E v aluatio n an d M an age m e nt

of Otalgia
Tiffany Peng Hwa, MD, Jason A. Brant, MD*

KEYWORDS
 Auricle  Cranial nerve  Ear pain  Otalgia

KEY POINTS
 Otalgia can be broadly categorized as primary otalgia (arising from disorders of auricle
and ear) and secondary otalgia (also known as nonotologic; arising from disorders other
than the ear).
 The ear has a robust nerve supply involving 5 cranial and cervical nerves, which can lead
to otalgia in a wide variety of conditions due to referred pain.
 Isolated otalgia without hearing loss, otorrhea, or abnormal otoscopic findings is most
commonly referred pain, and the most common cause is the temporomandibular joint
disorder.
 Persistent, progressive unilateral otalgia or a unilateral middle ear effusion warrants eval-
uation for a nasopharyngeal mass with nasal endoscopy and/or further imaging. Similarly,
symptoms such as progressive facial palsy, severe pain, or other cranial neuropathy war-
rants evaluation with further imaging.

INTRODUCTION

Otalgia, or subjective pain localized to the ear, is a common presenting symptom of

the head and neck in primary care clinics, otolaryngology clinics, and emergency de-
partments. In a multicenter retrospective analysis of United States national data, un-
specified otalgia was among the top 3 diagnoses among patients who presented to
the emergency department with otologic complaints.1 Although some causes of otal-
gia are familiar, such as acute otitis media (AOM) or acute otitis externa, the anatomy
of the ear, its complex sensory innervation, and close proximity to a multitude of struc-
tures with potentially causative pathology can complicate evaluation of otalgia in the
absence of overt physical findings.
In this article, the authors review the potential otologic and nonotologic causes of
otalgia and provide a framework with which to provide safe and effective care to pa-
tients presenting with this common and at-times elusive symptom.

Department of Otolaryngology/Head and Neck Surgery, Hospital of the University of Penn-

sylvania, 3400 Spruce Street, Silverstein 5, Philadelphia, PA 19103, USA
* Corresponding author.
E-mail address: [email protected]

Med Clin N Am 105 (2021) 813–826

https://doi.org/10.1016/j.mcna.2021.05.004 medical.theclinics.com
0025-7125/21/Published by Elsevier Inc.
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814 Hwa & Brant

DISCUSSION OF POTENTIAL CAUSES

Otalgia can be broadly categorized into primary, or otologic, and secondary, or non-
otologic, causes.2 Although the physiology of otalgia arising from disease manifest-
ing in the ear is self-evident, the evaluation of secondary otalgia relies on the
recognition that the sensory nerve supply to the ear arises from 4 cranial nerves
(CN) and the cervical plexus (Table 1).3 The source and course of these nerves pro-
vide important context during history-taking and physical examination. Thus, a thor-
ough understanding of the anatomy of the ear is critical to adequate assessment of
this condition.
In addition to causative anatomic site, the differential diagnosis for otalgia can be
organized by etiologic category (Box 1). Some entities in this differential would be fairly
apparent to the examiner through history and physical examination, such as in the
case of significant auricular trauma leading to an auricular hematoma or an ear foreign
body. In the following section, the authors review key diagnostic considerations in the
evaluation of primary and secondary otalgia.

Primary Otalgia
Primary otalgia can be systematically evaluated according to anatomic site, each of
which then informs the relevant differential diagnosis and associated symptom-
atology. Here the authors review causes of primary otalgia beginning with the external
ear and progressing medially toward the skull base.

Table 1
Nerve supply to the ear

Otologic Sensory Nonotologic Sensory

Nerve Distribution Distribution
C2-C3; greater auricular Cranial and lateral surface Anterior region of the
nerve of the auricle neck, posterior region of
the neck
CN V; trigeminal nerve Superior lateral surface of Face, sinuses, teeth, soft
the auricle and most of palate
the external auditory
meatus
(auriculotemporal
branch)
CN VII; facial nerve Posterior inferior external Anterior 2/3 of tongue
auditory canal and
adjacent tympanic
membrane
CN IX; glossopharyngeal Mucosal surface of Posterior 1/3 of tongue,
nerve/Jacobsen nerve tympanic membrane, tonsils, pharynx
middle ear
CN X; vagus nerve/Arnold Small areas of skin on Heart, lungs, trachea,
nerve cranial surface of the bronchi, larynx, pharynx,
auricle, posterior wall GI tract
and floor of the external
auditory meatus,
adjoining part of the
tympanic membrane

Abbreviation: GI, gastrointestinal.

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 Evaluation and Management of Otalgia 815

Box 1
Differential diagnosis of otalgia

Congenital
Branchial cleft cyst
Sebaceous cyst
Epidermoid cyst
Infectious
Perichondritis
Cellulitis
Acute otitis externa
Herpes zoster oticus
Malignant otitis externa
Acute otitis media—complicated or uncomplicated
Otomastoiditis/petrous apicitis
Suppurative labyrinthitis
Traumatic
Auricular trauma/hematoma
External auditory canal laceration
Tympanic membrane perforation (blast or puncture)
Ear foreign body
Autoimmune/Inflammatory
Relapsing polychondritis
Granulomatosis with polyangiitis (GPA)
Sarcoidosis
Neurologic
Trigeminal neuralgia
Glossopharyngeal neuralgia
Vagal neuralgia
Migraine
Neoplastic
Cutaneous malignancy
Nasopharyngeal carcinoma
Squamous cell carcinoma of the head and neck
Other
Chondrodermatitis nodularis helicis
TMJ arthralgia/arthritis
Dental pathology
Eagle syndrome

Auricle
Disorders of the auricle are limited to cutaneous pathology and of the underlying carti-
lage. In the cause of blunt auricular trauma, such as following an assault or an injury
sustained during contact sports without protective headgear, formation of a subper-
ichondrial auricular hematoma may cause severe otalgia localized to the auricle.4
This finding would generally be clinically apparent to the examining provider but none-
theless warrants discussion, as prompt recognition and drainage of an auricular he-
matoma may prevent irreversible cartilaginous remodeling, resulting in deformation
known as “cauliflower ear.”5
Infectious disorders may also affect the auricle, and clinicians must primarily differ-
entiate between perichondritis and cellulitis when an infectious process is suspected.6
Both conditions involve tender inflammation and erythema of the auricle, which is also
typically warm on examination. A history of minor trauma or recent piercing may be
elicited. Erythema that spares the lobule (the inferior most cutaneous aspect of the
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816 Hwa & Brant

auricle that does not contain cartilage), or lobule-sparing erythema, suggests peri-
chondritis, whereas involvement of the lobule suggests cellulitis. This differentiation
will direct management and course of treatment, as perichondritis typically warrants
a therapeutic with antipseudomonal activity and good cartilaginous penetration,
such as a fluoroquinolone.
Another noteworthy cause of auricular otalgia is chondrodermatitis nodularis helicis,
a focal, idiopathic benign skin lesion that is inflammatory in nature.7 This lesion, clas-
sically located on the helix of the auricular cartilage and roughly 3 mm in size, typically
affects middle-aged and older men but may affect women. It is exquisitely tender and
has the potential to disrupt sleep patterns. Clinicians should not mistake this entity for
cutaneous malignancy. Nonetheless, this disease has a propensity to recur, and man-
agement of this entity involves a wide breadth of conservative to excisional options.7
Additional disorders of the auricle, including cutaneous malignancies and autoim-
mune disorders, are discussed in a later section of this article.

External auditory canal

Disorders of the external auditory canal (EAC) cause pain through 1 of the 3 CN roots
supplying the skin of the canal. Because of the narrow space of this anatomic region of
the ear, any condition leading to narrowing of the EAC diameter or even occlusion of
the EAC will be associated with hearing loss.
The most common cause of otalgia arising from the EAC is infectious. The clinical
presentation of acute otitis externa (AOE) consists of pain and otorrhea, may be bac-
terial or fungal in origin, and typically follows minor, often inadvertent, trauma to the
EAC.8 Treatment typically consists of ototopical drops and maintenance of a dry
ear environment by avoiding water entry to the EAC. However, debridement by an
otolaryngologist may be required to clear the infection if sufficient debris is present
to limit therapeutic delivery, and multiple debridements may be required early in the
disease course for severe infection. On occasion, the EAC is so narrowed from infec-
tion that temporary placement of a wick is required to stent the ear canal open and
allow delivery of topical medications. Oral antibiotics are generally not indicated in
otherwise uncompleted AOE.
Herpes zoster oticus (HZO) is caused by reactivation of a latent Varicella zoster virus
infection in the geniculate ganglion and affecting the EAC.9 It is characterized by an up-
per respiratory infection followed by severe otalgia and a vesicular eruption principally
involving the EAC but may also involve the auricle and tympanic membrane. When
associated with an ipsilateral facial palsy, this condition is known as Ramsay-Hunt syn-
drome. However, HZO may also progress to involve adjacent CNs or additional
branches of the facial nerve, causing sensorineural hearing loss, tinnitus, vertigo, taste
change, or hyperacusis. Management following prompt recognition typically includes
antivirals and corticosteroids, although the efficacy of both have not been assessed
with large-scale clinical trials.10,11 If facial palsy with incomplete eye closure is present,
eye care is also advised to avoid exposure keratitis.
Another critically important infectious cause of otalgia in the EAC is malignant otitis
externa (MOE),12 which classically occurs in older patients with a history of diabetes
mellitus, although any immunocompromised state confers risk of MOE. A patient
with MOE will typically have a more indolent or subacute presentation than AOE,
but with similar initial symptoms of otalgia and otorrhea, classically following cerumen
removal. On examination, patients will pathognomonically demonstrate granulation
tissue at the bony-cartilaginous junction of the EAC. This tissue should be biopsied
to rule out malignancy as an alternate cause. Partial or complete facial palsy may
be present but is not required. Additional cranial neuropathies may also be present
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 Evaluation and Management of Otalgia 817

in severe disease tracking along the anterior or lateral skull base. Imaging with
computed tomography (CT) of the temporal bone will demonstrate osseous erosion
of the temporal bone in the EAC, which in severe cases may be extensive. Treatment
is primarily medical and requires long-term systemic antibiotics, often lasting 4 to
6 months. Antibiotic course is culture directed and serial imaging with gallium scan,
contrast-enhanced MRI, or PET/CT is used to determine treatment response.13 The
exact role of surgical debridement and hyperbaric oxygen is controversial but may
be warranted in failure of medical management or as an adjunctive therapy.
Otalgia of the EAC may be attributable to noninfectious causes, such as ear foreign
body. In the older population, it is not uncommon for patients to inadvertently lodge a
portion of a hearing aid or ear plug. If unrecognized, this can cause local inflammation
and potentially a secondary infection. In children, ear foreign bodies may consist of
any material—organic or inorganic—that is small enough to fit in the pediatric
EAC.14 Organic material is particularly prone to secondary infection. Prompt recogni-
tion and careful removal of the foreign body is necessary, and ototopical therapy may
be advised to treat residual inflammation. On occasion, a small insect is the respon-
sible offender, in which case viscous lidocaine or mineral oil should be used to termi-
nate the insect before removal.
Congenital lesions of the EAC are generally painless.15 However, they can occa-
sionally cause pain in the setting of secondary infection. In the presence of large
size or recurrent infections, clinicians should retain a high level of suspicion for a
possible branchial cleft cyst. If a branchial cleft cyst is identified, consultation with
an otolaryngologist is recommended for surgical excision.
Lastly, the patient’s prior history may yield important diagnostic clues. Patients who
are chronically exposed to bisphosphonates or who have undergone radiation of the
head and neck are at risk for development of osteoradionecrosis (ORN).16 Thus, pa-
tients who present with otalgia and are found to have exposed bone in the EAC
with a history of bisphosphonate use or head and neck radiation may be suffering
from chronic ORN. Typically these patients will see a reduction in pain once the active
phase of this disease has passed, but referral to otolaryngology is warranted for close
monitoring and management of this condition.

Middle ear and mastoid temporal bone

Disorders of the middle ear and mastoid temporal bone have the potential to cause
otalgia through both infectious and noninfectious means. Because of the nature of
the middle ear as an enclosed space (in the absence of a tympanic membrane perfo-
ration) containing the ossicles, pathology of the middle ear will typically be associated
with hearing loss. Depending on the exact cause, additional symptomatology may
include otorrhea, vertigo, aural fullness, and pressure.
Noninfectious tympanic membrane perforation may be secondary to penetrating
trauma, previous otologic procedure, or blast injury.17 In these circumstances, the
acute event leading to perforation is generally known to the patient and will have
been associated with significant pain. On otoscopic examination, a tympanic mem-
brane perforation may be visible, with or without associated evidence of recent
trauma, such as blood products. The presence of disproportionate hearing loss may
suggest ossicular discontinuity. A tuning fork examination can be used to elucidate
conductive versus sensorineural hearing loss. In general, no acute intervention is war-
ranted for a conductive hearing loss. However, if there is evidence of, or concern for,
substantial new sensorineural hearing loss, or significant vertigo/apparent nystagmus
should raise concerns for a possible perilymphatic fistula and need for urgent surgical
intervention, particularly in the presence of clear otorrhea on examination with a
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818 Hwa & Brant

history of penetrating trauma. Prompt evaluation with audiometry and otolaryngologic

consultation is warranted.
With respect to infectious causes, the middle ear may be afflicted with acute and
chronic otitis media, both of which have the potential to cause painful symptoms.
AOM, most commonly occurring in children, is typically associated with a preceding
upper respiratory tract infection.18,19 On examination, an inflamed and erythematous
tympanic membrane is appreciated and in the case of suppurative AOM purulence
may be visible through a spontaneously ruptured tympanic membrane. In the case
of otherwise uncomplicated AOM, treatment is primarily with oral antibiotics in the
presence of an intact tympanic membrane with the addition of ototopical therapy in
the presence of a ruptured tympanic membrane. Although treatment is often initially
observational in the pediatric population due to the preponderance of viral cause,
AOM in an adult is typically bacterial and warrants prompt treatment. Notably, AOM
has the potential to be associated with a variety of serious complications, including
facial palsy, coalescent mastoiditis, temporal bone subperiosteal abscess, sigmoid si-
nus thrombosis, meningitis, encephalitis, and brain abscess, among others.18,19 In
such cases, the patient should be evaluated for parenteral antibiotic therapy and
possible surgical intervention to decompress the middle and mastoid spaces through
either an ear tube, incision and drainage, or mastoidectomy.17 Clinicians and patients
alike should be aware of these potentially serious complications of AOM.
Chronic otitis media (COM) is a broad term encompassing multiple entities that
cause long-term otologic symptoms. These entities include, but are not limited to,
chronic tympanic membrane perforation, cholesteatoma, and eustachian tube
dysfunction. Typically, these entities are not painful in the absence of an acute exac-
erbation, such as a secondary infection.20 However, they can be associated with
vague painlike symptoms of aural fullness or pressure. Thorough evaluation of a pa-
tient with chronic ear disease reporting new pain includes thorough otoscopic exam-
ination to evaluate for new infection and potentially imaging studies to assess for
disease progression or recurrence in the case of cholesteatoma.

Inner ear and petrous apex of the temporal bone

Disorders of the inner ear—inclusive of the cochlea (the hearing organ) and the laby-
rinth (the balance organ)—are generally not painful. This generalization includes en-
tities leading to significant functional impairment, such as viral labyrinthitis and
sudden sensorineural hearing loss, which can result in permanent vestibular or audi-
ologic dysfunction but are not associated with pain. Well-recognized mass lesions of
the lateral skull base, such as vestibular schwannoma and glomus jugulare, are also
typically painless entities.
Consistent with the other anatomic sites of the ear, infectious entities affecting the
inner ear and medial temporal bone may be associated with pain. One such entity is
suppurative labyrinthitis,21 typically associated with sensorineural hearing loss and
significant vertigo, and may be a complication of AOM or a superinfected cholestea-
toma. Treatment is with systemic antibiotic therapy and consideration for surgical
exploration as warranted. Another entity affecting this region is petrous apicitis, an
osteomyelitic infection of the petrous apex (medial aspect) of the temporal bone clas-
sically associated with Gradenigo’s triad of retroorbital pain, otorrhea, and an abdu-
cens palsy.22 Treatment is generally medical with parenteral antibiotics.
In the absence of infectious cause, new and severe otalgia that is associated with
objective findings of inner ear dysfunction (sensorineural hearing loss, vestibular hypo-
function) should raise the ominous specter of something atypical, and further imaging
should be obtained to evaluate for underlying malignancy.
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 Evaluation and Management of Otalgia 819

Secondary Otalgia
It has been said that 50% of ear pain is secondary otalgia, and the other 50% is dental
pathology.23 With the exception of cutaneous auricular disorders, otalgia attributable
to primary otologic disease is universally associated with additional otologic symp-
toms, such as hearing loss, tinnitus, otorrhea, or vertigo. Thus, truly isolated otalgia
or otalgia in the absence of other otologic symptoms is highly suspicious for a second-
ary or referred cause.

Dental pathology and temporomandibular joint disorder

The most common causes of nonotologic ear pain are dental pathology, such as
caries or gingivitis, and TMJ disorder, inclusive of arthralgia and frank arthritis.23,24
Although both entities may be suggested by findings on physical examination, proper
management of these conditions involves referral or coordination with dental medicine
or oral surgery. In the case of TMJ disorder, some patients with myofascial pain
without frank joint dysfunction will benefit from conservative management, which is
comprised of warm compresses, intermittent nonsteroidfal anti-inflammatory drug
(NSAID) use, and isometric jaw exercises. Some patients may benefit from physical
therapy for the TMJ or fitting by their dentist or oral surgeon for a night guard to com-
bat nocturnal bruxism.

Nasopharynx/oropharynx/hypopharynx
Because of the nerve supply of the ear, otalgia may be referred from the nasopharynx
(via CN IX and V2), oropharynx (CN IX/X), and hypopharynx (CN X). This pain may be
infectious, noninfectious, or neoplastic in cause, and patients who report associated
symptoms localized to the pharynx such as progressive vocal dysfunction, respiratory
insufficiency/stridor, and progressive odynophagia/dysphagia should be referred for
laryngoscopic evaluation.25 Further, otalgia associated with a neck mass should be
considered a malignancy until proved otherwise.
Infectious causes that may cause referred ear pain include nasopharyngitis,
tonsillitis, pharyngitis, and supraglottitis. At times, the patient’s otalgia is so
intense and the feeling subjectively localized to the ear itself that they are hard
pressed to be convinced that their infection has an alternative source.25 Lastly,
neoplasms of these respective sites have potential to cause otalgia, through either
stretching of the nerves, direct invasion, or mass effect, as in the case of a naso-
pharyngeal mass blocking the eustachian tube and leading to a unilateral middle
ear effusion.26 Treatment of these conditions is directed to the underlying cause.
Although otalgia should resolve with adequate management of the underlying con-
dition in infectious causes and significantly improve with treatment of an underly-
ing malignancy, some patients may experience chronic pain disorder following
treatment.

Cervical spine
Cervical spine degenerative disease, consistent of disk changes/herniation, facet
disease, and spinal/foraminal stenosis, has been shown to be associated with
referred otalgia.27 CSDD is thought to be resultant of pain fibers in the upper cervi-
cal plexus affecting the greater auricular and lesser occipital nerves. A prior history
of rheumatologic disease and concomitant or recurrent neck pain are both predic-
tive of positive imaging findings. Patients are generally diagnosed on MRI and have
demonstrated improvement in otalgia symptoms with cervical spine physical ther-
apy. Failure of conservative measures warrants referral for evaluation by a spine
specialist.
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820 Hwa & Brant

Eagle syndrome
Eagle syndrome is a clinical entity resulting from elongation of the styloid process sec-
ondary to calcification of the stylohyoid ligament, often following trauma or tonsillitis.
The clinical syndrome associated with Eagle syndrome is variable but includes recur-
rent throat pain, globus sensation, dysphagia, and referred otalgia.28 Isolated otalgia is
uncommon. Diagnosis can be made with CT demonstrating calcification of the stylo-
hyoid ligament. Treatment is conservative with pain management as needed using
NSAIDs, but surgical excision may be warranted in patients with persistent or intoler-
able symptoms.
Neuropathic pain and migraine
In some patients, otalgia is attributable to a migrainous syndrome in which symptoms
are associated with identifiable triggers and with headache or headache syndromes.29
In such cases, most patients are responsive to antimigraine medications despite
reporting isolated otalgia at the time of presentation. On certain occasions, otalgia
can be attributable to neuralgia (trigeminal, glossopharyngeal, geniculate, all have
been implicated) with or without other more classic symptoms such as hemifacial
spasm in trigeminal neuralgia.30,31 Patients may respond to neuropathic pain manage-
ment with targeted medications, or in rare circumstances, they may be candidates for
microvascular decompression with neurosurgery.31–33
Otologic Manifestations of Systemic Disease
Autoimmune and granulomatous disease
Autoimmune conditions have the potential to affect nearly any site in the body, and
otologic manifestations of autoimmune disease are numerous. Although hearing
loss and vertigo are implicated in a wide variety of autoimmune conditions, otalgia
is specific to a relative paucity. Relapsing polychondritis, sarcoidosis of the middle
ear, and granulomatosis with polyangiitis (GPA; formerly known as Wegener granulo-
matosis) may cause otalgia.34–36 Relapsing polychondritis would generally be clinically
apparent, with visible tenderness and inflammation of the auricle that is noninfectious
and follows a relapsing-remitting time course. Sarcoidosis may be suspected based
on prior history and clinical scenario; serologic studies demonstrating hypercalcemia
and elevated ACE levels may be supportive. GPA is similarly a granulomatous disorder
and can be associated with significant pain and middle ear effusions due to mucosal
involvement of the disease. Serologic studies with elevated c-antineutrophil cyto-
plasmic antibody is supportive of this diagnosis. However, tissue biopsy from the mid-
dle ear or mastoid may be required to definitively confirm the diagnosis in both
sarcoidosis and GPA for specific cases.
Malignancy/neoplasm
In rare cases, otalgia is attributable to malignancy affecting the ear and temporal
bone, and this may be a clinically apparent cutaneous malignancy in the preauricular
soft tissue, postauricular soft tissues, on the auricle itself, or in the ear canal. Treat-
ment of this entity depends on the underlying pathology but may range from wide
local excision to extensive surgical resection and reconstruction with postoperative
radiation.37 Chronic otitis externa not responsive to typical treatments should raise
concern for malignancy of the external auditory canal, and biopsy should be
considered.
Although benign nerve sheath and vascular tumors of the temporal bone are not
typically associated with pain, a temporal bone neoplasm with significant otalgia rai-
ses concern for metastatic tumor. Previous reports have demonstrated this exact pre-
sentation in several malignancies, including adenocarcinoma and breast.38,39
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 Evaluation and Management of Otalgia 821

CLINICAL EVALUATION OF THE PATIENT WITH OTALGIA

Because of the multitude of potential causes, the authors advise a systematic

approach to clinical evaluation of the patient with otalgia. In this section, they review
critical elements of the history and physical examination and discuss clinical pearls for
diagnostic workup.

History
A thorough history is invaluable in the evaluation of any patient, and otalgia is no
exception. Patients should be asked to characterize the “PQRST” of their pain. Posi-
tion of the pain can yield important insights, as preauricular pain strongly suggests
TMJ disorder. Quality may be described as dull, sore, throbbing, or sharp; neuropathic
pain is typically sharp and shooting in quality. Radiation to other sites and high severity
may increase concern for secondary otalgia. Lastly, time course must fit the proposed
cause, and patients should report both timing of onset and overall progression as re-
lapsing/remitting versus constant or crescendo.
Every patient presenting with an ear-related complaint should be asked a complete
otologic review of symptoms, inclusive of hearing loss, tinnitus, vertigo/imbalance,
otalgia, otorrhea, facial weakness, or twitching (relevant due to the tortuous intratem-
poral course of the facial nerve). Pertinent positives should be further detailed.
Past medical history should include any history of noise exposure, personal history
of radiation to the head and neck, history of head trauma, headache or migraine his-
tory, and history of autoimmune disease. All prior otologic history, inclusive of recur-
rent infections, childhood ear procedures, and any otologic surgery, should be
elicited. Pertinent family history includes disorders of hearing and imbalance, as
well as history of migraine/headache disorder, pain disorder, malignancies, and auto-
immune disorders. Social history inclusive of occupation (to assess for occupational
exposures or hazards), toxic exposures, medications, and allergies should be thor-
oughly reviewed.

Physical Examination
Because of the extensive differential diagnosis at hand, a thorough physical examina-
tion is recommended in all patients presenting with otalgia, with particular focus on the
most common causes and the most important “can’t miss” findings.
A thorough ear examination begins with careful examination of the auricle itself
including the anterior and posterior faces, with close attention paid to any discolor-
ation or lesions of the skin, including dermatitis, cellulitic changes, or vesicular erup-
tion. Hair-bearing skin in the postauricular/mastoid region and the region of the
postauricular crease should be carefully examined and assessed for tenderness to
palpation. Subsequently, a thorough otoscopic examination should be performed
with careful sequential systematic evaluation of the external auditory canal, tympanic
membrane, and middle ear space. The external auditory canal skin should be evalu-
ated for evidence of dermatitis, ulceration, polypoid degeneration, exposed bone, ve-
sicular eruption, and any other focal lesions. The tympanic membrane should be
evaluated for erythema that suggests a current infection, scarring that suggests prior
infection, and retraction into the middle ear space, which may suggest chronic ear dis-
ease or eustachian tube dysfunction. The middle ear space itself should be assessed,
if not otherwise obstructed from view by an opaque tympanic membrane. If a serous
effusion is present bilaterally, the patient may benefit from a course of nasal and/or
oral corticosteroids. Subsequent follow-up with otolaryngology may be advised for
consultation to undergo myringotomy and tube placement. If a unilateral serous
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822 Hwa & Brant

effusion is present, referral to otolaryngology for nasal endoscopy and possible further
imaging is advised to rule out an obstructive nasopharyngeal mass as the underlying
cause.
Next, a comprehensive head and neck examination should be completed. During
the intraoral examination, the hard palate and dentition should be carefully examined
for signs of dental pathology, including caries, gingivitis, and bruxism. The posterior
oropharynx and tonsils should also be carefully examined for any signs of asymmetry.
If there are significant risk factors or high suspicion for oropharyngeal malignancy, the
provider may consider gentle palpation of the base of tongue with a gloved finger while
holding the protruded tongue steady with dry gauze. Lastly, the TMJ should be exam-
ined, assessing for subluxation with opening/closing of the jaw, as well as assessing
for tenderness to palpation.
The neck should be thoroughly examined for lymphadenopathy and assessment of
any focal tenderness. Focal tenderness along the greater cornu of the hyoid, superior
and lateral to the laryngeal complex and anterior to the sternocleidomastoid, may sug-
gest Eagle syndrome. In addition, the cervical spine should be gently palpated and
assessed for reproducibility of the patient’s symptoms with manipulation of the cervi-
cal spine.
A thorough CN examination should also be completed. The major divisions of the
facial nerve musculature should be examined individually and simultaneous bilateral
comparison performed to assess for asymmetry. Gross hearing may be assessed to
finger rub if an audiogram has not been performed. If a 512-Hz tuning fork is available,
tuning fork examination may be additionally performed.
Critically, if no cause for the patient’s otalgia is determined, a nasopharyngolaryngo-
scopy is necessary to evaluate for neoplasm, as otalgia may herald head and neck
malignancy with an otherwise clinically silent presentation.

AUDIOGRAM

A formal audiogram is advised in all patients reporting persistent or sudden hearing

loss and in any patient with new otologic symptoms and a prior history of ear surgery
or chronic ear disease. The audiogram is an extremely valuable diagnostic tool. In
addition to categorizing the type of hearing loss, assessing brainstem reflexes, and
evaluating the compliance of the tympanic membrane, information attained from a
complete audiometric evaluation may provide critical context to guide management
decisions.

Laboratory Studies
Serologic studies in the workup of otalgia are not routinely recommended. However,
they maybe diagnostically beneficial or required in certain clinical situations. If severe
infection is involved, the patient should be assessed for serologic markers of infection,
including complete blood count, erythrocyte sedimentation rate, and C-reactive pro-
tein. For patients who are under consideration for autoimmune disease, a full autoim-
mune panel is not required for isolated otalgia without hearing loss or other
symptoms, and targeted serologic studies should be pursued. If the patient also reports
fluctuating hearing loss, progressive hearing loss, or episodic vertigo in a Meniere-like
syndrome, referral to otolaryngology is recommended for further evaluation. Based on
the results of that assessment, the patient may require a full complement of serologic
studies to thoroughly evaluate for systemic manifestations of otologic disease.
With respect to other laboratory studies, routine culture data are not necessary in
uncomplicated and nonrecurrent otitis externa or otitis media. However, patients
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 Evaluation and Management of Otalgia 823

with apparent treatment-refractory disease should undergo culture swab for specia-
tion and sensitivity analysis. As previously noted, referral to an otolaryngologist is rec-
ommended for clinic-based biopsy when granulation tissue is identified in the external
auditory canal to rule out malignancy as an underlying cause, even when malignant
otitis externa is the expected diagnosis.

Radiographic Studies
Imaging is not indicated in the general diagnostic workup of otalgia but may be advis-
able in the right clinical scenario. Patients with suspicion for intratemporal complica-
tions of otologic infectious disease (eg, mastoiditis) may benefit from CT with thin cuts
of the temporal bone in anticipation of possible surgical intervention. Those who are
suspected to have an occult malignancy, particularly with examination abnormalities
affecting the parapharyngeal space, may undergo an MRI of the orbit/face/neck
with and without gadolinium in addition to CT. Any patients with a suspected intracra-
nial complication of infectious disease or focal neurologic deficits should undergo MRI
brain with and without contrast.

Consultation and Referrals

As discussed throughout this article, otalgia has an underlying differential diagnosis
that encompasses multiple organ systems across multiple medical disciplines. Most
patients have a diagnostically apparent cause, most commonly ear infection, TMJ dis-
order, or dental pathology. However, a significant portion of patients do not fall into
one of these categories. As a result, the patient’s journey to resolution may not be
linear, and the evaluation of their complaints may often require multidisciplinary coor-
dination. In addition to primary care, emergency medicine, and otolaryngology,
numerous specialties may assist in the evaluation of otalgia, including oral surgery/
general dentistry, dermatology, rheumatology, neurology, neurosurgery, infectious
disease, and gastroenterology, among others. In some rare cases, no specific cause
is found, and pain medicine contributes in the management of the patient’s bother-
some symptoms. Thorough initial evaluation and workup of their symptoms may yield
critical insights with respect to which specialty is most likely to offer the patient diag-
nostic insight and therapeutic benefit.

SUMMARY

Otalgia is a bothersome symptom leading to a significant number of outpatient and

emergency department visits annually. Because of the numerous potential causes
and primary sources of otalgia, a systematic approach to evaluation is critical to
properly evaluate and elucidate a diagnosis that will ultimately guide symptom re-
lief. The presence of hearing loss and/or otorrhea highly suggests primary otologic
disease, but isolated otalgia is nearly always resultant of disease processes
external to the ear. Providers should retain a global understanding of the underlying
anatomic rationale for referred ear pain and avoid overdiagnosis and treatment of
“ear infection” in patients with isolated otalgia. In some cases, a multidisciplinary
approach will be essential to accurate diagnosis and effective management.
Although a preponderance of isolated otalgia is attributable to TMJ disorder or
dental pathology, severe unilateral otalgia may portend a more ominous diagnosis,
such as an occult malignancy. Clinicians should have a low threshold for further
evaluation of persistent unilateral otalgia that is unresponsive to conservative man-
agement, particularly in the presence of risk factor for malignancy or alarm
symptoms.
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824 Hwa & Brant

CLINICS CARE POINTS

 Otalgia can be broadly categorized as primary otalgia (arising from disorders of auricle and
ear) and secondary otalgia (also known as nonotogenic; arising from disorders other than
the ear).
 The ear has a robust nerve supply involving 5 cranial and cervical nerves, which can cause
otalgia in a wide variety of conditions due to referred pain.
 Primary otalgia is nearly always associated with concurrent audiovestibular symptoms such as
hearing loss, vertigo, or otorrhea.
 Isolated otalgia without hearing loss, otorrhea, or abnormal otoscopic findings is most
commonly referred pain, and the most common cause is the TMJ disorder.
 Persistent, progressive unilateral otalgia or a unilateral middle ear effusion warrants
evaluation for a nasopharyngeal mass with nasal endoscopy and/or further imaging.
 Alarm symptoms such as progressive facial palsy, severe pain, or other cranial neuropathy
warrant evaluation with further imaging.

DISCLOSURE

The authors have nothing to disclose.

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