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TimoAtula

Ear Pain in an Adult

Primary ear pain originates from the ear.
Secondary ear pain is due to a cause outside the ear.
A common source of secondary ear pain is the temporomandibular joint, but secondary ear pain can also be caused by a problem in the area of the teeth, pharynx or neck.The pain can be referred by five different cranial nerves and other nerves.

Most often the pain is caused by an acute inflammation or injury, and physical examination reveals an abnormal finding.
Pressure change (flying, diving) may case pain, and possibly a barotitis or barotrauma Middle Ear Barotrauma (Ear Problems Associated with an Increase in Atmospheric Pressure).
Dysfunction of the eustachian tube may also cause pain.
Pain in chronic otitis media Chronic Otitis Media often indicates a complication.
Tumours in the ear canal Lesions and Tumours of the Ear Canal or middle ear are very rare causes of ear pain.

In adults, secondary pain is more common.
Secondary ear pain often has its origin in the temporomandibular joint or the dental occlusion Malocclusions of the Teeth. Temporomandibular pain is often felt in the ear rather than in the joint itself. Sometimes dental pain may be felt in the ear, in addition to the tooth.
Pain originating from the neck is commonly referred to the ear. Tension neck Neck and Shoulder Pain often causes pain in the insertion of the sternocleidomastoid muscle on the mastoid process. Ear pain may also have a cervical aetiology.
Diseases of the pharynx are common causes of referred ear pain. The pain caused by, for example, tonsillitis Sore Throat and Tonsillitis or a peritonsillar abscess Peritonsillitis and Peritonsillar Abscess may be reflected to the ear by the glossopharyngeal nerve.
Pain originating from the pharynx, tongue, or palate may sometimes be caused also by a rather unnoticeable abnormality, e.g. an early-stage tumour.
Diseases in the parotid gland Swelling of the Salivary Glands may also cause ear pain.
The vagus nerve may mediate pain from the larynx, oesophagus, thyroid gland or bronchi.
Dissection or other disorders of the large arteries of the chest and neck may also cause ear pain through the sympathic nervous system.

Note possible blisters and mucosal changes in the area of the ear and external auditory canal.
If no ear-related cause can be found for the pain, a further otorhinolaryngological examination should be carried out. In particular, the temporomandibular joint, anterior neck and the muscles of the posterior neck should be palpated.
In a patient with ear pain, also the teeth should be checked, and masticatory muscles and temporomandibular joints palpated. If the cause of the pain remains unknown, an assessment by a dentist is warranted.
- Palpation of the temporomandibular joints is done by feeling the joint at the orifice of the external acoustic meatus while the patient opens and closes his/her mouth repeatedly)
Orthopantomography should be performed in a prolonged condition, even if not all causes originating in the temporomandibular joint will be visualized by this method, e.g. dysfunction of the temporomandibular joint disc.

If the condition becomes prolonged and the cause of pain remains unclear, a consultation with an ENT specialist is warranted.
If the cause is suspected to lie in the temporomandibular joint or the dental occlusion, a dentist should be consulted.
Imaging studies and other further investigations are selected on the basis of the most likely cause.
If there is no reason to suspect any specific source of pain, the choice of further investigations should be left to the medical doctor consulted.

Ally M, Moinie A, Lomas J, et al. Aetiology and management options for secondary referred otalgia: a systematic review and meta-analyses. Eur Arch Otorhinolaryngol 2023;280(6):3033 [PubMed]
Hwa TP, Brant JA. Evaluation and Management of Otalgia. Med Clin North Am 2021;105(5):813-826 [PubMed]
Norris CD, Koontz NA. Secondary Otalgia: Referred Pain Pathways and Pathologies. AJNR Am J Neuroradiol 2020;41(12):2188-2198[PubMed]
Earwood JS, Rogers TS, Rathjen NA. Ear Pain: Diagnosing Common and Uncommon Causes. Am Fam Physician 2018;97(1):20-27 [PubMed]