Definition and Frequency
Ear pain (otalgia) is pain that arises from the outer ear (auricle), the outer ear canal, the eardrum or the middle ear, or that is referred from structures neighbouring these regions. In both children and adults it is one of the most common reasons for attending ENT outpatient clinics. In children it usually develops as a result of middle ear infections; in adults, although the source of the pain is often the ear itself, in a significant proportion the cause lies in structures outside the ear. For this reason, in every patient presenting with ear pain, the throat, teeth and jaw joint must be evaluated as well as the ear. In a considerable number of patients who attend the clinic with otalgia, the ear examination is completely normal; this shows how important the fact is that the ear shares a common nerve network with neighbouring structures.
In the medical literature, otalgia is considered in two main groups: primary otalgia refers to pain arising directly from the ear’s own structures, while secondary (or referred) otalgia refers to pain projected to the ear from a source outside it. This distinction is of great clinical importance, because the treatment approach is completely different. The nerves that carry sensation from the ear include branches of the trigeminal, facial, glossopharyngeal and vagus nerves as well as the upper cervical nerves, and these nerves also supply the teeth, jaw, throat, tongue base and larynx. Because of this shared nerve network, severe ear pain can be felt even when there is no disease at all in the ear.
Symptoms
Ear pain may be felt as stabbing, throbbing, constant or intermittent. It is often accompanied by a feeling of fullness in the ear, reduced hearing, itching, ringing or a sensation of pressure on the eardrum. In pain caused by infection, fever, ear discharge, tenderness that increases when the outer ear is touched or swelling behind the ear may be seen. If the pain gets worse at night, intensifies with chewing or is related to neck movements, the likelihood that its source is a structure outside the ear increases. Additional signs such as dizziness, loss of balance or facial paralysis may herald a more serious process and therefore require urgent evaluation.
The character of the pain can also shed light on the diagnosis. Sudden, sharp, one-sided pain is usually associated with an acute infection or a foreign body, whereas dull pain that gradually increases over weeks may suggest a chronic process or a source outside the ear. Pain that increases with swallowing points to a possible throat or laryngeal source, while pain that increases with chewing suggests a possible jaw joint or dental source. In older patients, especially those with a history of smoking and alcohol use, one-sided, unexplained ear pain lasting for weeks always requires a detailed ENT examination.
Causes and Risk Factors
The most common causes of ear pain include outer ear canal infections (otitis externa), middle ear infection (otitis media), impacted earwax (cerumen), eardrum injuries and pressure changes (air travel, diving). Beyond these, because the ear’s nerve network is shared with the throat, teeth, jaw joint and larynx, tonsillitis, dental decay and abscesses, dysfunction of the jaw joint (temporomandibular joint), sinusitis and even lesions of the larynx or pharynx can cause pain referred to the ear. Risk factors include frequent jaw clenching, teeth grinding (bruxism), upper respiratory tract infections, smoking, the habit of cleaning the ears with cotton swabs and prolonged use of earphones. In adults with one-sided, long-standing ear pain that does not respond to treatment, it is important — even though it is rare — to rule out a mass originating from the pharynx or larynx.
Although the most common cause of ear pain in children is middle ear infection, teething, a foreign body (a bead, a piece of a toy) or outer ear canal infections should also be considered. In adults, lifestyle-related factors come to the fore: prolonged use of earphones and tension in the head and neck region can pave the way for jaw joint dysfunction. Gum disease, an impacted wisdom tooth and dental abscesses — especially pain originating from the lower molars — are frequently referred to the ear. Chronic sinusitis and allergic rhinitis can impair Eustachian tube function, leading to a pressure imbalance in the middle ear and associated pain.
Diagnostic Process
The evaluation begins with a detailed history: the onset, duration and character of the pain, accompanying symptoms, a recent upper respiratory tract infection, contact with water and any history of dental problems are asked about. The condition of the outer ear canal and the eardrum is examined by otoscopy; redness, fluid build-up, perforation or bulging of the eardrum are looked for. In patients whose ear examination is normal, examination of the throat, nose, larynx and inside of the mouth is completed, with endoscopic methods if necessary. Palpation of the teeth and jaw joint and assessment of the neck for a mass or enlarged lymph nodes contribute to the diagnosis. In doubtful cases a hearing test (audiometry), tympanometry or imaging methods (computed tomography, magnetic resonance imaging) may be requested.
During the examination, assessing the mobility of the eardrum (pneumatic otoscopy) or measuring middle ear pressure with tympanometry can clarify the distinction between fluid build-up and a normal ear. In adult patients whose pain persists despite normal ear and throat-nose examinations — particularly those with risk factors (such as long-term smoking and alcohol use) — a detailed examination of the larynx and pharynx with a fibre-optic endoscope is a step that must not be skipped. This approach prevents a serious condition, however rare, from being missed.
Treatment Options
Conservative Treatment
Treatment is directed entirely at the underlying cause. In outer ear canal infections, antibiotic or antifungal ear drops are used; in middle ear infection, painkillers and, when necessary, oral antibiotic treatment. For pain due to impacted earwax, cleaning the ear in the clinic is usually sufficient. For pain due to pressure changes, nasal decongestant sprays and swallowing manoeuvres are recommended. In pain of dental or jaw joint origin, cooperation with the relevant specialty is needed; in these cases treatment directed at the ear brings no benefit.
Surgical Treatment
Ear pain itself usually does not require surgery; however, if the underlying cause calls for it, surgical options may be considered. For example, placement of ear tubes for recurrent middle ear infections, repair of the eardrum (tympanoplasty) if there is a permanent perforation or, in rare cases, surgical removal of masses originating from the pharynx or larynx may be needed. The decision to operate is evaluated individually according to the underlying diagnosis.
Recovery and Follow-up
Ear pain due to simple causes usually decreases markedly within a few days with appropriate treatment. If the pain lasts longer than 1–2 days, or is accompanied by fever, ear discharge, hearing loss, redness and swelling or dizziness, a physician’s evaluation is essential. If the pain recurs or becomes chronic despite treatment, a cause outside the ear needs to be investigated. A follow-up examination after treatment is important, especially in patients with eardrum damage or a history of recurrent infections.
In referred ear pain, the recovery time depends on the treatment of the underlying cause; for example, pain of dental origin subsides shortly after dental treatment is completed. In pain due to jaw joint dysfunction, the use of a night guard (occlusal splint) and physiotherapy approaches take effect within weeks. For patients experiencing recurrent or unexplained ear pain, not taking the symptoms lightly and attending check-ups at regular intervals is valuable for detecting rare but important underlying causes early.
Frequently Asked Questions
I have ear pain but there is no visible problem in my ear — is this normal? Yes, a significant proportion of ear pain is pain referred from the throat, teeth or jaw joint. If the ear examination is normal, these regions also need to be evaluated.
What can I do at home for ear pain? Mild painkillers and a warm compress can provide temporary relief; however, if the pain lasts longer than 1–2 days or symptoms such as fever or discharge appear, a physician should be consulted.
Is ear pain during a flight or a dive dangerous? It is usually temporary and eases with manoeuvres such as swallowing and chewing; however, with severe and prolonged pain, the eardrum needs to be checked for damage.
What might ear pain that gets worse at night in my child suggest? Pain due to a middle ear infection can get worse at night because of the change in pressure in the Eustachian tube when lying down; in this case a physician’s evaluation is recommended.
If the ear pain went away on its own, do I still need to see a doctor? Even if the pain has gone, the underlying cause (for example fluid build-up or a perforated eardrum) may persist; for this reason at least one follow-up examination is recommended.
For the summary:
Back to the short articleThis article is for general information purposes only; please consult your physician for diagnosis and treatment.