Primary otalgia (earache) is ear pain due to a problem in the ear. Referred otalgia is pain in the ear not due to an ear problem. It is nonotogenic ear pain. Otalgia is usually a sign of an acute or chronic infection of the external auditory canal or mastoid or an acute infection of the middle ear. These infections can be easily identified with careful examination.
Other common causes of ear pain are acute serous otitis media, eustachitis, acute otitic barotrauma, mastoiditis, traumatic perforation of the tympanic membrane, foreign bodies, and referred pain, such as that from temporomandibular joint (TMJ) dysfunction, impacted third molars, periodontal abscess, or recent dental work. About 50% of referred ear pain is caused by a dental problem.
If otologic examination fails to show the source of the pain, referred pain should be considered. Because the ear is innervated partially by sensory branches of the vagus nerve (Arnold’s nerve), glossopharyngeal nerve (Jacobson’s nerve), trigeminal nerve (auriculotemporal nerve), facial nerve, and branches of cranial nerves (CNs) II and III, pathologic conditions such as infection and malignant disease of the upper aerodigestive tract (carcinoma of the larynx, hypopharynx, oropharynx, and base of the tongue) and odontogenic disease can also cause otalgia (Fig. 12-1).
Otitis externa occurs more frequently in adults, particularly elderly diabetic patients, and in patients with seborrheic dermatitis or psoriasis of the scalp. Necrotizing otitis externa (a necrotizing osteomyelitis of the skull) occurs in diabetic and immunocompromised patients. Swimmer’s ear is common in people who swim frequently but also occurs in those who clean their ears with cotton swabs, paper clips, or towel tips or by other means.
Otitis media is more common in children, particularly those younger than 8 years. Various studies suggest that 20% of all children have at least three episodes of otitis media in their first year of life and that two thirds of all children have at least one episode before age 2 years. After upper respiratory infection (URI) and tonsillopharyngitis, otitis media is the third leading reason for pediatric office visits. Premature children on respirators are at higher risk, as are those with cleft palate and Down syndrome.
Serous otitis is also more common in children. It is usually not associated with severe pain, except when an acute infection results in acute otitis media. Serous otitis media is often asymptomatic but frequently detected on routine audiometric testing of schoolchildren, because it is the most common cause of hearing deficiencies in children.
Local causes of ear pain predominate in children, whereas the incidence of referred pain increases with age. One study showed that 60% of patients (mean age, 36 years) referred to an ear, nose, and throat clinic had referred pain to their ears. In 80% the ear pain was caused by cervical spine lesions, TMJ dysfunction, or dental pathology. Impacted third molars are more common in women between ages 15 and 25 and may cause referred ear pain. In elderly patients, malignant lesions of the oropharynx and larynx can cause referred otalgia.
Referred pain to the ear does not rule out a local painful process. Barotrauma should be considered in patients who have recently traveled by air and in scuba-diving enthusiasts. Pain from direct trauma can result from a blast or a slap on the ear and in ear picking.
Otitis externa is easily differentiated from otitis media in that patients with otitis externa find movement or pressure on the pinna extremely painful. In addition, they may have itching and tender swelling of the outer ear canal. Bilateral pain in the ears is more suggestive of otitis externa. When bilateral ear pain occurs in young children, bacterial infection of otitis media is more likely, and antibiotics may be indicated. Bilateral pain virtually rules out a referred source of the pain. The pain of otitis media has been described as a rapid-onset, deep-seated, severe pain that often prevents the patient from sleeping. Children who are too young to talk may present with irritability, restlessness, fever, poor feeding, or rubbing of the affected ear. Frequently, the patient has a history of a recent URI.
Serous otitis and eustachitis are not usually associated with a severe earache, but patients with these disorders may have some intermittent discomfort and may state that they hear crackling or gurgling sounds. Severe pain in and especially behind the ear occurs with acute mastoiditis. The patients have exquisite tenderness when pressure is applied over the mastoid process.
The pain of barotrauma may be severe and persistent, and superimposed otitis media occasionally develops. The pain is most frequently experienced during descent in an airplane, especially if the patient has a concurrent URI with eustachian tube dysfunction. The pain may be excruciating.
Patients with impacted cerumen may also complain of severe pain in the ear, or they may have only a vague sensation of discomfort sometimes associated with impaired hearing. On questioning, the patients may admit to a long-standing problem with cerumen accumulation in the ears, with exacerbation leading to visits to the physician.
The pain of TMJ dysfunction is usually intermittent and often worse in the morning if associated with night grinding. The pain may also occur toward the end of the day, especially if it is secondary to tension-induced bruxism (see Chapters 13 and 17).