Ear pain or otalgia or earache is a quite common complaint. A special feature of ear pain is that the cause of ear pain lies in the ear in only half of the cases. In the remaining number of cases, the pain in the ear is either due to a problem in some other part of the body or its cause is not known. This is known as referred ear pain or secondary ear pain, and it may have myriad causes because of complex innervations of the ear. Moreover, the severity of pain has no relation to the seriousness of the condition causing it, for e.g. ear pains due to cancer can be mild. The earache whose cause lies in the ear itself is referred to as primary otalgia. The causes of primary earache are often apparent during the examination of the ear.

As is the case with most other symptoms, the treatment of the condition is often dictated by the cause of the symptoms. Management of ear pain involves finding out the cause (if possible) and then treating it. When the cause of ear pain lies within the ear itself, it is easier to identify the cause and treat it. In cases where the cause is not evident per se, further detailed evaluation is often warranted. Main focus is to rule out the "dangerous" conditions first (those which can have serious complications if the diagnosis is missed or delayed) and then proceed further. Often in a significant percentage of such cases, no cause of the ear pain can be found (the "idiopathic" otalgia), and they are treated by a trial of symptomatic treatment depending upon the index of suspicion for various conditions. For e.g. NSAIDs could be tried if TMJ (temporomandibular joint) syndrome is more likely, or anti-epileptic drugs may be tried if neuralgia is more likely. If the problem continues to persist, further evaluation is often needed by various procedures and imaging techniques.

Ear Pain and the "Dangerous Five"

Tumors of head, neck and chest region may cause ear pain. The ear pain might be the only complaint initially. Thus thorough evaluation for an occult tumor in patients at high risk for such cancers is often the most important step. People considered to be at high risk are tobacco or alcohol users, those who are above 50 years of age, and those who also have weight loss or difficulty in swallowing or hoarseness of voice.

Heart attack may present atypically with ear pain. Ruling out heart attack as the cause of ear pain is important in persons who are at risk for coronary artery disease.

Patients with diabetes or immunosuppression due to any cause (steroid therapy, AIDS etc) require careful evaluation of ear pain to rule out malignant otitis externa, a condition characterized by the spread of external ear infection (otitis externa) to the bones of the skull and adjacent areas.

Temporal arteritis is another serious condition that can present with ear pain. Ruling out temporal arteritis as the cause of ear pain is very important, because it can cause permanent blindness if specific treatment is delayed. This condition is generally found in persons whose age is above 50 years and two-third of those affected have some abnormality in the temporal artery. Other symptoms that are often present are weight loss, fever, decreased appetite and a feeling of general discomfort.

Cholesteatoma usually presents with ear pressure or fullness, but in rare conditions can cause ear pain also. Affected person usually also has foul smelling ear discharge with hearing loss and vertigo. This condition is dangerous as the cyst may enlarge and can start eroding 'bones' (ossicular chain) inside the middle ear, inner ear and bony canal for facial nerve.

Most common causes of primary earache

As already described above, primary earache is the one in which the cause of the ear pain lies in the ear itself. The most common causes of primary otalgia are listed in the table below.

Table 1: Most Common Causes of Primary Earache

Infection of the middle ear (Acute Otitis Media) is one of the most common causes of ear pain. It is more common in winter season and might be preceded by a common cold. Common cold itself may cause ear pain, without being complicated by middle ear infection. Both of these together account for a significant percentage of ear pain cases.

External ear infection is another important cause of ear pain. It is also known as "swimmer's ear" because it is often caused by recent swimming. Often the affected person may experience pain when the external ear is pulled. This condition is more common in the summer season.

Presence of a foreign body in the ear canal can also cause earache, and this is a very common cause of earache in children. The commonly found foreign bodies are insects, paper, beads and popcorn kernels.

Traumatic injury to the ear and barotraumas may cause ear pain. The most common causes of barotraumas are scuba diving and airplane flight (during descent of the airplane). Having concomitant upper respiratory tract infection or rhinitis (runny nose/stuffy nose/ post-nasal drip) increases the risk of having barotraumas.

Some of the less common causes are myringitis (inflammation of the eardrum), mastoiditis (inflammation of the mastoid bone), cellulitis (inflammation of the connective tissue in the skin) and chondritis (inflammation of the cartilage in the external ear). These are not all the causes of primary otalgia, there are numerous other rare causes which we won't discuss here.

Most common causes of secondary earache

The table enlists some of the most common causes of secondary otalgia or referred otalgia.

Table 2: Most Common Causes of Secondary Earache

The ear receives innervations from six different nerves, and these nerves supply numerous other structures in head, neck and chest region. The pain arising from any of these structures may be referred to ear and this makes discerning the correct cause of secondary otalgia a daunting task. In many cases, no cause can be found, and they are referred to as 'idiopathic' cases.

A significant number of cases of earache are due to dental causes. Dental causes might be the most common causes of secondary otalgia. Numerous dental conditions can cause earache; however the most common ones are caries, periodontal abscesses and impacted third molars. Often the dental causes of earache are due to the involvement of the molar teeth.

Upper respiratory tract infections are another common cause of secondary otalgia. Note that upper respiratory tract infections can cause middle ear infection, which is a cause of primary otalgia. Common cold, sore throat and sinusitis are the most frequently encountered URTI causing secondary earache.

Another important cause of referred otalgia is TMJ syndrome. TMJ syndrome is due to disorders of the temporomandibular joint (jaw joint) or the muscles associated with it. Typically, the pain in the ear occurs with chewing. Other features of this condition are pain and crepitus (crackling sound/sensation) when talking and chewing.

Various other less common causes like neuralgia, cervical spondylosis, mouth ulcers, heartburn (acid reflux disease), etc. are listed in the table above. This list is not a complete list with all possible causes, as there are many rare causes which we have not enlisted in the table.

Ear Pressure or Fullness

Another complaint that is somewhat related to ear pain is ear pressure or fullness. In this, frank ear pain is often absent or minimal, but the person experiences a vague feeling of fullness or pressure in the ear. This may or may not be associated with some other symptoms like decreased hearing, tinnitus, vertigo, etc.

The most important condition to consider in this case is the acoustic neuroma. It is not the most common cause of ear fullness, but the most important one because it's a tumor affecting the nerve connecting the internal ear to the brain. Other features of acoustic neuroma are unilateral hearing loss, unilateral tinnitus and imbalance (vertigo). Absence of these associated symptoms does not rule out this condition. Another important condition to be considered is cholesteatoma (skin cyst in the middle ear). This condition usually also has foul smelling ear discharge with hearing loss and vertigo. Cholesteatomas generally produce only a sense of fullness and not pain in the ear.

The most common cause of such ear pressure might be the disturbances in the normal functioning of the eustachian tube. Malfunctioning eustachian tube results in negative middle ear pressure, which causes the feeling of fullness or pressure in the ear. The middle ear's only connection to the outside world is through the eustachian tube. The opening of Eustachian tube when we swallow food, drinks or saliva or when we yawn causes equalization of the pressure between the middle ear and the outside environment. Malfunctioning of this tube may be caused by allergic or infectious processes affecting the eustachian tube. Upper respiratory tract infection (soar throat, common cold) is a common cause of eustachian tube dysfunction.

Few other less common causes of ear pressure or ear fullness are fungal infection of the external ear, sinusitis, Ménière's disease (an inner ear disorder causing hearing and balance disturbances), a specific type of middle ear infection (serous otitis media) and cerumen impaction in the ear canal. Sometimes, afflictions of the jaw joints (temporomandibular joints) may result in feeling of fullness or pressure in the ears.