Ear Pain - Symptom Evaluation

About

Pain in the ear is either due to a condition that directly affects the ear, or is referred from the surrounding areas.

Ear pain is a common symptom that could occur either due to a problem in the ear itself or a neighboring part of the head or face. Ear pain due to a local cause is usually detected on ear examination. For example, an infection or a foreign body can be directly diagnosed through ear examination. If this examination does not show any abnormality, the surrounding structures like the mouth should also be examined.

The ear is made up of three parts: the external or outer ear, the middle ear and the inner ear. The external ear extends through the ear canal till the eardrum. The middle ear extends from the eardrum till a spiral structure called the cochlea, which forms the internal ear. Conditions that cause ear pain are usually located in the external or middle ear.

Common Causes of Ear pain

Conditions affecting the ear:

• Acute Otitis Externa: Otitis externa refers to infection of the external or outer ear. The patient complains of pain when the examiner pulls the cartilage of the ear or presses on the tragus (the small cartilaginous projection in front of the ear). The ear canal may be red and swollen. The infection may follow an insect bite, scratch or ear piercing.
• Acute Otitis Media: Acute otitis media is an infection of the middle ear and is one of the more common causes of ear pain. On examination of the ear, the eardrum may be red and bulging. In some cases especially in diabetes patients or patients with reduced immunity, the infection and pain can be severe; the condition is referred to as malignant otitis externa.
• Foreign Body in Ear: Foreign bodies inserted in the ears are common causes of ear pain in children. The foreign body is usually visible in the ear canal on examination and can be removed with a curette or a forceps. In some cases, excessive ear wax can result in ear pain.
• Changes in External Pressure: Changes in external pressure can result in ear pain. This situation is frequently experienced during a flight or while scuba diving. The pain usually subsides on its own. In some cases however, the pressure changes can damage the eardrum resulting in accumulation of fluid or blood in the middle ear.
• Trauma: Trauma to the ear due to injury can cause pain of the ear. A history of trauma is usually present in these patients.
• Cancer of the External Ear: Squamous cell cancer, a cancer affecting the external ear, is a rare cause of ear pain. The pain tends to be severe, deep and unrelenting.
• Ramsay Hunt Syndrome: Ramsay Hunt Syndrome is a condition where the nerves supplying to the area near the ear are affected by a viral infection called herpes zoster. The patient complains of features like ear pain, paralysis of the face and the presence of fluid-filled boils in the ear canal. Other associated symptoms include hearing loss, ringing in the ear, vertigo and taste disturbances.
• Relapsing Polychondritis: Relapsing polychondritis is a condition that affects the cartilages of different parts of the body including the ear. The ears appear red in color. However, the earlobe, which lacks cartilage, appears normal. The condition keeps relapsing. Cartilages in other organs are also often involved, which include the eyes, nose, heart, kidneys and the nervous system.

Conditions Causing Referred Pain to the Ear: Conditions that cause ear pain despite a normal ear examination are:

• TMJ Syndrome: The TMJ is the jaw joint. TMJ syndrome is a condition where the patient experiences ear pain especially while moving the jaw during activities like talking or chewing. Examination of the joint may elicit pain and a crepitus sound on moving the joint. The pain may subside with painkillers and a soft diet.
• Dental Causes: Pain in the molars due to caries, abscess or due to impaction of the molar can lead to referred pain in the ear. It is therefore extremely important to check the teeth in a patient complaining of ear pain.
• Sore Throat: Sore throat or enlarged and infected tonsils can result in ear pain. Again, this condition is diagnosed on examination of the mouth.
• Tumors of the face and neck region: Tumors of nose, mouth, neck and chest can rarely cause ear pain. The patient may show symptoms like difficulty with swallowing, hoarseness or weight loss. He/she may also give a history of smoking.
• Neuralgias: Neuralgias are conditions that affect nerves and cause severe pain in the distribution of the nerve. Neuralgias that cause severe pain around the face include trigeminal neuralgia, glossopharyngeal neuralgia and sphenopalatine neuralgia. The pain is often sharp, shooting, and severe and appears in paroxysms.
• Temporal Arteritis: Temporal arteritis is a condition that affects the blood vessels at the temple area. This pain may refer to the ear. The patient complains of pain when pressure is applied to the temporal arteries. The ESR test, which is a blood test, is usually abnormal in these patients.
• Cervical Spine Arthritis: Neck pain due to arthritis can also be referred to the ear. It is therefore necessary to examine the neck as well in a patient complaining of ear pain, especially if the ear examination is normal.

Frequently Asked Questions (FAQs)

1. Which doctor should I visit in case I suffer from ear pain?

You should visit an ENT (Ear-Nose-Throat) specialist in case you suffer from ear pain.

2. Why don't diseases of the inner ear produce pain?

The inner ear is supplied by nerves that do not have pain fibers. Therefore, diseases of the inner ear usually do not produce pain.

References:

1. Ely JW, Hansen MR, Clark EC. Diagnosis of Ear Pain. Am Fam Physician. 2008;77(5):621-628.