The painful ear

Abstract

Otalgia, or ear pain, is a common presentation in general practice. It can be broadly divided into primary and secondary otalgia. Primary otalgia is pain that arises from pathology of the external, middle and inner ear. Secondary otalgia, or referred otalgia, is pain that arises from pathology outside the ear. There are many causes of secondary otalgia, due to the complex sensory innervation of the ear. History and physical examination are vital in determining the aetiology. This clinical review discusses the possible causes of ear pain, and provides a systematic approach to assessment and management, including when to refer to specialists.

Clinical case scenario

John, a 68-year-old gentleman, attends your morning surgery. He is complaining of right ear pain and a sore throat. On reviewing his record, you discover that he has been suffering from these symptoms for 4 months with no improvement. He has had multiple courses of both oral and topical antibiotics prescribed by other GPs. He tells you that he has lost 1.5 stones in weight and is a smoker with a 50-pack-year history. Examination of the ears and otoscopy are normal. There is no lymphadenopathy palpable in the neck. You are concerned about the persistent symptoms and refer him to ear nose and throat (ENT) via the head and neck cancer 2-week wait pathway. Flexible nasoendoscopy performed by the ENT specialist reveals a large supraglottic tumour. John is referred for further imaging and listed for a panendoscopy and biopsy for staging and to confirm diagnosis of cancer and guide further treatment.

Anatomy and nerve supply of the ear

A good understanding of the anatomy and nerve supply of the ear is vital when considering the multiple causes of ear pain. Structurally, the ear can be divided into external, middle and inner ear. The external ear consists of the auricle, external auditory meatus and external auditory canal and ends at the tympanic membrane. The middle ear lies within the temporal bone and extends from the tympanic membrane to the lateral wall of the inner ear. It contains the three ossicles (malleus, incus and stapes), and connects to the posterior nasopharynx via the eustachian tube. The inner ear houses the vestibulocochlear organs.

The nerve supply to the ear is complex. The sensory innervation of the external ear (Fig. 1) comes from numerous nerves:

Auriculotemporal nerve (branch of the mandibular nerve, cranial nerve V₃)

Facial nerve (cranial nerve VII)

Vagus nerve (cranial nerve X)

Great auricular nerve (C2, C3)

Lesser occipital nerve (C2)

Figure 1.

Nerve supply of pinna.

The external auditory canal and tympanic membrane receive nerve supply from the auriculotemporal nerve and branches of the facial and vagal nerves. The glossopharyngeal nerve (cranial nerve IX) supplies sensation to the middle ear mucosa, medial surface of the tympanic membrane, the eustachian tube as well as mastoid air cells. Table 1 shows that these nerves supply many structures in the head and neck, and even the chest and abdomen in the case of the vagus nerve; irritation of any portion of these nerves can result in referred otalgia.

Table 1.

Nerve supply of the ear.

Nerve	Innervation of the ear	Innervation outside the ear
Auriculotemporal nerve (branch of the mandibular nerve from the trigeminal nerve)	Tragus, anterior pinna, anterior part of the external auditory canal and tympanic membrane	Temporomandibular joint. Trigeminal supplies the face, sinuses, palate and teeth, muscles of mastication.
Facial nerve	Concha, posterior part of the external auditory canal and tympanic membrane	Anterior two-thirds of the tongue, sublingual and submandibular glands, muscles of facial expression
Glossopharyngeal nerve	Mucosal surface of the tympanic membrane and middle ear, eustachian tube, mastoid air cells	Oropharynx, tonsils and posterior third of the tongue.
Vagus nerve	Concha, inferoposterior external auditory canal and tympanic membrane	Larynx, hypopharynx, thyroid gland, trachea, oesophagus and heart.
Great auricular nerve Lesser occipital nerve (Cervical plexus C2, 3)	Posterior lateral part of the pinna, postauricular region including the mastoid	C2, C3 supplies skin over the parotid gland, back of the head, sternocleidomastoid and cervical paraspinal muscles.

The aetiology of ear pain can be divided into primary and secondary causes (Table 2). Primary otalgia arises from pathology of the external, middle and inner ear. Secondary otalgia, or referred otalgia is pain that arises from pathology outside the ear.

Table 2.

Causes of otalgia.

Primary otalgia	Secondary otalgia
Infection – otitis externa, otitis media, bullous myringitis, pinna cellulitis, perichondritis	Dental infection and inflammation
Cerumen impaction	Temporomandibular disorders
Foreign bodies	Trigeminal neuralgia
Eustachian tube dysfunction	Sinonasal pathology – rhinosinusitis
Trauma – lacerations, pinna haematoma	Laryngeal/pharyngeal pathology – laryngitis, pharyngitis, tonsillitis, postoperative tonsillectomy, peritonsillar abscess
Relapsing polychondritis	Head and neck cancers
Cholesteatoma	Musculoskeletal pathology – cervical spine disease, myofascial pain syndrome
Neoplasms of the ear – basal cell carcinoma, squamous cell carcinoma, melanoma	Eagle’s syndrome
	Temporal arteritis
	Thyroiditis
	Gastroesophageal reflux
	Cardiac – angina, acute coronary syndrome

Primary causes of ear pain

Infections

Infection is the most common cause of primary otalgia and can occur in different parts of the ear. Acute otitis externa (AOE) is an infection of the external ear, commonly occurring in swimmers. Patients with ear eczema and diabetes mellitus are more at risk, as are immunocompromised patients. Symptoms include ear pain (particularly tragal tenderness), scanty discharge and hearing loss. Otoscopy often reveals an erythematous, swollen canal with discharge. The majority of cases are bacterial in nature, with Staphylococcus aureus and Pseudomonas aeruginosa being the most common pathogens (Neilan and Roland, 2010). Ten percent of AOE is fungal (Earwood et al., 2018), which usually occurs in patients who have received prolonged or multiple antibiotic treatments, disrupting their natural skin flora. Infection can spread to the pinna resulting in cellulitis of the pinna, leading to severe tenderness on even gentle palpation of the pinna on examination. Pinna cellulitis may also be preceded by insect bite or trauma. In diabetic or immunocompromised patients with persistent otitis externa, one must consider the diagnosis of necrotising (malignant) otitis externa. This is when the infection spreads to the skull base resulting in osteomyelitis. Pain is usually severe and deep-seated, and there may be granulation tissue in the external auditory canal. As the disease progresses, this may lead to cranial nerve palsies, commonly facial nerve palsy. The treatment of AOE according to the National Institute for Health and Excellence (NICE) is with topical antibiotic (+/– corticosteroid) ear drops (NICE, 2018a). Microsuction may be required in severe cases, with water precaution advice issued to all. Systemic antibiotics are not effective in AOE, and should be reserved for cases of pinna cellulitis or necrotising otitis externa.

Acute otitis media (AOM), most common in children, is an infection of the middle ear which may be caused by viruses or bacteria. Children are more vulnerable due to the shallower angle of the eustachian tube connecting the nasopharynx to the middle ear. In addition to ear pain, patients usually present with symptoms of an upper respiratory tract infection. The classic otoscopy finding is a red, bulging tympanic membrane (Fig. 2). Pain may increase until perforation of the ear drum occurs. For most patients, antibiotics do not reduce the risk of complications from AOM, nor improve pain at 24 hours, but treatment does carry the risk of side effects including vomiting, diarrhoea or rash (with a number needed to harm of only 14) (Venekamp et al., 2015). As such the NICE guidance (NICE, 2018b) is that antibiotics are not routinely required, as the majority of cases will resolve spontaneously. A Cochrane review (Venekamp et al., 2015) did show a small subgroup more likely to benefit from antibiotics, including those below 2 years in age with bilateral infections or those with otorrhoea.

Figure 2.

Otoscopic findings in AOM and bullous myringitis.

Bullous myringitis (BM) is a painful infection involving the eardrum resulting in formation of red bullous blisters (Fig. 2). It is mostly commonly caused by Streptococcus pneumoniae but can also be caused by other bacterial or viral pathogens similar to those in AOM. BM accounts for <10% of AOM cases (McCormick et al., 2003). Pain usually decreases after the blisters rupture spontaneously.

A rare complication of AOM is mastoiditis where infection enters the air cells behind the ear. Patients present with tenderness, erythema and oedema in the mastoid region, causing forward protrusion of the pinna. There may be fluctuance in the mastoid area. Mastoiditis requires hospital admission, intravenous antibiotics and often computed tomography (CT) imaging, as it may lead to severe complications including meningitis and intracranial abscess.

Cerumen impaction and foreign body

Cerumen impaction can lead to ear pain. Use of cotton buds may push cerumen further into the ear canal as well as cause microtrauma. Foreign bodies, often small toys or insects, in the ear canal can also result in ear pain; these can be identified by otoscopy and removed with forceps or suction. Insects should be killed by instilling mineral oil or lignocaine prior to removal. Suspicion of a button battery in the ear requires urgent referral to ENT for removal, as it may cause tissue and bony destruction of the ear canal and damage to hearing.

Eustachian tube dysfunction

Dysfunction of the eustachian tube can cause ear pain, if middle ear pressure is not equalised via the eustachian tube. Diagnosis is with otoscopic evidence of tympanic membrane retraction or tympanogram indicating negative middle ear pressure (Schilder et al., 2015). There is no nationally agreed protocol for management of eustachian tube dysfunction, but options range from simple monitoring, pressure equalisation techniques, the use of a steroid nasal spray or referral for surgical intervention (in severe or refractory cases) in the form of grommets or more recently balloon dilatation of the eustachian tube (Llewellyn et al., 2014).

Trauma

Trauma to the pinna is another cause of primary otalgia. Perichondritis is increasingly common, due to the popularity of piercing in the upper portion of pinna and requires treatment with systemic antibiotics. Blunt trauma, often from contact sports injury can cause pinna haematoma, which usually requires aspiration or incision and drainage urgently, as it can lead to ‘cauliflower ear’ deformity. This is due to separation of the perichondrium from the cartilage depleting the vascular supply, leading to avascular necrosis. These usually need splinting or pressure bandaging post-drainage to prevent re-accumulation.

Relapsing polychondritis

Relapsing polychondritis is a rare autoimmune cause of primary ear pain, characterised by recurrent cartilage inflammation, frequently affecting the auricle. The pinna would be erythematous, tender and swollen, with sparing of the ear lobe as it lacks cartilage. Other cartilaginous sites affected include nose, trachea and bronchi, therefore patients may present with airway symptoms. Patient should be referred to rheumatology for diagnosis, and treatment involves use of corticosteroids and immunomodulating drugs (Neilan and Roland, 2010). Often patients are managed by a team of specialists as multiple systems are involved.

Cholesteatoma

Cholesteatoma, which is an abnormal collection of keratinising squamous epithelium within the middle ear or mastoid air cell spaces, usually presents with fullness in the ear rather than pain. It is a benign condition, but can be locally destructive, usually associated with chronic, foul-smelling otorrhoea and conductive hearing loss, but may be asymptomatic in early stages. Although topical antibiotics may temporarily improve discharge, persistent discharge in the presence of an abnormal tympanic membrane and hearing loss should prompt routine referral for ENT review.

Neoplasms of the ear

Malignant neoplasms must be kept in mind as a potential cause of ear pain. They most commonly occur on the auricle or peri-auricular region, typically in sun-exposed areas. The most common malignancies are basal cell carcinoma, but squamous cell carcinoma (SCC) and melanoma also occur. As with cholesteatoma, pain is not usually the presenting feature of these lesions. Neoplasms may also occur in the external auditory canal or even the temporal bone (typically SCC), but are exceedingly rare (incidence of approximately 1 per 1 000 000 population worldwide) (Lovin and Gidley, 2019). They can be difficult to identify, due to their symptomology overlapping with other benign conditions. Risk factors include previous radiotherapy to the region and a preceding history of chronic ear discharge. Persistent ear pain refractory to antibiotics and associated with chronic otorrhoea or bleeding, particularly in a patient of advanced age with relevant risk factors should raise the suspicion of malignancy and warrants onward specialist referral.

Secondary causes of ear pain

Secondary causes of ear pain should be considered when physical examination of the ear is normal. They occur as a result of the multiple nerve supply to the ear as described previously, which also supply other parts of the body. Secondary or referred otalgia is more common in adults, whereas primary otalgia is more common in children (Majumdar et al., 2009).

Odontogenic cause

Dental structures are innervated by the trigeminal nerve. Odotogenic-referred ear pain is very common; this includes dental infections and abscesses, impacted wisdom teeth, as well as erupting dentition in children.

Temporomandibular disorder

Temporomandibular disorder (TMD) is a leading cause of secondary otalgia in adults, with 64% of patients with TMD complaining of ear pain (Cooper and Cooper, 1993). The pain may arise from the temporomandibular joint (TMJ) or the muscles associated with jaw movement. TMD usually presents with discomfort, clicking and crepitus on palpation of the TMJ on jaw movement. Other associated symptoms can include tinnitus and vertigo. Risk factors include parafunctional activities (teeth clenching, bruxism, nail biting, or excessive mouth opening when yawning), malocclusion as well as emotional stress. Management is primarily conservative, which includes analgesia, soft diet and avoidance of parafunctional activities which may exacerbate symptoms (NICE, 2016).

Sinonasal causes

Rhinosinusitis can result in referred otalgia, due to irritation of the trigeminal nerve. Similarly, neoplasms and surgery in the nasal cavity or paranasal sinuses can also result in referred ear pain.

Trigeminal neuralgia

Trigeminal neuralgia can also present with ear pain. Pain is usually unilateral and starts abruptly; lasting seconds in each attack episode, and following the distribution of the trigeminal nerve. Triggers can sometimes be identified, but examination is typically unremarkable. Carbamazepine is the treatment of choice for pain relief (NICE, 2018c).

Facial nerve pathology

Facial nerve pathology can present with otalgia. This includes Bell’s palsy and herpes zoster oticus (Ramsay Hunt syndrome), with both resulting in facial paralysis involving the forehead. The pain is retroauricular and less severe with Bell’s palsy, and usually precedes the onset of facial weakness. The cause of Bell’s palsy is considered to be acute viral infection; recovery is usually spontaneous. Ramsay Hunt syndrome is caused by viral infection with herpes zoster involving the geniculate ganglion. It presents with pain, vesicular rash on the pinna and ear canal and facial paralysis. The vestibulocochlear nerve (cranial nerve VIII) is often involved, resulting in sensorineural hearing loss as well as balance disturbance. A short course of high-dose systemic steroids should be prescribed within 72 hours of patients presenting (NICE, 2019), with the addition of oral antiviral for Ramsay Hunt syndrome.

Disorder of the aerodigestive tract

Pathology from anywhere within the upper aerodigestive tract can cause referred otalgia, due to the sensory supply from glossopharyngeal and vagus nerves. Pathology in the pharynx, such as pharyngitis, tonsillitis, postoperative tonsillectomy, peritonsillar abscess, and benign and malignant neoplasms, can all cause referred ear pain.

Similarly, pathology in the larynx results in ear pain from stimulation of the vagus nerve. Laryngitis may present with a sore throat, odynophagia, dysphagia, hoarseness and fever. Malignancy in this region must be excluded in patients with unexplained otalgia, especially in patients with risk factors such as smoking and chronic alcohol consumption.

Eagle’s syndrome

Eagle’s syndrome, caused by calcification of the styloid ligament, can present with sharp shooting pain in the ears as a result of irritation of the glossopharyngeal nerve from styloid process elongation. Other symptoms include tonsillar fossa pain, odynophagia and a foreign body sensation. It can be detected by manual palpation in the tonsillar fossa, where the styloid process may be palpable. Local anaesthetic injection can relieve symptoms, but the preferred treatment is surgical resection of the styloid process (Neilan and Roland, 2010).

Musculoskeletal cause

Irritation of C2 and C3 cervical nerves can cause secondary otalgia. Many patients with cervical spine degeneration or arthritis can present with referred ear pain (Jaber et al., 2008), along with neck pain and reduced neck movement. Myofascial pain, due to trigger points in the muscles of the neck and shoulder, can also present with referred otalgia (Neilan and Roland, 2010).

Temporal arteritis

Temporal arteritis can result in secondary otalgia and should be considered in patients 50 years or older. Symptoms include temporal pain, headache, scalp tenderness and jaw claudication. Clinical suspicion combined with elevated erythrocyte sedimentation rate should prompt urgent treatment with systemic steroids, and referral to rheumatology for confirmation of the diagnosis with temporal artery ultrasound or biopsy (NICE, 2020). Delayed treatment can result in blindness (Earwood et al., 2018).

Disorder of distant organs

Organs supplied by the vagus nerve include the oesophagus, thyroid and the heart. Therefore, conditions such as gastroesophageal reflux and thyroiditis can both present with referred ear pain, although patients would commonly present with other associated symptoms. More rarely, otalgia has been reported as a presenting symptom of myocardial ischaemia in a case report involving irritation of the vagus nerve (Dundar et al., 2014).

Clinical assessment

History

Assessment of a patient presenting with ear pain begins with a comprehensive history (Fig. 3). A thorough review of pain should include pain location, onset, character, duration, and any exacerbating and relieving factors. Associated otological symptoms such as otorrhoea, hearing loss, aural fullness, tinnitus and vertigo should be explored. The presence of these symptoms likely suggests primary otalgia. In children, fevers, reduced levels of feeding, and coryzal symptoms should be explored, which present in conjunction with otalgia in AOM. Any recent history of trauma or surgery to the ear should be elicited. If the cause is not apparent, secondary causes of otalgia must be considered, and associated symptoms from other anatomical regions which share sensory supply with the ears should be explored systematically. These include nasal and sinus symptoms, oropharyngeal symptoms including dental history and gastrointestinal symptoms such as reflux. Dysphagia, odynophagia, hoarseness, persistent sore throat, haemoptysis and weight loss (particularly in patients with a smoking and/or alcohol history) are considered red flags (Table 3) and should prompt suspicion of head and neck malignancies. Past medical history and medication history can be helpful in identifying diabetic and immunosuppressed patients who are at risk of necrotising otitis externa.

Table 3.

Red flags associated with ear pain.

Red flags associated with ear pain	Referral pathway
Persistent unexplained otalgia, particularly in the presence of: • Hoarseness, persistent sore throat, dysphagia, odynophagia, haemoptysis, neck lump • Unintended weight loss, smoking history, chronic alcohol consumption or previous radiation history to head and neck	2-week wait head and neck cancer
Intermittent unexplained otalgia, with no apparent red flags for head and neck cancer	Routine ENT referral
Pinna or periauricular lesion suspicious of malignancy	2-week wait dermatology/ENT/maxillofacial surgery (depending on GP locality)
Immunosuppressed or diabetes mellitus - risk of necrotizing otitis externa	Discuss with ENT on-call
Otoscopy findings of granulation or suspicion of cholesteatoma	Routine ENT referral
Facial nerve palsy	Exclude stroke (forehead sparing) Start steroids +/– aciclovir (if vesicles present) and refer to ENT emergency clinic
Foreign body in the ear	Button battery – refer to ENT on-call immediately Other – ENT emergency clinic
Suspicion of temporal arteritis	Urgent rheumatology referral (same day) Urgent ophthalmology referral if visual involvement (same day)

Examination

Examination should begin with general inspection of the external ear including preauricular and postauricular areas. This should be followed by otoscopy examining the external auditory canal and tympanic membrane. Common infective causes of primary otalgia should be apparent after this examination. Purulent discharge, erythema and oedema in the ear canal, as well as pain on insertion of otoscope indicate otitis externa; whereas an erythematous, bulging tympanic membrane indicates AOM. Mastoiditis will present with pinna protrusion, postauricular erythema and swelling, and loss of postauricular sulcus, typically in an ill patient. Finding of vesicles in the external ear or ear canal may indicate Ramsay Hunt syndrome. Any canal lesion, granulation or lesions suspicious of cholesteatoma or malignancy should prompt a referral to specialist (Table 3).

If the cause of otalgia is unclear after ear and otoscopy examination, one should proceed to head and neck examination including the cranial nerves to investigate causes of referred ear pain. This should include examination of the nasal cavity, oral cavity, oropharynx, teeth and TMJ. Any dentures should be removed for complete examination of the gum and teeth to exclude odontogenic causes of otalgia. The anterior nasal cavity can be examined with good lighting or with an otoscope; inflamed mucosa or nasal polyps suggest rhinosinusitis. TMD may present with tenderness or crepitus on palpation of the TMJ on jaw movement. Full neck palpation should be performed to identify any masses or lymphadenopathy. Trigger points to myofascial disorder may be identified. Finally, one should examine for cervical spine tenderness and range of cervical spine movement, particularly on complaints of any neck pain.

Investigations

Investigations are often not required if history and examination are sufficient to make a diagnosis, and appropriate treatment may be commenced. One may consider performing ear swabs in cases of recurrent or chronic otitis externa or media, particularly for excluding a fungal infection. Hearing tests including tuning fork tests should be performed in patients with associated hearing loss to distinguish between conductive and sensorineural hearing loss. Blood tests may be helpful in case of suspected temporal arteritis or thyroiditis. Patients with suspicion of head and neck malignancy often need CT or magnetic resonance imaging, although this should be requested by a specialist in secondary care after a 2-week wait (2WW) referral.

Management

Management of ear pain depends on the diagnosis. Simple analgesia should be offered, but is rarely the sole treatment. Management in primary care involves treating common infections, being aware of potential complications, identifying red flags and knowing when to refer to a specialist.

Specialist referral

Table 3 outlines the referral pathways for various red flag symptoms associated with otalgia. Pinna or periauricular lesions suspicious of malignancy should be referred to secondary care. The specialty of choice may be ENT, maxillofacial surgery or dermatology depending on the GP locality. Patients with persistent unexplained ear pain in the presence of any red flag symptoms associated with head and neck cancer should be referred to ENT via the 2WW pathway. However, patients with intermittent unexplained otalgia, with no apparent red flags can be seen by ENT routinely. The ear can be examined more closely with a microscope by a specialist and a formal hearing assessment can often be performed at the same appointment if required. Flexible nasoendoscopy is performed to exclude lesions in the nasal cavity, pharynx and larynx, which may suggest malignancy.

Patients with non-resolving otitis externa may benefit from microsuctioning and/or pope wick insertion; these can be performed in ENT emergency clinics. Suspicion of necrotising otitis externa, particularly in unwell, diabetic or immunocompromised patients should be discussed with the ENT specialist on-call for admission. A button battery in the ear canal warrants immediate ENT referral for removal, whereas simple, inert foreign bodies can be removed in ENT emergency clinics. Patients with facial nerve palsy can also be seen in ENT emergency clinics, usually a week after commencement of steroids +/– aciclovir. A suspicion of cholesteatoma warrants routine ENT referral.

Referral to a dental specialist should be considered if the symptoms are odontogenic in nature. Patients with TMD with persistent symptoms despite conservative treatment can be referred to an oral and maxillofacial surgery specialist. Finally, patients with suspicion of temporal arteritis should be referred urgently to rheumatology, or ophthalmology is there is any visual involvement.

Conclusion

Ear pain is very common and can be caused by a number of conditions, both within the ear and outside the ear. When the cause is apparent, management in primary care can be instigated effectively. If the patient does not respond to treatment as expected, or if no clear cause is identified, general practitioners must enquire about red flag symptoms and consider specialist referral for further investigation.

KEY POINTS

Ear pain is very common, and causes can be divided into primary (pathology of the ear) and secondary (pathology outside the ear)

Secondary or referred ear pain arises due to the multiple sensory innervation of the ear

Dental and TMJ pathologies are common causes of ear pain, especially in adults

Primary causes of ear pain such as infections can often be managed in primary care

Persistent or unexplained ear pain, with normal otology examination and/or presence of red flags should prompt referral to specialist, especially to exclude head and neck malignancy

Figure 3.

Algorithm for assessment of ear pain.

Footnotes

ORCID iD

Dr Kenneth Lai

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