Earache

Earache (otalgia) is pain felt in or around the ear. It arises from the ear itself (primary otalgia) or is referred from other structures (secondary otalgia). When the ear examination is normal, the cause is referred until proven otherwise, and persistent unilateral referred otalgia in an adult smoker or heavy drinker needs examination of the upper aerodigestive tract to exclude cancer.

Anatomy. The ear receives sensory supply from the trigeminal (auriculotemporal branch), facial (nervus intermedius), glossopharyngeal (tympanic branch) and vagus (Arnold nerve) cranial nerves, and from the greater auricular and lesser occipital nerves (C2 and C3). Convergence of these pathways in the brainstem explains referral from the teeth, jaw, tonsil, pharynx, larynx, thyroid and neck.

Classification. Primary otalgia: outer ear, middle ear, inner ear and mastoid disease. Secondary otalgia: dental, temporomandibular, oropharyngeal, laryngeal, salivary, cervical spine, neuralgic, vascular and other causes. Idiopathic and functional otalgia remain after exclusion.

Temporal patterns. Acute (hours to days: infection, trauma, barotrauma), subacute and chronic (cancer, temporomandibular disorder, neuralgia, cervical spine), and recurrent or paroxysmal (neuralgia, Eustachian tube dysfunction).

Key distinctions. Pain on pulling the pinna or pressing the tragus suggests otitis externa. Fever, hearing loss and a bulging drum suggest otitis media. Pain out of proportion with a swollen canal in a diabetic patient suggests malignant otitis externa. A normal ear with pain on swallowing, jaw movement or neck movement points to referral.

History. Onset, duration, severity, quality (dull, sharp, burning, stabbing), laterality, constancy or paroxysms, relation to swallowing, chewing, yawning, neck movement or cold, and triggers (flying, diving, swimming, cotton bud use, hearing aid use). Ask about otorrhoea, hearing loss, tinnitus, vertigo, fever, itch, facial weakness, rash, headache, jaw pain, toothache, sore throat, hoarseness, dysphagia, odynophagia, neck mass, weight loss, nasal obstruction, trismus, visual symptoms, jaw claudication, and exertional jaw or ear pain.

Background. Diabetes, immunosuppression, HIV, tobacco and alcohol use, betel nut chewing, previous ear surgery, grommets, eczema, dental disease, rheumatoid or other joint disease, and previous head and neck cancer or radiotherapy.

Examination.

• Pinna (redness, swelling, vesicles, tenderness on traction, perichondritis, relapsing polychondritis), post-auricular area (swelling, protruding ear, tenderness).
• Canal and tympanic membrane by otoscopy: swelling, discharge, debris, foreign body, perforation, bulging drum, bullae, retraction, granulation, mass, haemotympanum.
• Tuning fork tests, facial nerve, other cranial nerves.
• Mouth: dentition, tonsils, floor of mouth, tongue base (palpation), trismus; temporomandibular joint (click, tenderness, deviation); parotid gland; neck (nodes, thyroid, carotid tenderness, cervical spine movement).
• Flexible nasopharyngolaryngoscopy for persistent unilateral otalgia with a normal ear.
• Temporal artery tenderness and pulses in patients over 50.

Red flags

• Persistent unilateral otalgia with normal ears in a patient over 40 (especially smoker or drinker), or with hoarseness, dysphagia, neck mass, weight loss or trismus
• Diabetes or immunosuppression with severe pain, swollen canal, or granulation in the canal
• Facial weakness, vertigo or hearing loss
• Post-auricular swelling, protruding pinna, fever, or child with systemic illness
• Vesicles on the pinna, canal or palate
• Jaw claudication, scalp tenderness or visual symptoms
• Exertional jaw or ear pain with chest symptoms
• Neck pain after trauma or with neurological signs (dissection)
• Recent head injury with bleeding or CSF leak

Special groups. Children: acute otitis media, otitis externa, foreign body, tonsillitis, teething and dental disease. Pregnancy: avoid ciprofloxacin orally and tetracyclines; choose paracetamol for pain and amoxicillin for infection. Older adults: cancer and giant cell arteritis. Region specific: tuberculous otitis media, otomycosis in humid climates, and chronic suppurative otitis media with complications.

Primary, outer ear

• Otitis externa (diffuse), furuncle, malignant (necrotising) otitis externa
• Perichondritis, relapsing polychondritis, auricular haematoma, trauma, frostbite, insect bite
• Herpes zoster oticus (Ramsay Hunt syndrome)
• Foreign body, impacted wax with infection
• Squamous cell carcinoma and basal cell carcinoma of the pinna and canal
• Keratosis obturans, canal cholesteatoma

Primary, middle and inner ear

• Acute otitis media, bullous myringitis, otitis media with effusion
• Mastoiditis, petrous apicitis (Gradenigo syndrome)
• Barotrauma and Eustachian tube dysfunction
• Chronic suppurative otitis media, cholesteatoma
• Tympanic membrane perforation (trauma)
• Glomus tumour, middle ear carcinoma

Secondary, dental and temporomandibular

• Dental caries and abscess, impacted third molar, dry socket, periodontal disease
• Temporomandibular disorder

Secondary, oropharyngeal and laryngeal

• Acute tonsillitis, quinsy, pharyngitis, tonsillar and peritonsillar abscess
• Carcinoma of the tonsil, tongue base, pharynx, larynx and hypopharynx
• Tonsillectomy bed pain, glossopharyngeal neuralgia, Eagle syndrome
• Infectious mononucleosis, retropharyngeal abscess, epiglottitis

Secondary, salivary and neck

• Parotitis, parotid stone and tumour, mumps
• Cervical spondylosis, cervical rib, cervical nodes, thyroiditis
• Carotidynia, carotid artery dissection

Secondary, neurological and systemic

• Trigeminal neuralgia, geniculate neuralgia (nervus intermedius), glossopharyngeal neuralgia, post-herpetic neuralgia
• Giant cell arteritis
• Angina and other cardiac causes of jaw and ear pain (rare)
• Sinusitis, nasopharyngeal carcinoma
• Functional and idiopathic otalgia

Reasoning. Examine the ear first. If findings explain the pain, treat. If the ear is normal, look for a source in the mouth, throat, larynx, neck and temporomandibular joint, and use nasendoscopy and imaging for persistent pain.

First line. Otoscopy (with microscopy when available), tuning forks, temperature, blood pressure, glucose in diabetes, examination of the mouth, throat, neck and temporomandibular joint.

Targeted tests

• Swab for culture in discharging ear, treatment failure, diabetes or immunosuppression.
• Full blood count, C reactive protein, ESR, glucose and HbA1c in suspected deep infection or malignant otitis externa.
• ESR and C reactive protein for suspected giant cell arteritis (a normal ESR does not exclude it), with temporal artery ultrasound or biopsy. Biopsy remains useful for up to 2 weeks after steroids start.
• Flexible nasopharyngolaryngoscopy for persistent unilateral otalgia with a normal ear (urgent within 2 weeks when over age 40 with tobacco or alcohol use).
• Dental panoramic radiograph or cone beam CT for dental causes. Ultrasound of the neck and parotid for masses, stones and nodes.
• CT temporal bone with contrast for suspected mastoiditis, petrous apicitis, malignant otitis externa or cholesteatoma. MRI for suspected intracranial extension, skull base disease or nasopharyngeal carcinoma.
• CT neck with contrast and biopsy for suspected tumour or deep neck abscess.
• Varicella zoster PCR from vesicle fluid.
• MRI brain for suspected neuralgia from a structural cause. ECG and troponin if pain is exertional or accompanied by chest symptoms.
• Cervical spine imaging for suspected cervical origin.

Limitations. A normal ear examination and normal initial imaging do not exclude early head and neck cancer, which needs endoscopy and often biopsy. ESR and C reactive protein can be normal in giant cell arteritis. Clinical findings in otitis media in children are confused by crying and wax.

Analgesia (all patients)

• Paracetamol 1 g orally every 4 to 6 hours (maximum 4 g in 24 hours; 2 g in 24 hours when weight is under 50 kg, with chronic alcohol use or liver disease). Children: 15 mg/kg orally every 4 to 6 hours (maximum 60 mg/kg in 24 hours).
• Ibuprofen 400 mg orally every 6 to 8 hours with food (maximum 2.4 g in 24 hours); avoid in renal impairment, heart failure, peptic ulcer and the third trimester. Children over 3 months: 5 to 10 mg/kg every 6 to 8 hours (maximum 30 mg/kg in 24 hours).
• Topical analgesic drops (lidocaine or phenazone with lidocaine) only with an intact drum.

Acute otitis media

• Analgesia and review at 48 to 72 hours. Give antibiotics at once for age under 2 years with bilateral disease, perforation with discharge, severe systemic illness, or immunocompromise, and give a delayed prescription otherwise.
• Adults: amoxicillin 500 mg orally three times daily for 5 to 7 days (maximum 3 g daily). Penicillin allergy: clarithromycin 500 mg orally twice daily for 5 days (halve when creatinine clearance is under 30 mL/min).
• Children: amoxicillin 40 to 90 mg/kg daily in 2 or 3 divided doses (maximum 3 g daily) for 5 days, or 10 days when under 2 years or severe. Penicillin allergy: clarithromycin 7.5 mg/kg orally twice daily (maximum 500 mg a dose) for 5 days.
• Treatment failure at 48 to 72 hours: amoxicillin with clavulanic acid 625 mg orally three times daily in adults, with ENT review.

Otitis externa

• Aural toilet by microsuction or gentle dry mopping, with a wick when the canal is swollen.
• Ciprofloxacin 0.3 percent with dexamethasone 0.1 percent ear drops, 4 drops into the canal twice daily for 7 days, which is safe with a perforation.
• Acetic acid 2 percent as spray or drops 5 drops three times daily for 7 days is an alternative for mild disease. Avoid aminoglycoside and polymyxin containing drops when the drum is perforated.
• Keep the ear dry, no cotton buds, no swimming, and treat eczema.
• Systemic antibiotics only for spreading cellulitis, fever, diabetes or immunosuppression: flucloxacillin 500 mg to 1 g orally four times daily for 7 days (clarithromycin 500 mg twice daily in penicillin allergy).
• Furuncle: flucloxacillin 500 mg to 1 g orally four times daily for 7 days, with incision and drainage for fluctuant lesions.
• Perichondritis: ciprofloxacin 500 mg orally twice daily for 10 to 14 days (to cover Pseudomonas) with urgent ENT review. Adjust to creatinine clearance and avoid in pregnancy and in children unless essential.

Malignant (necrotising) otitis externa. Admit. Ceftazidime 2 g IV every 8 hours, or ciprofloxacin 400 mg IV every 8 to 12 hours initially, then oral ciprofloxacin 750 mg twice daily for a minimum of 6 weeks.

Adjust for creatinine clearance (QT and tendon warnings). Arrange glycaemic control, CT or MRI and ENT surgical review. Monitor C reactive protein, ESR and cranial nerves.

Ramsay Hunt syndrome. Valaciclovir 1 g orally three times daily for 7 days with prednisolone 1 mg/kg orally daily (maximum 60 mg) for 7 days then reduced over 7 days, started within 72 hours.

Adjust valaciclovir: creatinine clearance 30 to 49 mL/min, 1 g every 12 hours; 15 to 29 mL/min, 1 g daily; under 15 mL/min, 500 mg daily. Protect the eye in facial palsy.

For post-herpetic neuralgia use neuropathic pain drugs: amitriptyline 10 mg at night increased by 10 mg weekly to 25 to 75 mg, or gabapentin 300 mg at night increased every 3 to 7 days.

Mastoiditis and intracranial complications. Admission, blood cultures, CT, ceftriaxone 2 g IV daily (children 50 to 80 mg/kg IV once daily, maximum 2 g).

Add metronidazole 500 mg IV every 8 hours when chronic disease or cholesteatoma is likely. Urgent ENT surgery for subperiosteal abscess or failure to improve in 24 to 48 hours.

Barotrauma and Eustachian tube dysfunction. Autoinflation (Valsalva or Toynbee manoeuvres), oxymetazoline 0.05 percent nasal spray 2 sprays to each nostril twice daily for no more than 3 days, intranasal corticosteroid (mometasone 50 micrograms, 2 sprays to each nostril once daily), and avoid flying or diving until resolved.

Foreign body. Remove under direct vision. Kill live insects first with olive oil or lidocaine. A button battery in the ear is an emergency; remove it at once and do not irrigate.

Bullous myringitis. Analgesia and antibiotic: amoxicillin 500 mg orally three times daily for 5 to 7 days in adults (clarithromycin 500 mg twice daily in penicillin allergy).

Referred causes

• Dental disease: dentist referral, with amoxicillin 500 mg orally three times daily for 5 days for abscess and drainage.
• Temporomandibular disorder: ibuprofen 400 mg orally three times daily with food for up to 2 weeks (maximum 2.4 g daily), soft diet, jaw rest, heat, and dental splint or physiotherapy.
• Tonsillitis and quinsy: analgesia; phenoxymethylpenicillin 500 mg orally four times daily for 10 days for streptococcal tonsillitis (clarithromycin 500 mg twice daily in allergy).
• Quinsy needs same day ENT drainage with benzylpenicillin 1.2 g IV every 6 hours and metronidazole 500 mg IV every 8 hours.
• Trigeminal and glossopharyngeal neuralgia: carbamazepine 100 mg orally twice daily, increased by 100 to 200 mg every 2 to 3 days to a usual 400 to 800 mg daily (maximum 1.6 g daily).
• Monitor sodium, blood count and liver function on carbamazepine. Test HLA-B*1502 in people of Han Chinese, Thai or other South East Asian ancestry.
• Giant cell arteritis: prednisolone 40 to 60 mg orally each morning started at once, aspirin 75 mg daily, and same day specialist review.
• Giant cell arteritis with visual symptoms: methylprednisolone 500 mg to 1 g IV daily for 3 days.
• Head and neck cancer: urgent 2 week referral to ENT and head and neck oncology with biopsy.
• Cervical spine: analgesia, physiotherapy and spinal review.
• Carotid artery dissection: emergency stroke care.

Monitoring. Review at 48 to 72 hours for infection, at 2 weeks for persistent pain, and 6 weeks after a perforation. Check glucose in diabetes.

Referral and escalation. Same day: malignant otitis externa, mastoiditis, intracranial complications, suspected giant cell arteritis with visual symptoms, facial palsy with vesicles, dissection. Urgent within 2 weeks: persistent unilateral referred otalgia with risk factors, mass lesion, or granulation in the canal. Dentistry and maxillofacial services for dental and temporomandibular causes.

Admission criteria. Malignant otitis externa, mastoiditis, immunocompromised patients with severe infection, quinsy, deep neck infection, dissection, or children with systemic illness.

Discharge and safety netting. Review at 48 to 72 hours if not improving. Return for post-auricular swelling, fever, facial weakness, hearing loss, vertigo, severe headache, drowsiness, stiff neck, new discharge, spreading redness, hoarseness, difficulty swallowing, or pain that persists beyond 2 weeks.