Ear pain resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Samah Obaiah, MD[2]

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Ear pain resident survival guide Microchapters


Ear pain or otalgia maybe it is a pain that originates outside the ear or the pain that originates from the ear, and the etiology can be difficult to establish because of the complex innervation of the ear. Branches of the fifth, seventh, ninth, and tenth cranial nerve along with cervical nerves 1, 2, and 3 all contribute to sensation in the middle ear, external auditory canal, auricle, and peri-auricular tissues. Irritation of any portion of these cranial nerves can result in otalgia[1].otalgia can be the manifestation of myocardial ischemia (ie, an angina equivalent) because the vagus nerve provides sensory innervations for both structures. Intermittent pain is much more likely to be associated, for example, with musculoskeletal conditions as temporomandibular joint (TMJ) dysfunction and other myofascial pain dysfunction syndromes.otalgia classified as primary, which originated from the ear, and secondary, which originated outside the ear. When the ear examination is abnormal, the source of the pain from the ear (primary otalgia); when the ear examination is typically normal, the pain source is not the ear(secondary otalgia) [2].Examination should be carried out including inspection of nasal cavity, oral cavity, neck, and possibly the larynx[1].


Life Threatening Causes

Otalgia is not life-threatening, but some characteristics make a serious diagnosis more likely in patients with Otalgia. As patients who are 50 years or older have coronary artery disease, have diabetes, or are immunocompromised are at higher risk. Also, patients who smoke, drink alcohol, or lose weight unintentionally should undergo more scrutiny. Otalgia may also be the first sign of:[2][3][4]

Common Causes

Common causes for Primary Otalgia[4]

Common causes for Secondary Otalgia[3][4]


Shown below is an algorithm summarizing the diagnosis of Ear pain according to the American Family Physician AFP 2008 guidelines.

patient present with history of ear pain

Pain (factors should be considered location, duration, aggravating factors, alleviating factors, associated symptoms, previous episodes, medical history, smoking status, and alcohol abuse.)

Symptoms of primary otalgia such as -

  • Otorrhea
  • Tympanic membrane fullness
  • Vertigo

Symptoms of secondary otalgia

  • Pain with chewing
  • Sinusitis
  • Dental procedures
  • A history of gastroesophageal reflux.
  • No hearing loss
ear examination include:-
  • inspection of the auricle and periauricular region
  • otoscopic examination, which may require cerumen removal.
abnormal findings with apperant the causes identified( primary otalgia)
normal or equivocal findings
Treat underlying cause
more evaluation and examine nose, throat, neck, chest(consider audiometry,tympanometry,pneumetic otoscopy)
dental etiology
temporomandibular joint syndrome
Dental referral
pain killer as primary care and soft diet if the pain presistent, refer to dental care
HX of smoking, alcohol use, age older than 50 years,
Coronary artery disease risk factors
HX of headache, malaise, wight loss, fever, or anorexia and age older than 50 years
No risk factors of serious diagnosis
more evaluation by nasolaryngoscopy, tympanometry, audiometry,or magnetic resonance imaging,and computed tomography (if there is a history of cancer, positron emission tomography may be performed to provide)
ECG,chest radiography ,troponin maeseurment
ESR reat
Otolaryngology referral
send to emergency department
depends on the rate of patient more than 50mm per hour immedate otolaryngology or ophthalmology consultation
Observe or treat empirically as pain killer, soft diet
  • if pain presistent more evaluation and refer


Shown below is an algorithm summarizing the treatment of Ear pain according the the American Family Phsyician guidelines.

patient with ear pain
Infection treat with antibiotics topical or systemic, cleaning of the area, and oral analgesics for comfort
referred ear pain
If no responsed refered to evaluation by otorhinolaryngology, IV antibiotics, and hospital admission.
There is procedural management by a health professional, in addition to antibiotic therapy as:-
  • Removal of impacted desquamated keratin debris in the ear canal in case of Keratosis obturat.
  • Surgical debridement, Surgical drainage could be required in case of Chronic perichondritis.
  • When the development of bullae on the tympanic membrane can be punctured to give pain relief.
  • Foreign bodies in the ear canal can cause pain and be treated with careful removal.
  • Infected sebaceous cyst is treated with incision and drainage of the cysts, oral antibiotics, and otorhinolaryngology assessment.
depends on the underlying cause


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