Otalgia physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S [2]


Otalgia is one of the leading complaints in the pediatric age group. Otitis media, otitis externa, and ear trauma are among the leading causes of ear pain. When the ear is the source of the pain (primary otalgia), the ear examination is usually abnormal. When the ear is not the source of the pain (secondary otalgia), the ear examination is typically normal.

Physical Examination

The physical examination should include an exhaustive otologic, neuro-otologic, head, and neck examination. Mandatory examinations should include:


  • Sinuses should be evaluated for any sinusitis.


Abnormal Ear Examination

  • In acute otitis media the tympanic membrane is red and bulging outwards.
  • In otitis externa (swimmer's ear) the ear canal is red and swollen. Small debris can be seen in the ear canal or covering the tympanic membrane. There is pain when ones pulls on the auricle or presses on the tragus.
  • Foreign bodies like small beads, lead balls, paper, insects etc., can be seen in the ear canal especially in children.
  • In barotrauma, which occurs while scuba diving or during an airplane flight with the onset of pain during descent the tympanic membrane is typically hemorrhagic, and there may be blood or serous fluid in the middle ear. Upper respiratory infections and allergic rhinitis increase the risk of acute barotrauma by causing Eustachian tube dysfunction.
  • Malignant otitis externa which is caused by Pseudomonas bacteria in immunocompromised and diabetic patients is characterized by severe, deep, unrelenting pain and by granulation tissue on the anterior inferior aspect of the external auditory canal at the bony-cartilaginous junction.
  • Ramsay Hunt syndrome (herpes zoster oticus) typically causes ear pain, facial paralysis, and vesicles in the external auditory canal.
  • Cholesteatomas are collection of desquamating epithelium in the form of cysts. When they gradually enlarge they can erode the ossicular chain, inner ear, and bony facial nerve canal causing ear pain and hearing loss.
  • Relapsing polychondritis a systemic disease of cartilages involves ear pinna producing a red or violaceous auricle.

Normal Ear Examination

  • Temporomandibular joint (TMJ) syndrome is characterized by pain and crepitus with talking or chewing, and tenderness or crepitus on palpation of the TMJ joint. Ear pain is caused while chewing.
  • Dental caries, periodontal abscesses, and impacted third molars are the usual dental causes that cause ear pain. Molar tooth involvement typically causes ear pain. Tapping on the teeth with tongue blade causes tenderness.
  • Pharyngitis and tonsillitis also cause referred ear pain with normal ear examination.
  • Tumors in the nose, nasopharynx, oral cavity, oropharynx, hypopharynx, infratemporal fossa, neck, or chest can cause ear pain. The most common sites are the base of the tongue, tonsillar fossa, and hypopharynx. Risk factors for head and neck tumors include tobacco or alcohol use, dysphagia, weight loss, radiation exposure, hoarseness, and age older than 50 years.
  • Neuralgias involving the cranial nerves V and IX also cause referred pain to the ear.
  • In paralysis of the VII cranial nerve post-auricular pain exists in 25% cases. Patients experience facial paralysis, excessive tearing, taste disturbances, and hyperacusis.
  • Temporal arteritis also known as giant cell arteritis which causes pain in the temporal region of head can cause referred pain to the ear. Raised erythrocyte sedimentation rate is the marker of the disease.

Pneumatic otoscope can be used to assess tympanic membrane mobility which in turn is used to assess middle ear effusions like acute otitis media and middle ear effusions.[2][3][4]


  • Rhinoscopy
  • Nasopharyngoscopy


  • Indirect laryngoscopy


  • Palpation of the neck is important to look for thyroid disease, adenopathy, and musculoskeletal disorders.

Some studies have shown a well known association of ear pain and malignant upper aerodigestive tract tumors. So in case of failure to establish an accurate diagnosis a tumor should be suspected and work-up for it should be started.


  1. Beers SL, Abramo TJ (2004). "Otitis externa review". Pediatr Emerg Care. 20 (4): 250–6. doi:10.1097/01.pec.0000121246.99242.f5. PMID 15057182.
  2. Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA; et al. (2014). "Clinical practice guideline: acute otitis externa". Otolaryngol Head Neck Surg. 150 (1 Suppl): S1–S24. doi:10.1177/0194599813517083. PMID 24491310.
  3. Scrivani SJ, Keith DA, Kaban LB (2008). "Temporomandibular disorders". N Engl J Med. 359 (25): 2693–705. doi:10.1056/NEJMra0802472. PMID 19092154.
  4. Rosenfeld RM, Shin JJ, Schwartz SR, Coggins R, Gagnon L, Hackell JM; et al. (2016). "Clinical Practice Guideline: Otitis Media with Effusion (Update)". Otolaryngol Head Neck Surg. 154 (1 Suppl): S1–S41. doi:10.1177/0194599815623467. PMID 26832942.

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