Diagnosis of Ear Pain
JOHN W. ELY, MD, MSPH; MARLAN R.HANSEN, MD; and ELIZABETH C.CLARK, MD, MPH
University of Iowa Carver College of Medicine, Iowa City, Iowa
Am Fam Physician. 2008 Mar 1;77(5):621-628.
http://www.aafp.org/afp/2008/0301/p621.pdf
When a patient presents with ear pain, the ear exam will either be normal or abnormal. The most common causes of ear pain with an abnormal exam are otitis media, otitis externa, a foreign body, or barotrauma. Acute otitis media will have a red, bulging tympanic membrane. Otitis externa (swimmers ear) will have debris over the tympanic membrane as well as swelling and erythema in the ear canal. Barotrauma can occur from an airplane flight or scuba diving. The tympanic membrane or middle ear may be bleeding.
With a normal exam, the causes are TMJ, dental issues, pharyngitis, tonsillitis, cervical spine arthritis, or idiopathic.TMJ syndrome may have increased pain while talking or chewing food. If the exam is normal, but the cause is not apparent, "worst- case scenario" illness should be investigated. Patients with risk factors for cancer, such a tobacco use, alcohol use, or age greater than 50 years, may need imaging. Patients with risk factors for coronary disease or thoracic aneurysm may need an ECG, chest x-ray, or troponins. Temporal arteritis should also be rules out.
Malignant otitis externa is severe, deep pain from osteitis of the skull base. It is from Pseudomonas, and is seen in the diabetic and immunocompromised. Ramsey Hunt syndrome is due to a herpes zoster infection of cranial nerves V, VII, IX, and X. Symptoms include hearing loss, tinnitus, and vertigo. Polychondritis effects the ear cartilage (sparing the earlobe), causing a red or violet auricle. Cholesteatomas are epithelial cysts the destroy the inner ear, ossicles, and facial nerve canal. They should be easily visualized. Tumors causing ear pain are commonly found at the base of the tongue, tonsillar fossa, and hypopharynx. Bells palsy will affect the upper and lower face
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