Ear pain, also known as earache or otalgia, is pain in the ear. Some causes of ear pain require a procedure or surgery. The pain may also be continuous or intermittent.
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 hearing loss, dizziness or ringing in the ear. Additional red flags include diabetes, a weakened immune system, swelling seen on the outer ear, or swelling along the jaw.
Causes
Ear pain has a variety of causes, the majority of which are not life-threatening. Ear pain can originate from a part of the ear itself, known as primary ear pain, or from an anatomic structure outside the ear that is perceived as pain within the ear, known as secondary ear pain.
Primary ear pain is most commonly caused by infection or injury to one of the parts of the ear. Blunt trauma, such as a blow to the ear, can result in a hematoma, or collection of blood between the cartilage and perichondrium of the ear. This type of injury is particularly common in contact sports such as wrestling and boxing. Environmental injuries include sunburn, frostbite, or contact dermatitis.
- Auricular Cellulitis: a superficial infection of the ear that may be precipitated by trauma, an insect bite, or ear piercing
- Perichondritis: infection of the perichondrium, or fascia surrounding the ear cartilage, which can develop as a complication of untreated auricular cellulitis. It is important to identify and treat perichondritis with antibiotics to avoid permanent ear deformities.
- Relapsing polychondritis: a systemic inflammatory condition involving cartilage in many parts of the body, but often including the cartilage of both ears. The severity and prognosis of the disease varies widely.
Otitis externa
Otitis externa, also known as "swimmer's ear", is a cellulitis of the external ear canal. In North America, 98% of cases are caused by bacteria, and the most common causative organisms are Pseudomonas and Staph aureus. Risk factors include exposure to excessive moisture (e.g. 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 is a rare and potentially life-threatening complication of otitis externa in which the infection spreads from the ear canal into the surrounding skull base, hence becoming an osteomyelitis. It is very rare in children, though can be seen in immunocompromised children and adults. Cerumen impaction may cause ear pain, but it can also prevent thorough examination of the ear and identification of an alternate source of pain.
- Foreign body: commonly include insects or small objects like beads
- Tumors: the most common ear canal tumor is squamous cell carcinoma. Symptoms can resemble those of otitis externa, and cancer should be considered if the symptoms are not improving on appropriate treatment. Acute otitis media is also most common in these first 3 years of life, though older children may also experience it.
- Mastoiditis: infection of the air cells in the mastoid process, the area of the skull located right behind the ear This has been thought to be caused by type II nerves responding to damage of the outer hair cells.
Referred ear pain
A variety of conditions can cause irritation of one of the nerves that provides sensation to the ear.
Conditions causing irritation the trigeminal nerve (cranial nerve V):
- 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): These three are indistinguishable in terms of the pain experienced.
Secondary ear pain
thumb|Referred otalgia from neck and head sourcesMany different nerves provide sensation to the various parts of the ear, including cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and X (vagus), and the great auricular nerve (cervical nerves C2-C3). 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. In addition, swimming is the most significant risk factor for otitis externae, though other risk factors include high humidity in the ear canal, eczema and/or ear trauma.
If red flags are present it may be necessary to do additional workup such as a CT scan or biopsy to rule out a more dangerous diagnosis. Such diagnoses include malignant (or necrotizing) otitis externa, mastoiditis, temporal arteritis, and cancer. While the presence of a red flag does raise suspicion for one of these four disease, it does not guarantee a diagnosis as any one symptom can be seen in a variety of situations. For example, jaw claudication can be seen in temporal arteritis, but also in TMJ dysfunction.
|-
| rowspan="2" |Acute otitis media
|History of URI within 10 days
|Child pulling on ear
|Severe pain; feels deep inside the ear.
|-
|Fever
|Hearing loss
|Pain may disrupt sleep
|-
|Perforated tympanic membrane
| colspan="3" |Discharge followed by pain improvement
|-
| rowspan="3" |Mastoiditis*
|Children
|History of URI >10 days
|Recent history of URI or ear infection
|-
|Fevers/chills
|May see signs of otitis media on exam
|Pain is located behind the ear with postauricular (i.e. near mastoid process) swelling*
|-
| colspan="3" |Diagnose 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
(otitis media with effusion)
|No signs of infection
|Prominent hearing loss
|May have history of URI or acute otitis media
|-
| rowspan="3" |Otitis externa
|Swimming
|Psoriasis
|Seborrheic dermatitis
|-
|Q-tips in the ear
|Bilateral pain
|Scaling
|-
|Itching
|Pain exacerbated when ear is pulled
|May see granulation tissue in canal on exam
|-
| rowspan="2" |Necrotizing/malignant
otitis externa*
|Diabetes
|Immuno-compromised
|Constant pain with increasing severity at night*
|-
|Purulent discharge*
|Pain out of proportion to exam findings*
|Biopsy granulation tissue for culture
|-
|Chondritis vs perichondritis
|Recent ear trauma (i.e. ear piercing)
|External ear appears inflamed
|Chondritis more likely than perichondritis if ear shape is distorted
|}
{| class="wikitable"
|+Referred causes
!Diagnosis
! colspan="2" |Features For symptoms that are not responsive to treatment within 10 days, a physician should evaluate for necrotizing external otitis.
A common cause of primary otalgia is ear infection called otitis media, meaning an infection behind the eardrum. That changed when the otoscope was invented in the 1840s by Anton von Troeltsh in Germany. Increasing resistance makes antibiotics less effective. The term antibiotic stewardship is then used to describe the systematic effort to educate antibiotic prescribers to only give these medications when they are warranted. In particular to children, most ear pain resolves by itself with no complications. There are guidelines in place to help determine when antibiotics for ear pain are needed in children.
The ear itself played a role in treatment via acupuncture, also known as auriculotherapy. It was believed that acupuncture of the ear could be used to correct other pain or disorders in the body. Such practices may have started as far back as the Stone Age. The first documentation of auriculotherapy in Europe was in the 1600s. One physician described stimulating the ear by burning or scarring to treat sciatic pain, while another physician applied this treatment for toothache. Paul Nogier is known as the father of ear acupuncture for his theory that parts of the ear corresponds to other areas of the body in a reliable fashion.
Research
There are currently studies going on delivering antibiotics directly into the middle ear.