Physiology

Ear shares sensory fibers from head, neck and chest
1. Trigeminal Nerve (CN 5)
2. Facial Nerve (CN 7)
3. Glossopharyngeal Nerve (CN 9)
4. Vagus Nerve (CN 10)
5. Cervical nerves (C2 and C3)
Primary Ear Pain sources
1. Auricle (CN 5, 7, 10 and C2-3)
2. External auditory canal (CN 5,7, 10)
3. Tympanic Membrane (CN 7, 9, 10)
4. Middle Ear (CN 5, 7, 9)

History

Pain location, duration
Palliative and provocative factors
Prior episodes of Ear Pain
Tobacco Abuse
Alcohol Abuse
Associated symptoms suggestive of primary Otalgia
1. Otorrhea
2. Tympanic Membrane fullness
3. Vertigo
4. Hearing Loss
5. Continuous and progressive Ear Pain
Associated symptoms suggestive of secondary Otalgia
1. Pain worse with chewing
2. Sinusitis
3. Dental procedures
4. Gastroesophageal Reflux
5. Hearing Loss absent
6. Intermittent Ear Pain

History
Red Flags to suggest secondary cause

Age over 50 years (malignancy, Temporal Arteritis)
Excessive Tobacco use (malignancy, vascular disease)
Cardiac Risk Factors (Coronary Artery Disease, thoracic aneurysm)

Exam

External Ear exam
1. Auricle
2. Periauricular area
Otoscopy
1. External auditory canal
2. Tympanic Membrane
Mouth Exam
1. Dental Infection or Dental Pain
2. Pharyngitis
Nasal Exam
1. Paranasal Sinus tenderness
Other regional exam
1. Temporomandibular Joint exam

Causes
Primary Ear Conditions (50-60% of Otalgia cases)

Common
1. Cerumen Impaction
2. Ear Canal Foreign Body
3. Otitis Externa
4. Suppurative Otitis Media
5. Serous Otitis Media
6. Eustachian Tube Dysfunction (often with Upper Respiratory Infection)
7. Ear Barotrauma
Uncommon: Urgent
1. Malignant Otitis Externa
2. Cholesteatoma
3. Mastoiditis
4. Cellulitis (auricle)
Uncommon: Other
1. Ramsay Hunt Syndrome (Herpes Zoster Oticus)
2. Relapsing Polychondritis
3. Granulomatosis with Polyangiitis (previously known as Wegener's Granulomatosis)
4. Ear Trauma

Causes
Secondary, Referred Pain (40-50% of Otalgia cases)

Common
1. Dental causes (38%) such as Dental Caries, Periodontal Abscess
2. Temporomandibular Joint Disorders (35%)
3. Cervical Spine disorders (8%) or Myofascial Pain
4. Parotitis
5. Pharyngitis
Uncommon: Urgent
1. Head and Neck tumors
2. Temporal Arteritis
3. Carotidynia
4. Angina Pectoris or Acute Coronary Syndrome
5. Thoracic aneurysym
Uncommon: Other
1. Bell's Palsy
2. Eagle's Syndrome (styloid process elongation)
3. Gastroesophageal Reflux
4. Oral Aphthous Ulcers
5. Periauricular or cervical adenitis
6. Sialolithiasis
7. Sinusitis
8. Thyroiditis (rare cause of isolated Otalgia)
9. Trigeminal Neuralgia and other regional Neuropathy (5%)

Evaluation
Secondary Ear Pain (no primary ear source identified)

Malignancy risk factors (age >50, Tobacco Abuse, Alcohol Abuse, weight loss)
1. Nasolaryngoscopy
2. CT or MRI imaging
3. Otolaryngology
Temporal Arteritis (age >50, Jaw Claudication, Polymyalgia Rheumatica)
1. Erythrocyte Sedimentation Rate (>50 mm/h)
Suspected thoracic source (e.g. Coronary Artery Disease)
1. Electrocardiogram
2. Chest XRay
3. Evaluate for Coronary Artery Disease, thoracic aorta
Temporomandibular Joint Dysfunction or dental source
1. Symptomatic management (NSAIDs, soft diet)
2. Dental referral (or Temporomandibular Joint clinic)

Management

Treat underlying cause
Systemic Analgesics (e.g. Acetaminophen, Ibuprofen)
Topical Anesthetics (if no TM Rupture)
1. Aurodex (Benzocaine and Antipyrine)
  1. Not available in U.S. as of 2016
  2. Risk of Contact Dermatitis (use with caution)
  3. Risk of methhemoglobinemia (do not use under age 2 years)
  4. Avoid Auralgan (expensive trade name replacement) without improved efficacy

References

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