms such as fever, dizziness, ear itchiness, or a sense of fullness. Pain can be continuous or intermittent and may worsen with chewing. Red flags in adults include hearing loss, dizziness, or ringing in the ear, particularly in those with diabetes or a weakened immune system.


Primary Ear Pain

Primary ear pain is often due to infections or injuries:

  • External Ear: Blunt trauma, sunburn, frostbite, contact dermatitis, auricular cellulitis, perichondritis, and relapsing polychondritis.
  • Otitis Externa: Known as "swimmer's ear," it is commonly caused by bacteria like Pseudomonas and Staph aureus. Malignant otitis externa, a severe complication, mainly affects diabetics and requires extensive antibiotic therapy.
  • Mechanical Obstruction: Earwax impaction and foreign bodies like insects or beads.
  • Less Common Causes: Herpes zoster (Ramsay Hunt syndrome) and tumours like squamous cell carcinoma.
Otitis media
Otitis media

Middle and Inner Ear

  • Acute Otitis Media: Infection of the middle ear, common in children under three, caused by bacteria like Streptococcus pneumoniae and Haemophilus influenzae. Complications include hearing loss, facial nerve paralysis, mastoiditis, and brain abscess.
  • Trauma: Barotrauma from atmospheric pressure changes and tympanic membrane rupture.
  • Noxacusis: Pain from noise exposure due to damage to the outer hair cells.

Secondary (Referred) Ear Pain

Conditions causing referred ear pain involve irritation of nerves supplying the ear:

  • Trigeminal Nerve (CN V): TMJ syndrome, myofascial pain syndrome, trigeminal neuralgia, dental pain, oral cavity carcinoma.
  • Facial and Glossopharyngeal Nerves (CN VII and IX): Tonsillitis, post-tonsillectomy pain, pharyngitis, sinusitis, parotitis, oropharyngeal carcinoma.
  • Vagus Nerve (CN X): GERD, myocardial ischaemia.
  • Cervical Nerves (C2-C3): Cervical spine issues, temporal arteritis.
Referred otalgia from neck and head sources
Referred otalgia from neck and head sources


Diagnosis mainly relies on clinical evaluation. Acute causes are often infectious or traumatic, while chronic causes may indicate referred pain or serious conditions like cancer. Red flags warrant further testing such as CT scans or biopsies.

A decision tree to help readers decide likely diagnoses for acute ear pain
Acute ear pain decision tree
Chronic ear pain decision tree
Chronic ear pain decision tree



Bacterial infections like acute otitis media, otitis externa, and auricular cellulitis often require antibiotics. Severe infections (e.g., malignant otitis externa, mastoiditis) necessitate hospitalisation and IV antibiotics.


Certain conditions, such as keratosis obturans and infected sebaceous cysts, may require procedural interventions. Foreign bodies in the ear canal should be removed carefully.

Other Treatments

Non-infectious causes are managed based on the underlying condition:

  • Autoimmune Disorders: Immunomodulating medications for relapsing polychondritis.
  • TMJ Dysfunction: Soft diet, NSAIDs, heat packs, and dental referral.
  • Myofascial Pain Syndromes: NSAIDs, physical therapy, and potential local anaesthetic injections.
  • Neuralgias: Medications like carbamazepine.


Primary otalgia is more common, especially in children, with otitis media being a significant cause. Otitis externa peaks in children aged 7-12. Cerumen impaction and barotrauma are also common. Secondary otalgia frequently affects adults, often due to referred pain from dental, sinus, or throat issues.

Professor Anton Friedrich von Tröltsch 1869 O. Roth, Inventor of the otoscope
Professor Anton Friedrich von Tröltsch 1869 O. Roth, Inventor of the otoscope

Self-assessment MCQs (single best answer)

What is the most common cause of primary ear pain?

Which bacteria are commonly associated with otitis externa, also known as "swimmer's ear"?

Which of the following conditions is NOT a cause of secondary (referred) ear pain?

What is a red flag symptom in adults with ear pain that warrants further investigation?

Which nerve is associated with referred ear pain from TMJ syndrome?

Which condition is characterised by pain from noise exposure due to damage to the outer hair cells?

What kind of treatment is typically required for malignant otitis externa?

Which of the following is a common cause of primary ear pain in children under three?

Which medication is commonly used to manage neuralgias related to ear pain?

What is the recommended management for ear pain due to TMJ dysfunction?


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Very good material. Brilliant for CPD.

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