Ear ache/Otalgia

Ear ache, or as it is more technically termed otalgia, can originate from the ear or can be pain referred from other areas that share similar nerve conduction pathways. For example, a tonsil or throat infection is often associated with ear ache, as the throat and ear share pain-conducting nerve pathways. Referred otalgia can be from: maxillofacial/dental/cervical sources, the upper aerodigestive tract, or from neuralgias.

Pain originating from the ear can be associated with hearing loss, a discharge, itchiness, tinnitus, or dizziness. If the ear looks normal and there are no other ear-associated symptoms, then it is likely the pain is referred, ie originates from elsewhere.

An ENT doctor would ask about associated symptoms to help determine the likely source of the pain (ear or referred). They would examine your ear, mouth (including your teeth and gums) and jaw joints. They should examine your neck too. They would need to perform a flexible nasendoscopy to examine the upper aerodigestive tract, and potentially arrange an MRI scan of the nasopharynx and neck, or dental/jaw x-rays/CT.

Sources of ear ache include:

Primary/Otogenic

External ear: inflammatory/infectious, trauma, neoplastic, other (wax impaction, foreign body)

Middle ear/mastoid/Inner Ear: inflammatory/infectious (Acute Otitis Media, Chronic Suppurative Otitis Media, cholesteatoma, mastoiditis, petrous apicitis,labyrinthitis), trauma, neoplastic

Referred otalgia

1. Maxillofacial/Dental/Cervical

Inflammatory/infectious: dental caries/abscess, periodontitis

Trauma: fractures, dentures

Neoplastic: keratocystic odontogenic tumour, ameloblastoma

Other: TMJ (temporomandibular joint) disorders, myofascial pain syndromes, cervical spine osteoarthritis, Eagle's syndrome (sharp oropharyngeal/facial/ear pain, dysphagia, globus, tinnitus, neurology (TIA/CVA - compression ICA) on head rotation due to styloid process >3cm or calcified stylohyoid ligament. This can be felt on bimanual palpation, and a CT confirms the diagnosis. It can be treated with partial styloidectomy, +/- repair of ICA, anti-inflammatories, antidepressants, steroids (Watt Weems Eagle 1937 American otorhinolaryngologist)

2. Aerodigestive tract

Inflammatory/infectious: sinusitis (acute or chronic rhinosinusitis), lymphatic adenitis, adenoiditis, tonsillitis/quinsy, salivary gland adenitis/stones, oral ulcers, deep neck space infection, thyroiditis, laryngitis, croup, supraglottitis, Gastro-Oesophageal Reflux Disease

Trauma: mucosal laceration, post-operative

Neoplastic: benign/malignant lesions of nasal cavity, sinuses, nasopharynx, oropharynx, oral cavity , floor of mouth, tongue, parapharyngeal space, hypopharynx, larynx, thyroid, and Primary of Unknown Origin

3. Neuralgias

Trigeminal or Glossopharyngeal (severe pain in tongue, throat, ear, tonsils, +/- vagal stimulation (bradycardia, hypotension, syncope), often triggered by swallowing, drinking cold fluid, sneezing, coughing, talking, throat clearing, touching the gums/throat) - both associated with MS - therefore MRI/MRA head required. Can be due to tumours or blood vessel compressing the nerve. Treated with: carbamazepine/gabapentin, neurosurgery

Pain characteristics

Continuous => infection

Intermittent => musculoskeletal (eg TMJ dysfunction)

Deep boring pain => cancer

The treatment would depend on the symptoms, clinical findings and cause.