{{Short description|Pain in the ear}} {{Redirect|Earache|record label|Earache Records}} {{Infobox medical condition (new) | name = Ear pain | synonyms = Earache, otalgia | image = Defense.gov photo essay 110719-F-ET173-093.jpg | caption = Examination of the ear canal and eardrum | pronounce = | field = [[ENT surgery]] | symptoms = | complications = | onset = | duration = | types = | causes = | risks = | diagnosis = | differential = | prevention = | treatment = | medication = | prognosis = | frequency = | deaths = }} '''Ear pain''', also known as '''earache''' or '''otalgia''', is [[pain]] in the [[ear]].<ref>{{Cite web|url=https://medlineplus.gov/ency/article/003046.htm|title=Earache: MedlinePlus Medical Encyclopedia|website=medlineplus.gov|language=en|access-date=2017-10-02}}</ref><ref name=":2" /> Primary ear pain is pain that originates from the ear. Secondary ear pain is a type of [[referred pain]], meaning that the source of the pain differs from the location where the pain is felt.
Most causes of ear pain are non-life-threatening.<ref name=AFP2018/><ref name=Sullivan2012/> Primary ear pain is more common than secondary ear pain,<ref name=Conover2013/> and it is often due to infection or injury.<ref name=AFP2018/> The conditions that cause secondary (referred) ear pain are broad and range from temporomandibular joint syndrome to inflammation of the throat.<ref name=AFP2018/>
In general, the reason for ear pain can be discovered by taking a thorough history of all symptoms and performing a physical examination, without need for imaging tools like a CT scan.<ref name=AFP2018/> However, further testing may be needed if red flags are present like hearing loss, dizziness, ringing in the ear or unexpected weight loss.<ref name=RedFlagPosition2014/>
Management of ear pain depends on the cause. If there is a bacterial infection, [[antibiotic]]s are sometimes recommended and over the counter pain medications can help control discomfort.<ref name="Tintinalli8th">{{Cite book|title=Tintinalli's Emergency Medicine: A Comprehensive Study Guide|last=Coombs|first=Carmen|date=2016|publisher=McGraw-Hill Education|isbn=978-0071794763|editor-last=Tintinalli|editor-first=Judith E.|edition=8|location=New York, NY|chapter=Chapter 118: Ear and Mastoid Disorders in Infants and Children|editor-last2=Stapczynski|editor-first2=J. Stephan|editor-last3=Ma|editor-first3=O. John|editor-last4=Yealy|editor-first4=Donald M.|editor-last5=Meckler|editor-first5=Garth D.|editor-last6=Cline|editor-first6=David M. | name-list-style = vanc |chapter-url=http://accessmedicine.mhmedical.com/content.aspx?aid=1121507452}}</ref> Some causes of ear pain require a procedure or surgery.<ref name=Tintinalli8th/><ref name="Stallard2017">{{Cite book|title=CURRENT Diagnosis & Treatment: Emergency Medicine|last=Stallard|first=Timothy C.| name-list-style = vanc |date=2017|publisher=McGraw-Hill Education|editor-last=Stone|editor-first=C. Keith|edition=8|location=New York, NY|chapter=Chapter 32: Emergency Disorders of the Ear, Nose, Sinuses, Oropharynx, & Mouth|editor-last2=Humphries|editor-first2=Roger L. |chapter-url=http://accessmedicine.mhmedical.com/content.aspx?aid=1144316285}}</ref><ref name=Harrisons19th/>
83 percent of children have at least one episode of a middle ear infection by three years of age.<ref name=Rosa-Olivares2015/>
== Signs and symptoms == Ear pain can present in one or both ears. It may or may not be accompanied by other symptoms such as [[fever]], [[vertigo|sensation of the world spinning]], ear itchiness, or a sense of fullness in the ear. The pain may or may not worsen with chewing.<ref name=AFP2018>{{cite journal | vauthors = Earwood JS, Rogers TS, Rathjen NA | title = Ear Pain: Diagnosing Common and Uncommon Causes | journal = American Family Physician | volume = 97 | issue = 1 | pages = 20–27 | date = January 2018 | pmid = 29365233 | url = https://www.aafp.org/afp/2018/0101/p20.html }}{{open access}}</ref> The pain may also be continuous or intermittent.<ref>{{cite journal | vauthors = Harrison E, Cronin M | title = Otalgia | journal = Australian Family Physician | volume = 45 | issue = 7 | pages = 493–7 | date = July 2016 | pmid = 27610432 | url = https://www.racgp.org.au/afp/2016/july/otalgia/ }}</ref>
Ear pain due to an infection is the most common in children and can occur in babies.<ref name=Rosa-Olivares2015>{{cite journal | vauthors = Rosa-Olivares J, Porro A, Rodriguez-Varela M, Riefkohl G, Niroomand-Rad I | title = Otitis Media: To Treat, To Refer, To Do Nothing: A Review for the Practitioner | journal = Pediatrics in Review | volume = 36 | issue = 11 | pages = 480–6; quiz 487–8 | date = November 2015 | pmid = 26527627 | doi = 10.1542/pir.36-11-480 }}</ref> Adults may need further evaluation if they have hearing loss, dizziness or ringing in the ear.<ref name=RedFlagPosition2014>{{Cite web|url=http://www.entnet.org/content/position-statement-red-flags-warning-ear-disease|title=Position Statement: Red Flags-Warning of Ear Disease|date=2014-03-20|publisher=American Academy of Otolaryngology–Head and Neck Surgery|access-date=2018-03-13|language=en|archive-date=2018-03-14|archive-url=https://web.archive.org/web/20180314174443/http://www.entnet.org/content/position-statement-red-flags-warning-ear-disease|url-status=dead}}</ref> Additional red flags include diabetes, a weakened immune system, swelling seen on the outer ear, or swelling along the jaw.<ref>{{Cite book |first=Debara L. |last= David M. Kaylie |chapter-url=https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/approach-to-the-patient-with-ear-problems/earache|chapter=Earache|title=Merck Manual, Professional Version |date=October 2016|language=en-US}}</ref>
== Causes == Ear pain has a variety of causes, the majority of which are not [[life-threatening]].<ref name=AFP2018/><ref name=Sullivan2012>{{Cite book|chapter=Chapter 17:Ear Pain|chapter-url=http://accessmedicine.mhmedical.com/content.aspx?aid=56851975|title=The Patient History: An Evidence-Based Approach to Differential Diagnosis|last=Sullivan|first=Daniel J.|date=2012|publisher=The McGraw-Hill Companies|editor-last=Henderson|editor-first=Mark C.|edition=2|location=New York, NY|editor-last2=Tierney|editor-first2=Lawrence M.|editor-last3=Smetana|editor-first3=Gerald W. | name-list-style = vanc }}</ref> Ear pain can originate from a part of the ear itself, known as primary ear pain, or from an anatomic structure outside the ear that is perceived as pain within the ear, known as secondary ear pain.<ref name=AFP2018/> Secondary ear pain is a type of [[referred pain]], meaning that the source of the pain differs from the location where the pain is felt. Primary ear pain is more common in children, whereas secondary (referred) pain is more common in adults.<ref name="Medscape2017">{{Cite journal|last=Li|first=John|date=2017-09-21|title=Otalgia: Background, Pathophysiology, Epidemiology|url=http://emedicine.medscape.com/article/845173-overview|journal=Medscape}}</ref>
Primary ear pain is most commonly caused by [[infection]] or injury to one of the parts of the ear.<ref name=AFP2018/>
=== External ear === Many conditions involving the external ear will be visible to the naked eye. Because the external ear is the most exposed portion of the ear, it is vulnerable to trauma or environmental exposures.<ref name=uptodateearachekids>{{Cite web|url=https://www.uptodate.com/contents/evaluation-of-earache-in-children?search=otalgia&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1|title=Evaluation of earache in children|last=Greenes|first=David|website=www.uptodate.com|access-date=2018-03-14}}</ref> Blunt trauma, such as a blow to the ear, can result in a [[hematoma]], or collection of blood between the cartilage and [[perichondrium]] of the ear. This type of injury is particularly common in contact sports such as wrestling and boxing.<ref>{{Cite journal|last=Leybell|first=Inna|date=2017-06-20|title=Auricular Hematoma Drainage: Overview, Indications, Contraindications|url=https://emedicine.medscape.com/article/82793-overview?pa=KsCj71gG5weYJTrPE6frS5b019MGCIK7/ESOkZM/LamsQWeCEbSd3zYot28Bg1dOs7CF3wx2Tu1U792SxywYLg==|journal=Medscape}}</ref> Environmental injuries include [[sunburn]], [[frostbite]], or [[contact dermatitis]].<ref name=uptodateearachekids/>
Less common causes of external ear pain include:<ref name=uptodateearachekids/><ref name=Lustig2018>{{Cite book|chapter=Chapter 8: Ear, Nose, & Throat Disorders |chapter-url=http://accessmedicine.mhmedical.com/content.aspx?aid=1145394181|title=Current Medical Diagnosis & Treatment 2018|last1=Lustig|first1=Lawrence R.|last2=Schindler|first2=Joshua S. | name-list-style = vanc |date=2017|publisher=McGraw-Hill Education|editor-last=Papadakis|editor-first=Maxine A.|location=New York, NY|editor-last2=McPhee|editor-first2=Stephen J.|editor-last3=Rabow|editor-first3=Michael W.}}</ref> * Auricular [[Cellulitis]]: a superficial infection of the ear that may be precipitated by trauma, an insect bite, or ear piercing * [[Perichondritis]]: infection of the [[perichondrium]], or [[fascia]] surrounding the ear [[cartilage]], which can develop as a complication of untreated auricular cellulitis. It is important to identify and treat perichondritis with antibiotics to avoid permanent ear deformities. * [[Relapsing polychondritis]]: a systemic inflammatory condition involving cartilage in many parts of the body, but often including the cartilage of both ears. The severity and prognosis of the disease varies widely.<ref>{{Cite web|url=https://emedicine.medscape.com/article/331475-clinical|title=Relapsing Polychondritis Clinical Presentation: History, Physical, Causes|last=Compton|first=Nicholas|website=emedicine.medscape.com|language=en|access-date=2018-03-14}}</ref>
==== Otitis externa ==== [[Otitis externa]], also known as "swimmer's ear", is a [[cellulitis]] of the external ear canal. In North America, 98% of cases are caused by bacteria, and the most common causative organisms are [[Pseudomonas aeruginosa|''Pseudomonas'']] and [[Staphylococcus aureus|''Staph aureus'']].<ref name=Rosenfeld2014>{{cite journal | vauthors = Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA, Huang WW, Haskell HW, Robertson PJ | title = Clinical practice guideline: acute otitis externa | journal = Otolaryngology–Head and Neck Surgery | volume = 150 | issue = 1 Suppl | pages = S1–S24 | date = February 2014 | pmid = 24491310 | doi = 10.1177/0194599813517083 | s2cid = 40005605 }}</ref> Risk factors include exposure to excessive moisture (e.g. from swimming or a warm climate) and disruption of the protective [[Earwax|cerumen]] barrier, which can result from aggressive ear cleaning or placing objects in the ear.<ref name=Yoon2013>{{Cite book|chapter=Chapter 18: Ear, Nose, & Throat |chapter-url=http://accessmedicine.mhmedical.com/content.aspx?aid=1128023540|title=CURRENT Diagnosis & Treatment Pediatrics|last1=Yoon|first1=Patricia J.|last2=Scholes|first2=Melissa A.|last3=Friedman|first3=Norman R.|date=2016|publisher=McGraw-Hill Education|editor-last=Hay|editor-first=William W.|edition=23rd|location=New York, NY|editor-last2=Levin|editor-first2=Myron J.|editor-last3=Deterding|editor-first3=Robin R.|editor-last4=Abzug|editor-first4=Mark J.| name-list-style = vanc |isbn=978-0071848541}}</ref>
Malignant otitis externa is a rare and potentially life-threatening complication of otitis externa in which the infection spreads from the ear canal into the surrounding skull base, hence becoming an [[osteomyelitis]].<ref name=Lustig2018/> It occurs largely in diabetic patients.<ref name=uptodatenecrotizing>{{Cite web|url=https://www.uptodate.com/contents/malignant-necrotizing-external-otitis?search=otitis%20externa&source=search_result&selectedTitle=3~85&usage_type=default&display_rank=3#H4|title=Malignant (necrotizing) otitis externa|last=Grandis |first=Jennifer |display-authors=etal |date=February 2018|website=www.uptodate.com |access-date=2018-03-14|url-access=subscription}}</ref> It is very rare in children, though can be seen in [[immunocompromised]] children and adults.<ref name=Yoon2013/> ''[[Pseudomonas aeruginosa|Pseudomonas]]'' is the most common causative organism.<ref name=uptodatenecrotizing/> The pain tends to be more severe than in uncomplicated otitis externa, and laboratory studies often reveal elevated inflammatory markers ([[Erythrocyte sedimentation rate|ESR]] and/or [[C-reactive protein|CRP]]). The infection may extend to [[cranial nerves]], or rarely to the [[meninges]] or brain.<ref name=uptodatenecrotizing/> Examination of the ear canal may reveal [[granulation tissue]] in the inferior canal. It is treated with several weeks of IV and oral antibiotics, usually [[Quinolone antibiotic|fluoroquinolones]].<ref name=uptodatenecrotizing/>
==== Mechanical obstruction ==== * [[Earwax]] impaction: results in 12 million medical visits annually in the United States.<ref>{{Cite journal|vauthors=Schwartz S, etal |date=January 2017 |title=Clinical Practice Guideline (Update): Earwax (Cerumen Impaction) Executive Summary |doi=10.1177/0194599816678832 |pmid=28045632 |doi-access=free |journal=Otolaryngology–Head and Neck Surgery |volume=156 |issue=1 |pages=14–29}}</ref> Cerumen impaction may cause ear pain, but it can also prevent thorough examination of the ear and identification of an alternate source of pain. * [[Foreign body]]: commonly include insects or small objects like beads<ref name=Conover2013/>
==== Less common ==== * [[Varicella zoster virus|Herpes zoster]]: varicella zoster virus can reactivate in an area that includes the ear. Reactivation can produce pain and visible [[Cutaneous condition|vesicles]] within the ear canal and, when combined with facial paralysis due to [[facial nerve]] involvement, is called [[Ramsay Hunt syndrome type 2|Ramsay Hunt syndrome]].<ref>{{Cite web|url=https://www.uptodate.com/contents/clinical-manifestations-of-varicella-zoster-virus-infection-herpes-zoster?sectionName=Ramsay%20Hunt%20syndrome%20(Herpes%20zoster%20oticus)&anchor=H15&source=see_link#H15|title=Clinical manifestations of varicella-zoster virus infection: Herpes zoster|last=Albrecht|first=Mary|date=August 2016|website=www.uptodate.com|access-date=2018-03-14}}</ref> * [[Neoplasm|Tumors]]: the most common ear canal tumor is squamous cell [[carcinoma]]. Symptoms can resemble those of otitis externa, and cancer should be considered if the symptoms are not improving on appropriate treatment.<ref name=Lustig2018/>
=== Middle and inner ear ===
==== Acute otitis media ==== [[File:Otitis media entdifferenziert2.jpg|thumb|Otitis media]] Acute [[otitis media]] is an infection of the middle ear. More than 80% of children experience at least one episode of otitis media by age 3 years.<ref>{{cite journal | vauthors = Leung AK, Wong AH | title = Acute Otitis Media in Children | journal = Recent Patents on Inflammation & Allergy Drug Discovery | volume = 11 | issue = 1 | pages = 32–40 | date = 2017 | pmid = 28707578 | doi = 10.2174/1874609810666170712145332 }}</ref> Acute otitis media is also most common in these first 3 years of life, though older children may also experience it.<ref name=Yoon2013/> The most common causative bacteria are ''[[Streptococcus pneumoniae]]'', ''[[Haemophilus influenzae]]'', and ''[[Moraxella catarrhalis]]''.<ref name=Yoon2013/> Otitis media often occurs with or following [[Upper respiratory tract infection|cold]] symptoms.<ref name=uptodateearachekids/> The diagnosis is made by the combination of symptoms and examination of the [[Eardrum|tympanic membrane]] for redness, bulging, and/or a middle ear effusion (collection of fluid within the middle ear).<ref name=Conover2013/>
Complications of otitis media include [[Conductive hearing loss|hearing loss]], [[facial nerve paralysis]], or extension of infection to surrounding anatomic structures, including:<ref>{{Cite web|url=https://www.uptodate.com/contents/acute-otitis-media-in-children-epidemiology-microbiology-clinical-manifestations-and-complications?sectionName=Bullous%20myringitis&anchor=H25&source=see_link#H27 |url-access=subscription |title=Acute otitis media in children|last=Klein |first=Jerome |display-authors=etal |date=September 2017|website=www.uptodate.com|access-date=2018-03-14}}</ref> * [[Mastoiditis]]: infection of the air cells in the [[Mastoid part of the temporal bone|mastoid process]], the area of the skull located right behind the ear<ref name=Yoon2013/> * Petrositis: infection of the [[Petrous part of the temporal bone|petrous portion of the temporal bone]] * [[Labyrinthitis]] * [[Meningitis]] * [[Subdural empyema|Subdural abscess]] * [[Brain abscess]] * [[Cerebral venous sinus thrombosis]]
==== Trauma ==== * [[Barotrauma]]: results from changes in [[atmospheric pressure]] that occur, for example, when descending in a plane or deep diving. As atmospheric pressure increases with descent, the [[eustachian tube]] collapses due to pressure within the middle ear being less than the external pressure, which causes pain. In severe cases, middle ear [[Bleeding|hemorrhage]] or tympanic membrane rupture can result.<ref name=Lustig2018/> * [[Eardrum|Tympanic membrane]] rupture: disruption of the eardrum. This can be caused by a blow to the ear, blast injury, barotrauma, or direct penetration of the tympanic membrane by an object entering the ear.<ref name=Conover2013/> * [[Hyperacusis#Noxacusis (pain hyperacusis)|Noxacusis (Pain Hyperacusis)]]: causes pain in the ear when exposed to noise that typically does not cause pain.<ref>{{cite web |date= |title=What is Hyperacusis |url=https://hyperacusisresearch.org/what-is-hyperacusis/ |url-status=live |archive-url=https://archive.today/20230929060000/https://hyperacusisresearch.org/what-is-hyperacusis/ |archive-date=29 September 2023 |access-date=28 September 2023 |website=Hyperacusis Research}}</ref> This has been thought to be caused by type II nerves responding to damage of the outer hair cells.<ref>Liu, C., Glowatzki, E., & Fuchs, P. A. (2015). Unmyelinated type II afferent neurons report cochlear damage. ''Proceedings of the National Academy of Sciences of the United States of America'', ''112''(47), 14723–14727. https://doi.org/10.1073/pnas.1515228112</ref>
=== Referred ear pain === A variety of conditions can cause irritation of one of the nerves that provides sensation to the ear.
Conditions causing irritation the trigeminal nerve (cranial nerve V):<ref name=AFP2018/> * [[Temporomandibular joint dysfunction|Temporomandibular joint syndrome]]: inflammation or abnormal movements of the joint between the jaw and skull. These disorders are most common in women of childbearing age, and are uncommon in children younger than 10 years old.<ref name=Goddard2017>{{Cite book|chapter=Chapter 26. Temporomandibular Disorders|chapter-url=http://accessmedicine.mhmedical.com/content.aspx?aid=55768069|title=CURRENT Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery|last=Goddard|first=Greg|date=2012|publisher=The McGraw-Hill Companies|editor-last=Lalwani|editor-first=Anil K.|edition=3|location=New York, NY}}</ref><ref>{{Cite journal|last=Tsai|first=Vivian|date=2018-01-02|title=Temporomandibular Joint Syndrome: Background, Pathophysiology, Epidemiology|url=https://emedicine.medscape.com/article/809598-overview#a6|journal=Medscape}}</ref><ref name=uptodateearachekids/> * [[Myofascial pain syndrome]]: pain in the muscles involved in chewing. There may be certain parts of the muscles or [[tendon]]s ([[connective tissue]] connecting the muscles to bones) that are especially painful when pressed<ref name=Goddard2017/> * [[Trigeminal neuralgia]]: attacks of shooting pain down the face that may be triggered by touching the face or temperature changes<ref>{{Cite journal|last=Singh|first=Manish|date=2017-09-26|title=Trigeminal Neuralgia: Practice Essentials, Background, Anatomy|url=https://emedicine.medscape.com/article/1145144-overview|journal=Medscape}}</ref> * Dental pain from [[Tooth decay|cavities]] or an abscess * Oral cavity carcinoma Conditions causing irritation of the facial nerve (cranial nerve VII) or glossopharyngeal nerve (cranial nerve IX):<ref name=AFP2018/> * [[Tonsillitis]]: infection/inflammation of the tonsils * Post-[[tonsillectomy]]: pain following surgical removal of the tonsils * [[Pharyngitis]]: infection/inflammation of the throat * [[Sinusitis]] * [[Parotitis]]: inflammation of the parotid gland, the salivary gland right in front of the ear * [[Carcinoma]] of the oropharynx (base of tongue, soft palate, pharyngeal wall, tonsils) Conditions causing irritation of the vagus nerve (cranial nerve X):<ref name=AFP2018/> * [[Gastroesophageal reflux disease|GERD]] * [[Myocardial ischemia]] (inadequate oxygen supply to the heart muscle)
Conditions causing irritation of cervical nerves C2-C3:<ref name=AFP2018/><ref name=uptodateearachekids/> * [[Cervical vertebrae|Cervical spine]] trauma, [[arthritis]] (joint inflammation), or tumor * [[Giant-cell arteritis|Temporal arteritis]]: an [[Autoimmunity|autoimmune]] disorder leading to inflammation of the temporal artery, a large artery in the head. This condition tends to occur in adults older than 50.<ref name=Lustig2018/>
==Pathophysiology== ===Primary ear pain=== The ear can be anatomically divided into the [[external ear]], the [[external auditory canal]], the middle ear, and the [[inner ear]].<ref name=BigPictureEar>{{Cite book|chapter=Chapter 19. Ear |chapter-url=http://accessmedicine.mhmedical.com/content.aspx?aid=8667313|title=The Big Picture: Gross Anatomy|last1=Morton|first1=David A.|last2=Foreman|first2=K. Bo|last3=Albertine|first3=Kurt H.| name-list-style = vanc |date=2011|publisher=The McGraw-Hill Companies|location=New York, NY|isbn=978-0071476720}}</ref> These three are indistinguishable in terms of the pain experienced.<ref name=":2">{{cite book|editor-last1=Sharav|editor-first1=Yair|editor-last2=Benoliel|editor-first2=Rafael| name-list-style = vanc |title=Orofacial Pain and Headache|date=2008|publisher=Elsevier Health Sciences|page=91|chapter-url=https://books.google.com/books?id=t6oAmPp6okgC&pg=PA91|chapter=Chapter 6: Otolaryngological aspects of orofacial pain|last1=Gross|first1=Manachem|last2=Eliashar|first2=Ron |isbn=9780723434122}}</ref>
===Secondary ear pain=== [[File:Referred_Otalgia.png|thumb|Referred otalgia from neck and head sources<ref>{{Cite journal|last1=Chen|first1=R. C.|last2=Khorsandi|first2=A. S.|last3=Shatzkes|first3=D. R.|last4=Holliday|first4=R. A.|date=2009-11-01|title=The Radiology of Referred Otalgia|journal=American Journal of Neuroradiology|language=en|volume=30|issue=10|pages=1817–1823|doi=10.3174/ajnr.A1605|issn=0195-6108|pmid=19797791|pmc=7051282|doi-access=free}}</ref>]]Many different nerves provide sensation to the various parts of the ear, including cranial nerves V ([[Trigeminal nerve|trigeminal]]), VII ([[Facial nerve|facial]]), IX ([[Glossopharyngeal nerve|glossopharyngeal]]), and X ([[Vagus nerve|vagus]]), and the [[great auricular nerve]] (cervical nerves C2-C3).<ref name=BigPictureEar/><ref name="otalgia1">{{cite journal | vauthors = Scarbrough TJ, Day TA, Williams TE, Hardin JH, Aguero EG, Thomas CR | title = Referred otalgia in head and neck cancer: a unifying schema | journal = American Journal of Clinical Oncology | volume = 26 | issue = 5 | pages = e157–62 | date = October 2003 | pmid = 14528091 | doi = 10.1097/01.coc.0000091357.08692.86 | s2cid = 35512999 }}</ref> These nerves also supply other parts of the body, from the mouth to the chest and abdomen. Irritation of these nerves in another part of the body has the potential to produce pain in the ear.<ref name=BigPictureEar/> This is called referred pain. Irritation of the trigeminal nerve (cranial nerve V) is the most common cause of referred ear pain.<ref name=AFP2018/>
== Diagnostic == [[File:EAR_PAIN_framework_1.jpg|thumb|upright=1.4|Acute ear pain decision tree<ref name="Sullivan2012" /><ref name="Stallard2017" /><ref name="Harrisons19th" />|alt=A decision tree to help readers decide likely diagnoses for acute ear pain]] [[File:EAR_PAIN_framework_2.jpg|thumb|upright=1.4|Chronic ear pain decision tree<ref name="Sullivan2012" /><ref name="Stallard2017" /><ref name="Harrisons19th" />]] While some disorders may require specific imaging or testing, most etiologies of ear pain are diagnosed clinically. Because the differential for ear pain is so broad, there is no consensus on the best diagnostic framework to use. One approach is to differentiate by time course, as primary causes of ear pain are typically more acute in nature, while secondary causes of ear pain are more chronic.
Acute causes may be further distinguished by the presence of fever (indicating an underlying infection) or the absence of fever (suggesting a structural problem, such as trauma or other injury to the ear). [[Etiologies]] leading to chronic pain may be broken down by the presence or absence of worrisome clinical features, also known as red flags.
One red flag is the presence of one or multiple risk factors including smoking, heavy alcohol use (greater than 3.5 drinks per day), diabetes, coronary artery disease, and older age (greater than 50).<ref name="AFP2018" /> These factors increase the risk of having a serious cause of ear pain, like cancer or a serious infection. In particular, second hand smoke may increase risk of acute otitis media in children.<ref>{{Cite news|url=https://www.nidcd.nih.gov/health/ear-infections-children#5|title=Ear Infections in Children|date=2015-08-18|work=NIDCD|access-date=2018-03-14|language=en}}</ref> In addition, swimming is the most significant risk factor for otitis externae, though other risk factors include high humidity in the ear canal, [[eczema]] and/or ear trauma.<ref name="AFP2012">{{cite journal|vauthors=Schaefer P, Baugh RF|date=December 2012|title=Acute otitis externa: an update|url=https://www.aafp.org/afp/2012/1201/p1055.html|journal=American Family Physician|volume=86|issue=11|pages=1055–61|pmid=23198673}}</ref>
If red flags are present it may be necessary to do additional workup such as a [[CT scan]] or [[biopsy]] to rule out a more dangerous diagnosis. Such diagnoses include malignant (or necrotizing) otitis externa, mastoiditis, [[Giant-cell arteritis|temporal arteritis]], and cancer. While the presence of a red flag does raise suspicion for one of these four disease, it does not guarantee a diagnosis as any one symptom can be seen in a variety of situations. For example, [[jaw claudication]] can be seen in temporal arteritis, but also in [[Temporomandibular joint dysfunction|TMJ dysfunction]].<ref name="Sullivan2012" />
If there are no red flags, other sources of referred ear pain become more likely and are reasonable to pursue. {| class="wikitable" |+Infectious causes !Diagnosis ! colspan="3" |Features<ref name=Sullivan2012/><ref name=Stallard2017/><ref name=Harrisons19th>{{cite book|editor-last1=Kasper|editor-first1=Dennis L.|editor-last2=Fauci|editor-first2=Anthony S.|editor-last3=Hauser|editor-first3=Stephen L.|editor-last4=Longo|editor-first4=Dan L.|editor-last5=Jameson|editor-first5=J. Larry|editor-last6=Loscalzo|editor-first6=Joseph| name-list-style = vanc |title=Harrison's Manual of Medicine|date=2016|publisher=McGraw-Hill Education|edition=19th|chapter-url=http://accessmedicine.mhmedical.com/content.aspx?bookid=1820§ionid=127554985|chapter=Chapter 58: Sore Throat, Earache, and Upper Respiratory Symptoms|isbn=978-0071828529}}</ref> |- | rowspan="2" |'''Acute [[otitis media]]''' |History of [[Upper respiratory tract infection|URI]] within 10 days |Child pulling on ear |Severe pain; feels deep inside the ear. |- |Fever |Hearing loss |Pain may disrupt sleep |- |'''Perforated tympanic membrane''' | colspan="3" |Discharge followed by pain improvement |- | rowspan="3" |'''[[Mastoiditis]]*''' |Children |History of URI >10 days |Recent history of URI or ear infection |- |Fevers/chills |May see signs of otitis media on exam |Pain is located behind the ear with postauricular (i.e. near [[Mastoid part of the temporal bone|mastoid process]]) swelling* |- | colspan="3" |Diagnose with CT |- |'''Chronic suppurative otitis media''' |Conductive hearing loss |Relapsing/remitting or chronic discharge |May see perforation of tympanic membrane or [[cholesteatoma]] on exam |- |'''Serous otitis media'''
'''(otitis media with effusion)''' |No signs of infection |Prominent hearing loss |May have history of URI or acute otitis media |- | rowspan="3" |'''[[Otitis externa]]''' |Swimming |Psoriasis |[[Seborrhoeic dermatitis|Seborrheic dermatitis]] |- |Q-tips in the ear |Bilateral pain |Scaling |- |Itching |Pain exacerbated when ear is pulled |May see granulation tissue in canal on exam |- | rowspan="2" |'''Necrotizing/malignant''' '''otitis externa*''' |Diabetes |Immuno-compromised |Constant pain with increasing severity at night* |- |Purulent discharge* |Pain out of proportion to exam findings* |Biopsy granulation tissue for culture |- |'''[[Chondritis]] vs [[perichondritis]]''' |Recent ear trauma (i.e. ear piercing) |External ear appears inflamed |Chondritis more likely than perichondritis if ear shape is distorted |}
{| class="wikitable" |+Referred causes !Diagnosis ! colspan="2" |Features<ref name=Sullivan2012/><ref name=Stallard2017/><ref name=Harrisons19th/> |- |'''[[Gastroesophageal reflux disease|GERD]]''' | colspan="2" |Bilateral pain |- |'''[[Neuralgia]]''' | colspan="2" |Pain described as tingling/sharp/burning sensation; episodes can start with light touch |- |'''Malignancy*''' | colspan="2" |Weight loss* |- |'''Arthritis of the neck''' | colspan="2" |Pain exacerbated by neck movement |- |'''[[Eagle syndrome]]''' | colspan="2" |Swallowing exacerbates pain |- |'''Infected 3rd molar''' | colspan="2" |Extreme food temperatures exacerbate pain |- |'''Temporal arteritis*''' |Patient age > 50* |Chewing exacerbates pain* |- | rowspan="2" |'''TMJ dysfunction''' |Patient grinds teeth |Bilateral pain |- |Pain + [[crepitus]] with TMJ palpation |Jaw clicking |} <nowiki>*</nowiki>Indicates a "Can't Miss" diagnosis or a red flag. {| class="wikitable" |+Other causes !Diagnosis ! colspan="3" |Features<ref name=Sullivan2012/><ref name=Stallard2017/><ref name=Harrisons19th/> |- |'''[[Barotrauma]]''' |Recent ear trauma |Recent scuba diving or flying (+/- onset of pain coinciding with event) |Hearing loss |- | rowspan="2" |'''[[Eustachian tube dysfunction]]''' |Pain described as ear pressure or "plugged up" sensation in ears |Unilateral hearing loss |Crackling/gurgling sounds in ear |- |History of seasonal allergies |Poor [[Pupillary reflex|light reflex]] and TM mobility |Air-fluid levels present |- |'''[[Earwax|Cerumen]] Impaction''' |Q-tips in the ear |Pain described as ear pressure or "plugged up" sensation in ears |May need to remove any ear wax present to rule this out as the underlying etiology |}
== Management == Management of ear pain depends on the underlying cause.
=== Antibiotics === While not all causes of ear pain are treated with antibiotics, those caused by bacterial infections of the ear are usually treated with antibiotics known to cover the common bacterial organisms for that type of infection. Many bacterial ear infections are treated with cleaning of the area, topical or systemic antibiotics, and oral analgesics for comfort.<ref name="Tintinalli8th" /><ref name="Neilan20102" /><ref name="Harrisons19th" /> Some types of bacterial ear infections can benefit from warm compresses included in the treatment.<ref name="Tintinalli8th" /> Some of the causes of ear pain that are typically treated with either a topical or systemic antibiotic include: * Uncomplicated [[Otitis externa|acute bacterial otitis externa]] (AOE).<ref name="Tintinalli8th" /><ref name="Neilan20102">{{cite journal | vauthors = Neilan RE, Roland PS | title = Otalgia | journal = The Medical Clinics of North America | volume = 94 | issue = 5 | pages = 961–71 | date = September 2010 | pmid = 20736106 | doi = 10.1016/j.mcna.2010.05.004 }}</ref> For symptoms that are not responsive to treatment within 10 days, a physician should evaluate for [[Otitis externa|necrotizing external otitis]].<ref name="Tintinalli8th" /> * [[Otitis media|Acute otitis media]] (AOM) self-resolves within 24–48 hours in 80% of cases.<ref name="Neilan20102" /> If it does not self-resolve, AOM thought to be caused by bacteria is treated with systemic antibiotics. If symptoms do not respond to a week of treatment, a physician should evaluate for [[mastoiditis]].<ref name="Neilan20102" /> * Acute [[folliculitis]].<ref name="Neilan20102" /> * Auricular [[cellulitis]].<ref name="Harrisons19th" /> * Suppurative [[otitis media]].<ref name="Stallard2017" /> There is also a risk for [[Eardrum|tympanic membrane]] rupture.<ref name="Stallard2017" /> * [[Perichondritis]]. An [[Otorhinolaryngology|otorhinolaryngologist]] should also evaluate it and if a foreign body is present in the cartilage, this foreign body should be removed.<ref name="Neilan20102" /><ref name="Stallard2017" /> If there is cartilage involvement, then more advance care with hospitalization is needed.<ref name="Stallard2017" /> * [[Sinusitis]] can cause secondary ear pain. Treating the underlying [[sinusitis]] will treat the ear pain. (See [[sinusitis]].)<ref name="Neilan20102" /> Some bacterial infections may require a more advanced treatment with evaluation by [[otorhinolaryngology]], IV antibiotics, and hospital admission. * [[Otitis externa|Necrotizing external otitis]] is potentially fatal and should be evaluated by an otorhinolaryngologist with admission to the hospital and IV antibiotics.<ref name="Neilan20102" /><ref name="Stallard2017" />(See [[otitis externa]].) * Acute [[mastoiditis]] is treated with admission to the hospital, [[otorhinolaryngology]] consultation and empiric IV antibiotics.<ref name="Neilan20102" /><ref name="Tintinalli8th" /><ref name="Stallard2017" /><ref name="Harrisons19th" /> Cases with intracranial involvement are treated with a mastoidectomy with [[myringotomy]].<ref name="Neilan20102" /><ref name="Harrisons19th" /> * [[Chondritis]].<ref name="Neilan20102" /><ref name="Stallard2017" />
=== Procedures === Some causes of ear pain require procedural management alone, by a health professional, or in addition to antibiotic therapy. * [[Keratosis obturans]] is treated with removal of impacted desquamated keratin debris in the ear canal.<ref name="Neilan20102" /> * Chronic [[perichondritis]] and [[chondritis]] that continues to be symptomatic despite appropriate antibiotic management may require surgical debridement.<ref name="Neilan20102" /> Surgical drainage could be required.<ref name=Harrisons19th/> * [[Bullous myringitis]] leads to the development of bullae on the tympanic membrane that can be punctured to give pain relief.<ref name="Neilan20102" /> * Foreign body in the ear canal can cause pain and be treated with careful removal.<ref name=Stallard2017/> * Infected [[sebaceous cyst]] is treated with [[incision and drainage]] of the cysts, oral antibiotics and [[otorhinolaryngology]] assessment.<ref name=Stallard2017/>
=== Other === Given the variety of causes of ear pain, some causes require treatment other than antibiotics and procedures. * [[Relapsing polychondritis]] is an autoimmune disease treated with immunomodulating medications (medications that help modulate the immune system).<ref name="Neilan20102" /> * [[Temporomandibular joint dysfunction]] can lead to secondary ear pain and can be initially treated with a soft food diet, [[Nsaids|NSAIDs]], application of a heat pack, massage of local area, and a referral to a dentist.<ref name="Neilan20102" /><ref name=Lustig2018/> * [[Myofascial pain syndrome]]s are initially treated with NSAIDs and physical therapy. Local anesthetic injection into the muscle trigger point can be considered in severe cases.<ref name="Neilan20102" /> * [[Glossopharyngeal neuralgia]] is treated with [[carbamazepine]].<ref name=Lustig2018/>
== Epidemiology == 2/3 of people presenting with ear pain were diagnosed with some sort of primary otalgia and 1/3 were diagnosed with some sort secondary otalgia.<ref name=Conover2013>{{cite journal | vauthors = Conover K | title = Earache | journal = Emergency Medicine Clinics of North America | volume = 31 | issue = 2 | pages = 413–42 | date = May 2013 | pmid = 23601480 | doi = 10.1016/j.emc.2013.02.001 }}</ref>
A common cause of primary otalgia is ear infection called otitis media, meaning an infection behind the eardrum.<ref name=AFP2018/> The peak age for children to get acute otitis media is ages 6–24 months. One review paper wrote that 83% of children had at least one episode of acute otitis media by 3 years of age.<ref name=Rosa-Olivares2015/> Worldwide, there are 709 millions cases of acute otitis media every year.<ref name=":1" /> Hearing loss globally due to ear infection is estimated to be 30 people in every 10,000.<ref name=":1" /> Around the world there is around 21,000 to 28,000 deaths due to complications from ear infections.<ref name=":1" /> These complications include brain abscesses and meningitis.
Otitis externae peaks at age 7–12 years of age and around 10% of people has had it at least once in their lives.<ref name=Rosa-Olivares2015/>
Cerumen impaction occurs in 1 out of every 10 children, 1 in every 20 adults and 1 in every 3 elderly citizens.<ref name=Rosa-Olivares2015/>
Barotrauma occurs around 1 in every 1000 people.<ref name=Conover2013/>
Of people presenting with ear pain, only 3% was diagnosed with eustachian tube dysfunction.<ref name=AFP2018/>
== History == [[File:Professor_Anton_Friedrich_von_Tröltsch_1869_O._Roth.jpg|alt=Professor Anton Friedrich von Tröltsch 1869 O. Roth.jpg|thumb|Professor Anton Friedrich von Tröltsch 1869 O. Roth, Inventor of the otoscope]] Not much was known about ear pain and acute otitis media before the 17th century. It was a common phenomenon with no treatment.<ref name=":0">{{Cite journal|last=Altemeier|first=William A|date=2000-10-01|title=A Brief History of Otitis Media|journal=Pediatric Annals|language=en|volume=29|issue=10|pages=599|doi=10.3928/0090-4481-20001001-03|pmid=11056932|issn=0090-4481}}</ref> That changed when the [[otoscope]] was invented in the 1840s by [[Anton von Troeltsch|Anton von Troeltsh]] in [[Germany]].<ref name=":0" /> Another shift came with the invention of antibiotics. Before antibiotics was introduced there used to be a high rate of ear infections spreading to the bone around the ear, but that is now considered a rare complication.<ref name="Conover2013" />
== Society and culture == There was previously a strong tradition of treating acute otitis media with amoxicillin.<ref name="Conover2013" /> One quote from the 1980s shows this sentiment by saying "any child with an earache has an acute amoxicillin deficiency".<ref name="Conover2013" /> However, people started realizing that using antibiotics too much can cause bacteria to gain resistance.<ref>{{Cite journal|last=Fleming|first=Alexander|date=25 June 1945|title=The Penicillin Finder Assays its Future|journal=The New York Times|pages=21}}</ref> Increasing resistance makes antibiotics less effective. The term [[Antimicrobial stewardship|antibiotic stewardship]] is then used to describe the systematic effort to educate antibiotic prescribers to only give these medications when they are warranted. In particular to children, most ear pain resolves by itself with no complications.<ref name=":1">{{cite journal | vauthors = Qureishi A, Lee Y, Belfield K, Birchall JP, Daniel M | title = Update on otitis media - prevention and treatment | journal = [[Infection and Drug Resistance]] | volume = 7 | pages = 15–24 | date = January 2014 | pmid = 24453496 | pmc = 3894142 | doi = 10.2147/IDR.S39637 | doi-access = free }}</ref> There are [https://www.aafp.org/patient-care/clinical-recommendations/all/otitis-media.html guidelines] {{Webarchive|url=https://web.archive.org/web/20200808162547/https://www.aafp.org/patient-care/clinical-recommendations/all/otitis-media.html |date=2020-08-08 }} in place to help determine when antibiotics for ear pain are needed in children.
The ear itself played a role in treatment via [[acupuncture]], also known as [[auriculotherapy]]. It was believed that acupuncture of the ear could be used to correct other pain or disorders in the body. Such practices may have started as far back as the [[Stone Age]]. The first documentation of auriculotherapy in [[Europe]] was in the 1600s. One physician described stimulating the ear by burning or scarring to treat sciatic pain, while another physician applied this treatment for toothache. Paul Nogier is known as the father of ear acupuncture for his theory that parts of the ear corresponds to other areas of the body in a reliable fashion.<ref>{{cite journal|vauthors=Gori L, Firenzuoli F|date=September 2007|title=Ear acupuncture in European traditional medicine|journal=Evidence-Based Complementary and Alternative Medicine|volume=4|issue=Suppl 1|pages=13–6|doi=10.1093/ecam/nem106|pmc=2206232|pmid=18227925}}</ref>
== Research == There are currently studies going on delivering antibiotics directly into the middle ear.<ref name=":1" />
== References == {{Reflist}}
== External links == {{Medical resources | ICD10 = {{ICD10|H92.0}} | ICD9 = {{ICD9|388.7}} | ICDO = | OMIM = | MedlinePlus = 003046 | eMedicineSubj = ent | eMedicineTopic = 199 | DiseasesDB = 18027 | SNOMED CT = 16001004 }} {{Outer and middle ear disease}} {{Authority control}}
[[Category:Diseases of the ear and mastoid process]] [[Category:Otorhinolaryngology]] [[Category:Otology]]