Ear pain, Otalgia, earache

Ear pain refers to pain in the ear.

Primary ear pain is pain that originates from the ear. 

Secondary ear pain is a type of referred pain, meaning that the source of the pain differs from the location where the pain is felt.

2/3 of people present with ear pain are diagnosed with some sort of primary otalgia and 1/3 were diagnosed with some sort secondary otalgia.

Most causes of earache are non-life-threatening.

Primary ear pain is more common than secondary ear pain.

Primary ear pain is often due to infection or injury.

The conditions that cause secondary or referred ear pain are broad and range from temporomandibular joint syndrome to inflammation of the throat.

Ear pain can generally be discovered by taking a thorough history of all symptoms and performing a physical examination, without need for imaging.

Imaging may be needed if hearing loss, dizziness, ringing in the ear or unexpected weight loss accompany ear pain.

Ear pain can present in one or both ears. 

It may or may not be accompanied by fever, vertigo, ear itchiness, or a sense of fullness in the ear. 

The pain may or may not worsen with chewing.

The ear pain may also be continuous or intermittent.

83 percent of children have at least one episode of a middle ear infection with pain by three years of age.

Ear pain due to an infection is the most common in children and can occur in babies.

Adults may need further evaluation if they have associated hearing loss, dizziness or ringing in the ear.

Management of ear pain depends on the cause. 

A bacterial infection may require antibiotics.

Over  the counter pain analgesics  can help control discomfort.

Some causes of ear pain require a procedure or surgery.

Ear pain can be primary or secondary.

Ear pain originates  from a part of the ear itself, known as primary ear pain.

If the pain originates from an anatomic structure outside the ear that is perceived as pain within the ear, it is known as secondary ear pain.

Secondary ear pain is a type of referred pain.

Primary ear pain is more common in children, whereas referred pain is more common in adults.

Primary ear pain is most commonly caused by infection or injury to one of the parts of the ear.

The external ear is the most exposed portion of the ear making it vulnerable to trauma or environmental exposures.

Blunt trauma can result in a hematoma between the cartilage and perichondrium of the ear. 

Trauma type of injuries are common in contact sports such as wrestling and boxing.

Environmental injuries to the external ear include sunburn, frostbite, or contact dermatitis.

Other causes of external ear pain include:

Auricular cellulitis, which is a superficial infection of the ear that may be precipitated by trauma, an insect bite, or ear piercing.

Perichondritis: an infection of the perichondrium, or fascia surrounding the ear cartilage, which can develop as a complication of untreated auricular cellulitis. 

Perichondritis treatment with antibiotics avoids permanent ear deformities.

Relapsing polychondritis: a systemic inflammatory condition involving cartilage in many parts of the body, including the cartilage of both ears.

Otitis externa, is a cellulitis of the external ear canal. 

In the US 98% of cases are caused by bacteria, and the most common causative organisms are Pseudomonas and Staph aureus.

Risk factors for otitis external include exposure to excessive moisture from swimming or a warm climate, and disruption of the protective cerumen barrier, which can result from aggressive ear cleaning or placing objects in the ear.

Malignant otitis externa refers to a rare and potentially life-threatening complication of otitis externa: the infection spreads from the ear canal into the surrounding skull base, hence becoming an osteomyelitis.

Malignant otitis externa mainly in diabetic patients.

Pseudomonas is the most common causative organism in malignant otitis externa.

Pain in malignant otitis externa tends to be more severe than in uncomplicated otitis externa, and laboratory studies often reveal elevated inflammatory markers-ESR and/or CRP.

Malignant otitis externa infection may extend to cranial nerves, or rarely to the meninges or brain.

Earwax impaction: results in 12 million medical visits annually in the United States, causing ear pain.

Foreign body: commonly include insects and small objects.

Herpes zoster: varicella zoster virus can reactivate in an area that includes the ear, and may produce pain and visible vesicles within the ear canal.

When combined with facial paralysis due to facial nerve involvement, is called Ramsay Hunt syndrome.

Tumors: the most common ear canal tumor is squamous cell carcinoma., which can resemble otitis externa.

Acute otitis media is an infection of the middle ear. 

More than 80% of children experience at least one episode of otitis media by age 3 years.

Around the world there is around 21,000 to 28,000 deaths due to complications from ear infections.

These complications include brain abscesses and meningitis.

Common cause of primary otalgia is otitis media, meaning an infection behind the eardrum.

The peak age for children to get acute otitis media is ages 6–24 months. 

83% of children had at least one episode of acute otitis media by 3 years of age.

Worldwide, there are 709 millions cases of acute otitis media every year.[36] Hearing loss globally due to ear infection is estimated to be 30 people in every 10,000.

While acute otitis media is also most common in these first 3 years of life, though older children may also experience it.

The most common associated bacteria for otitis media are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

Otitis media often occurs with or following colds.

The diagnosis of otitis media is made by the combination of symptoms and examination of the tympanic membrane for redness, bulging, and/or a middle ear effusion.

Complications of otitis media include: hearing loss, facial nerve paralysis, or extension of infection to surrounding anatomic structures.

Surrounding extensions include:


Petrositis: infection of the petrous portion of the temporal bone



Subdural abscess

Brain abscess

Cerebral venous sinus thrombosis

Ear pain may occur due to barotrauma resulting from changes in atmospheric pressure that occur when descending in a plane or deep diving. 

As atmospheric pressure increases with descent, the eustachian tube collapses due to pressure within the middle ear being less than the external pressure, resulting in pain, middle ear hemorrhage or tympanic membrane rupture.

Tympanic membrane rupture can be caused by a blow to the ear, blast injury, barotrauma, or direct penetration of the tympanic membrane by an object entering the ear.

Noxacusis causes pain in the ear when exposed to noise that typically does not cause pain.

Noxacusis has been thought to be caused by type II nerves responding to damage of the outer hair cells.

Referred ear pain occurs from irritation of one of the nerves that provides sensation to the ear:

Irritation the trigeminal nerve (cranial nerve V)

Temporomandibular joint syndrome

Myofascial pain syndrome

Trigeminal neuralgia:

Dental pain from cavities or an abscess

Oral cavity carcinoma

Conditions causing irritation of the facial nerve (cranial nerve VII) or glossopharyngeal nerve (cranial nerve IX)






Carcinoma of the oropharynx-base of tongue, soft palate, pharyngeal wall, tonsils

Conditions causing irritation of the vagus nerve (cranial nerve X)


Myocardial ischemia 

Conditions causing irritation of cervical nerves C2-C3

Cervical spine trauma, arthritis, or tumor

Temporal arteritis

Primary ear pain is divided into the external ear, the external auditory canal, the middle ear, and the inner ear.

Secondary ear pain referred to as otalgia is from neck and head sources.

Nerves that provide sensation to the various parts of the ear, include cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and X (vagus), and the great auricular nerve (cervical nerves C2-C3).

As these nerves also supply other parts of the body, from the mouth to the chest and abdomen, irritation of these nerves in another part of the body has the potential to produce pain in the ear:referred pain.

Irritation of the fifth cranial nerve, (trigeminal nerve) is the most common cause of referred ear pain.

Most etiologies of ear pain can be diagnosed clinically. 

Primary causes of ear pain are typically more acute in nature, while secondary causes of ear pain are more chronic.

Acute causes may be further distinguished by the presence or absence of fever.

Fever may indicate an underlying infection.

The  absence of fever may suggest a structural problem, such as such as trauma or other injury to the ear.

Chronic pain etiology may be broken down by the presence or absence of worrisome clinical features.

Worrisome features in chronic pain include the presence of smoking, heavy alcohol use, diabetes, coronary artery disease, and older age.

Such factors increase the risk of having a serious cause of ear pain: cancer or a serious infection. 

Second hand smoke may increase risk of acute otitis media in children.

Swimming is the most significant risk factor for otitis externae.

Risk factors for otitis externae include high humidity in the ear canal, eczema and/or ear trauma.

The presence of such warning clinical features may require additional workup such as a CT scan or biopsy.

Such diagnoses include malignant otitis externa, mastoiditis, temporal arteritis, and malignancy.

Diagnosis Features in infection related earache.

Acute otitis mediaHistory of URI, severe ear pain; feels deep inside the ear, fever hearing loss

Perforated tympanic membrane Discharge followed by pain improvement

Mastoiditis in Children , with History of URI >10 days or ear infection


May see signs of otitis media on exam

Pain is located behind the ear with postauricular swelling

Diagnosed with CT

Chronic suppurative otitis media Conductive hearing loss

Relapsing/remitting or chronic discharge

May see perforation of tympanic membrane or cholesteatoma on exam

Serous otitis media

No signs of infection

Prominent hearing loss, 

May have history of URI or acute otitis media

Otitis externa Swimming Psoriasis Seborrheic dermatitis

Otitis externae peaks at age 7–12 years of age and around 10% of people has had it at least once in their lives.[10]

Necrotizing/malignant otitis externa

Chondritis vs perichondritis Recent ear trauma External ear appears inflamed

Barotrauma Recent ear trauma Recent scuba diving or flying, Hearing loss

Eustachian tube dysfunctionPain described as ear pressure or plugged up sensation in ears

Unilateral hearing loss Crackling/gurgling sounds in ear

History of seasonal allergies Poor light reflex and TM mobility Air-fluid levels present

Cerumen Impaction-described as ear pressure or plugged up sensation in ears

Management of ear pain depends on the underlying cause.

Ear pain caused by bacterial infections of the ear are usually treated with antibiotics known to cover the common bacterial organisms for that type of infection. 

Some bacterial ear infections can benefit from warm compresses.

Some of the causes of ear pain that are typically treated with either a topical or systemic antibiotic include:

Uncomplicated acute bacterial otitis externa.

Acute otitis media (AOM) self-resolves within 24–48 hours in 80% of cases.

If it does not self-resolve, AOM thought to be caused by bacteria is treated with systemic antibiotics. 

If symptoms do not respond to a week of treatment, evaluation for mastoiditis should occur.

Acute folliculitis

Auricular cellulitis

Suppurative otitis media


Sinusitis can cause secondary ear pain. 

Necrotizing external otitis is potentially fatal and should be evaluated with admission to the hospital and IV antibiotics.

Acute mastoiditis is treated with admission to the hospital, and empiric IV antibiotics.


Keratosis obturans is treated with removal of impacted desquamated keratin debris in the ear canal.

Chronic perichondritis and chondritis that continues to be symptomatic despite appropriate antibiotic management may require surgical debridement.

Bullous myringitis can lead to the development of bullae on the tympanic membrane that can be punctured to give pain relief.

Foreign body in the ear canal can cause pain.

Relapsing polychondritis is an autoimmune disease treated with immunomodulating medications.

Temporomandibular joint dysfunction can lead to secondary ear pain and can be treated.

Myofascial pain syndromes are initially treated with NSAIDs and physical therapy.

Glossopharyngeal neuralgia is treated with carbamazepine.

Cerumen impaction occurs in 1 out of every 10 children, 1 in every 20 adults and 1 in every 3 elderly citizens.

Barotrauma to the ear occurs around 1 in every 1000 people.

Of people presenting with ear pain, only 3% was diagnosed with eustachian tube dysfunction.

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