Ear Pain

Department of the Navy
Bureau of Medicine and Surgery

Ear pain (otalgia) is a common presenting complaint confronting the practicing GMO. Pain may be caused by intrinsic otopathology or might be referred from a distant pathologic process. Even though the most common cause of otalgia is infection, anything from a foreign body to barotrauma to oropharyngeal tumors may cause this symptom. Your approach should focus on the diagnosis and treatment of acute processes while excluding serious pathology.

Obtain a detailed history. Inquire about symptoms of pain, discharge, hearing loss, vertigo, and pain in other areas such as the pharynx or larynx. Conversely, an oropharyngeal process may cause "referred" ear pain. Severe otalgia may radiate to the jaw or neck. Determine if there was a precedent upper respiratory infection before the onset of otalgia that might suggest an infectious process such as acute sinusitis or otitis media. Ask about swimming history (swimmers ear) or exposure to rapid pressure changes (usually on descent) from flying or deep sea diving. This may indicate barotrauma complicated by oxygen otitis media. Constitutional symptoms may include fever, chills, positional vertigo, tinnitus, nausea and vomiting, sore throat, dental pain, headache, and cranial nerve palsies. A review of symptoms must include respiratory, neurologic, metabolic, cardiovascular, and infectious complaints. Review the past medical history for any similar symptoms and for any chronic medical conditions that may predispose to this complaint.

The primary focus is on the ear, oropharynx, and nasopharynx (i.e., eustachian tube). Also perform a neck exam and a brief neurologic exam with attention to gait, cranial nerves, and the presence or absence of positional nystagmus. Examination of the ear begins with several simple clinical tests to evaluate the presence or absence of hearing loss. Hearing loss is divided into conductive and sensorineural.

• Lesions in the sound conducting system, which includes the ear canal and drum, middle ear, and ossicles, cause a conductive loss.

• Sensorineural loss is secondary to abnormalities of the vestibulocochlear system.

Begin with the voice test by occluding one ear while whispering or rubbing fingers together and repeat for the other side. Hearing is likely normal if the patient can pass these tests. Rinne's test evaluates conductive hearing loss by use of a 512 Hz tuning fork. The tuning fork is struck, placed on the mastoid process, and then 1 to 2 inches away from the ear. The patient is asked which was louder. A normal (positive Rinne's) test is when air conduction is greater than bone conduction (air conduction (AC) > bone conduction (BC)). Remember that this test by itself is unreliable if the patient has total neural deafness in one ear. This will be differentiated with the Weber's test. After striking the tuning fork, place it on the midline of the skull (forehead or teeth). Ask the patient where the sound is loudest. A normal test is when sound is heard in the middle of the head. Unilateral conductive loss will present with sound louder in the abnormal ear. With a sensorineural hearing loss, the sound is heard in the normal ear.

The external ear including the periauricular areas (mastoid and lymph nodes), pinna, and external canal area are examined for evidence of trauma (laceration and hematoma) and infection (erythema, drainage, or pain with movement of the pinna). The tympanic membranes need to be examined for evidence of perforation (common for barotrauma and Q-tip usage), erythema, normal landmarks (retraction or bulging), mobility, bullae, and effusions (serous, suppurative, or bloody). Examination of the oropharynx and surrounding structures is necessary to exclude sources of referred pain. Malocclusions and otalgia suggest TMJ syndrome. Assess for evidence of sinusitis by palpating for facial tenderness. Examine the oropharynx for dental lesions (tooth decay, gingivitis, abscess), peritonsillar abscess, or tumors.

Differential Diagnosis of Otalgia

Determine whether the pain is localized or referred.

• Local: trauma, either direct or indirect (hematoma, barotrauma, perforation), external otitis, furuncle, otitis media (acute or chronic).

• Referred: sinusitis, TMJ syndrome, dental disease, peritonsillar abscess, cervical arthritis, occipital neuralgia, foreign bodies of the hypopharynx, larynx, cervical esophagus, and less commonly, lesions involving cranial nerves VII, IX, and X such as disease of the thyroid, chest, and abdomen. Herpes Zoster oticus and Bell's palsy may also produce referred pain with cranial nerves V and VII.

General Treatment Guidelines

Generally treat the underlying condition.

• Otitis Externa

This condition is most commonly caused by Pseudomonas and less commonly by fungi. Treatment includes thorough suctioning and placement of a cotton wick saturated with Cortisporin Otic suspension for 5 to 7 days. Domboro's Otic solution is useful as an astringent and maintaining an acidic pH. Advise the patient to keep the ear canal dry. Remember that this condition is painful and will usually require a strong analgesic.

• Furuncles of the ear canal

These generally require localized warm compresses, antibiotics, and incision and drainage.

• Bullous Myringitis

Causes can include Mycoplasma or viral infections. If you suspect a bacterial cause, prescribe a 10 day course of erythromycin or tetracycline.

• Otitis Media

This condition is most commonly caused by Streptococcus pneumoniae followed by H. influenzae, and then Moraxella. Less frequent bacterial pathogens associated with otitis media include Streptococcus pyogenes and Staphlococcus aureus. Amoxacillin, followed by Augmentin or Pediazole, are the first line drugs of choice. Second or third-line agents for persistent infection include second or third generation cephalosporins and the macrolides including Biaxin and Zithromax. Other effective antibiotics are Pediazole and Septra. Myringotomy is indicated in patients with severe pain, toxicity, persistent high fever, or with associated complications such as facial nerve palsies, meningitis, or brain abscess.

• Barotitis

Inner ear inflammation caused by exposure to differing atmospheric pressures should be treated with analgesics and oral decongestants. Antibiotics are rarely indicated.

• TM Perforations

These injuries generally heal spontaneously without further treatment. Patients should be instructed to avoid water in the ear. If the ear is contaminated with saltwater, swimming pool water, or by a penetrating object, the patient should be placed on a course of systemic antibiotics such as Dicloxacillin or Augmentin. Large perforations will require urgent ENT referral.

The majority of patients with otalgia can be managed effectively by these simple treatment guidelines and will not require referral.

• Acute otitis media or sinusitis complicated by meningitis, cranial nerve involvement, focal neurologic deficits, labyrinthitis, mastoiditis, and cavernous sinus thrombosis.

• Gradenigo's syndrome (chronically draining ear with ipsilateral abducens palsy and pain behind the ipsilateral orbit).

• Systemic toxicity.

• Peritonsillar abscess.

• Retropharyngeal abscess.

• Neck abscess.

• Dental abscess (dental referral).

• Spreading periauricular cellulitis unresponsive to antibiotics.

• Tumors.

Non-emergent referrals would include:

• Chronic sinusitis

• Chronic otitis externa and media.

• TMJ unresponsive to conservative measures (dental referral).

• Recurrent vertigo.

• Non-healing or large tympanic membrane perforations.

• Recurrent tonsillitis.

• Nasal or sinus polyps (especially if on flight status).

• Karmody, C. Textbook of Otolaryngology. Lea & Febiger, 1983

• Rosen, P. Emergency Medicine, Concepts and Clinical Practice. Second edition, C.V. Mosby Co., 1988.

• Tintinalli, J. Emergency Medicine, Comprehensive Study Guide. McGraw Hill, 4^th Edition, 1996.

• Fairbanks, D. Antimicrobial Therapy in Otolaryngology-Head and Neck Surgery. American

• Academy of Otolaryngology-Head and Neck Foundation Inc. 5^th Edition, 1989