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Saturday, August 23, 2025

Earache


Introduction

Earache, or otalgia, is pain felt in one or both ears. It is among the most frequent reasons for visiting primary care and ENT clinics. While often due to benign causes such as otitis media or externa, ear pain may also reflect serious conditions like mastoiditis, dental disease, or even head and neck tumors.

Because the ear shares sensory innervation with cranial nerves (trigeminal, facial, glossopharyngeal, vagus) and cervical nerves, pain may originate from outside the ear (secondary/referred otalgia). Proper evaluation is therefore crucial.


Anatomy and Pain Pathways

  • External ear: Auricle, external auditory canal, innervated by auriculotemporal (V3), great auricular (C2–C3).

  • Middle ear: Tympanic membrane, ossicles, Eustachian tube, innervated by glossopharyngeal nerve.

  • Inner ear: Cochlea, vestibular system (usually not painful).

  • Shared innervation explains referred pain from teeth, pharynx, larynx, TMJ, and cervical spine.


Causes of Earache

1. Primary Otalgia (Ear-Origin)

a. External Ear Disorders

  • Otitis externa (“swimmer’s ear”): Infection of ear canal.

  • Furunculosis: Staphylococcal infection of canal hair follicle.

  • Foreign body or impacted earwax.

  • Trauma: Q-tips, sharp objects, barotrauma (flying/diving).

b. Middle Ear Disorders

  • Acute otitis media (AOM): Common in children; often follows URI.

  • Otitis media with effusion (OME): Fluid behind intact eardrum, may cause dull ache.

  • Chronic suppurative otitis media (CSOM): Persistent perforation and discharge.

  • Barotrauma: Eustachian tube dysfunction.

c. Inner Ear Disorders

  • Rarely painful, but acute labyrinthitis may cause discomfort plus vertigo.

d. Other Ear Causes

  • Mastoiditis (post-otitis complication).

  • Herpes zoster oticus (Ramsay Hunt syndrome).


2. Secondary (Referred) Otalgia

  • Dental problems: Caries, abscess, impacted wisdom tooth.

  • Temporomandibular joint (TMJ) dysfunction.

  • Pharyngeal/laryngeal inflammation or tumor.

  • Tonsillitis, peritonsillar abscess.

  • Cervical spine arthritis.

  • Neuralgias (trigeminal, glossopharyngeal).


Clinical Presentation

  • Otitis externa: Ear pain, worse with movement of auricle, itching, discharge.

  • Acute otitis media: Severe pain, fever, irritability in children, hearing loss.

  • OME: Dull pain/pressure, hearing loss, no fever.

  • Chronic otitis media: Persistent discharge with mild pain.

  • Dental pain: Jaw/tooth pain radiating to ear.

  • TMJ dysfunction: Ear pain with chewing, clicking jaw.

  • Pharyngeal pathology: Sore throat, odynophagia with referred ear pain.


Diagnostic Approach

1. History

  • Onset, duration, unilateral/bilateral.

  • Associated fever, hearing loss, discharge, tinnitus, vertigo.

  • Recent swimming, flying, URI.

  • Dental or throat pain.

2. Examination

  • Otoscopy:

    • AOM: Bulging, red tympanic membrane.

    • OME: Retracted or dull tympanic membrane, fluid line.

    • Otitis externa: Swollen, tender ear canal, discharge.

  • Oropharyngeal exam: Tonsils, pharynx.

  • Dental exam.

  • TMJ palpation.

  • Neck exam: Lymph nodes, cervical spine.

3. Investigations

  • Not always needed in simple AOM/otitis externa.

  • Culture of discharge (chronic/recurrent).

  • Audiometry (hearing loss).

  • CT/MRI if complications suspected (mastoiditis, tumor).


Management and Treatment

Treatment depends on the underlying cause.


A. Otitis Externa

  • Ear canal cleaning (aural toilet).

  • Topical antibiotics:

    • Ciprofloxacin 0.3% ear drops: 3–4 drops twice daily for 7–10 days.

    • Ofloxacin 0.3% ear drops: 5 drops twice daily for 7–10 days.

  • Topical corticosteroid combination: Ciprofloxacin + dexamethasone drops reduce inflammation.

  • Analgesics: Paracetamol 500–1000 mg every 6–8 h or Ibuprofen 400 mg every 8 h.

  • Keep ear dry, avoid Q-tips.


B. Acute Otitis Media (AOM)

  • Children >2 years, mild cases: Observation ± analgesics.

  • Antibiotics (if severe, bilateral, or <2 years):

    • Amoxicillin: 500 mg orally every 8 h for 5–7 days (children: 80–90 mg/kg/day divided).

    • If resistant: Amoxicillin–clavulanate: 875/125 mg orally twice daily for 7–10 days.

  • Analgesics/antipyretics: Paracetamol or Ibuprofen.

  • Decongestants/antihistamines: Not routinely recommended.


C. Otitis Media with Effusion (OME)

  • Usually resolves spontaneously.

  • Observation for 3 months.

  • Autoinflation techniques (Valsalva).

  • If persistent with hearing loss: tympanostomy tubes.


D. Chronic Suppurative Otitis Media (CSOM)

  • Aural toilet + topical antibiotics:

    • Ciprofloxacin drops 3–4 drops twice daily for 10–14 days.

  • Surgery (tympanoplasty, mastoidectomy) if persistent.


E. Mastoiditis (Complication)

  • Requires hospitalization.

  • IV antibiotics:

    • Ceftriaxone 2 g IV once daily.

  • Surgery (mastoidectomy) if abscess present.


F. Herpes Zoster Oticus (Ramsay Hunt)

  • Antivirals: Acyclovir 800 mg orally five times daily for 7–10 days.

  • Corticosteroids: Prednisone 60 mg orally daily, taper over 7–10 days.

  • Analgesics.


G. Referred Otalgia

  • Dental abscess: Amoxicillin–clavulanate 875/125 mg orally twice daily for 7 days + dental extraction/drainage.

  • Tonsillitis: Penicillin V 500 mg orally 2–3 times daily for 10 days (or amoxicillin).

  • TMJ dysfunction: NSAIDs (Ibuprofen 400 mg orally every 8 h), jaw exercises, mouth guards.

  • Neuralgias: Carbamazepine 200 mg orally twice daily, titrate as needed.


Complications

  • Hearing loss (temporary or permanent).

  • Mastoiditis, meningitis, brain abscess (from untreated otitis media).

  • Chronic suppuration.

  • Facial nerve palsy (Ramsay Hunt syndrome).


Prognosis

  • Most ear infections resolve with appropriate treatment.

  • Recurrent or chronic ear disease may cause hearing impairment.

  • Referred pain resolves once primary source is treated.


Patient Education

  • Do not insert objects (cotton swabs, pins) into ear canal.

  • Dry ears after swimming or bathing.

  • Treat colds, allergies, and sinus problems promptly.

  • Complete full antibiotic course if prescribed.

  • Seek urgent care if earache is associated with high fever, dizziness, or swelling behind the ear.




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