Ear pain

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.[14]  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.[15] Environmental injuries include sunburn, frostbite, or contact dermatitis.[14]

Less common causes of external ear pain include:[14][16]

• 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.[17]

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 and Staph aureus.[18] Risk factors include exposure to excessive moisture (e.g. from swimming or a warm climate) and disruption of the protective cerumen barrier, which can result from aggressive ear cleaning or placing objects in the ear.[19]

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.[16] It occurs largely in diabetic patients.[20] It is very rare in children, though can be seen in immunocompromised children and adults.[19] Pseudomonas is the most common causative organism.[20] The pain tends to be more severe than in uncomplicated otitis externa, and laboratory studies often reveal elevated inflammatory markers (ESR and/or CRP). The infection may extend to cranial nerves, or rarely to the meninges or brain.[20] 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 fluoroquinolones.[20]

• Earwax impaction: results in 12 million medical visits annually in the United States.[21] 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[5]

• Herpes zoster: varicella zoster virus can reactivate in an area that includes the ear. Reactivation can produce pain and visible vesicles within the ear canal and, when combined with facial paralysis due to facial nerve involvement, is called Ramsay Hunt syndrome.[22]
• 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.[16]

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.[23] Acute otitis media is also most common in these first 3 years of life, though older children may also experience it.[19] The most common causative bacteria are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.[19] Otitis media often occurs with or following cold symptoms.[14] The diagnosis is made by the combination of symptoms and examination of the tympanic membrane for redness, bulging, and/or a middle ear effusion (collection of fluid within the middle ear).[5]

Complications of otitis media include hearing loss, facial nerve paralysis, or extension of infection to surrounding anatomic structures, including:[24]

• Mastoiditis: infection of the air cells in the mastoid process, the area of the skull located right behind the ear[19]
• Petrositis: infection of the petrous portion of the temporal bone
• Labyrinthitis
• Meningitis
• Subdural abscess
• Brain abscess

• Barotrauma: results from changes in atmospheric pressure that occur 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 hemorrhage or tympanic membrane rupture can result.[16]
• 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.[5]

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):[3]

• 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.[25][26][14]
• Myofascial pain syndrome: pain in the muscles involved in chewing. There may be certain parts of the muscles or tendons (connective tissue connecting the muscles to bones) that are especially painful when pressed[25]
• Trigeminal neuralgia: attacks of shooting pain down the face that may be triggered by touching the face or temperature changes[27]
• Dental pain from cavities or an abscess
• Oral cavity carcinoma

Conditions causing irritation of the facial nerve (cranial nerve VII) or glossopharyngeal nerve (cranial nerve IX):[3]

• 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):[3]

• GERD
• Myocardial ischemia (inadequate oxygen supply to the heart muscle)

Conditions causing irritation of cervical nerves C2-C3:[3][14]

• Cervical spine trauma, arthritis (joint inflammation), or tumor
• Temporal arteritis: an 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.[16]

The ear can be anatomically divided into the external ear, the external auditory canal, the middle ear, and the inner ear.[28] These three are indistinguishable in terms of the pain experienced.[2]

Referred otalgia from neck and head sources[29]

Many different nerves provide sensation to the various parts of the ear, including cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and X (vagus), and the great auricular nerve (cervical nerves C2-C3).[28][30] 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.[28] This is called referred pain. Irritation of the trigeminal nerve (cranial nerve V) is the most common cause of referred ear pain.[3]

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.[7][33][9] Some types of bacterial ear infections can benefit from warm compresses included in the treatment.[7] Some of the causes of ear pain that are typically treated with either a topical or systemic antibiotic include:

• Uncomplicated acute bacterial otitis externa (AOE).[7][33] For symptoms that are not responsive to treatment within 10 days, a physician should evaluate for necrotizing external otitis.[7]
• Acute otitis media (AOM) self-resolves within 24–48 hours in 80% of cases.[33] 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.[33]
• Acute folliculitis.[33]
• Auricular cellulitis.[9]
• Suppurative otitis media.[8] There is also a risk for tympanic membrane rupture.[8]
• Perichondritis. An otorhinolaryngologist should also evaluate it and if a foreign body is present in the cartilage, this foreign body should be removed.[33][8] If there is cartilage involvement, then more advance care with hospitalization is needed.[8]
• Sinusitis can cause secondary ear pain. Treating the underlying sinusitis will treat the ear pain. (See sinusitis.)[33]

Some bacterial infections may require a more advanced treatment with evaluation by otorhinolaryngology, IV antibiotics, and hospital admission.

• Necrotizing external otitis is potentially fatal and should be evaluated by an otorhinolaryngologist with admission to the hospital and IV antibiotics.[33][8](See otitis externa.)
• Acute mastoiditis is treated with admission to the hospital, otorhinolaryngology consultation and empiric IV antibiotics.[33][7][8][9] Cases with intracranial involvement are treated with a mastoidectomy with myringotomy.[33][9]
• Chondritis.[33][8]

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.[33]
• Chronic perichondritis and chondritis that continues to be symptomatic despite appropriate antibiotic management may require surgical debridement.[33] Surgical drainage could be required.[9]
• Bullous myringitis leads to the development of bullae on the tympanic membrane that can be punctured to give pain relief.[33]
• Foreign body in the ear canal can cause pain and be treated with careful removal.[8]
• Infected sebaceous cyst is treated with incision and drainage of the cysts, oral antibiotics and otorhinolaryngology assessment.[8]

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).[33]
• Temporomandibular joint dysfunction can lead to secondary ear pain and can be initially treated with a soft food diet, NSAIDs, application of a heat pack, massage of local area, and a referral to a dentist.[33][16]
• Myofascial pain syndromes are initially treated with NSAIDs and physical therapy. Local anesthetic injection into the muscle trigger point can be considered in severe cases.[33]
• Glossopharyngeal neuralgia is treated with carbamazepine.[16]