Painful ear

Surgery > Ear, nose & throat

Differential Diagnosis Schema 🧠

Infectious Causes

Acute otitis media: Often presents with otalgia, fever, and hearing loss; common in children.
Otitis externa: Symptoms include ear pain, discharge, and tenderness on tragal movement; commonly associated with water exposure.
Mastoiditis: Postauricular swelling, erythema, and tenderness with history of recent otitis media.
Herpes zoster oticus (Ramsay Hunt syndrome): Severe otalgia, vesicular rash in the ear canal, and facial nerve palsy.
Furunculosis: Localized erythema, swelling, and severe pain in the ear canal; often due to Staphylococcus aureus.

Traumatic Causes

Ear trauma: Blunt or penetrating trauma leading to pain and possible hearing loss.
Barotrauma: Discomfort or pain associated with pressure changes, such as during flying or diving; may include hearing loss and tinnitus.

Referred Pain

Temporomandibular joint (TMJ) disorders: Pain often referred to the ear, exacerbated by jaw movement.
Dental infections: Referred pain from molar teeth, particularly if related to periapical abscess.
Throat infections: Referred pain from tonsillitis or pharyngitis.
Cervical spine disorders: Degenerative changes or nerve impingement may refer pain to the ear.

Neoplastic Causes

Nasopharyngeal carcinoma: May present with otalgia due to eustachian tube obstruction; associated with hearing loss and nasal symptoms.
Glomus tumor: Pulsatile tinnitus and hearing loss with referred otalgia.
Ear canal carcinoma: Persistent otalgia with otorrhea and possible hearing loss; requires biopsy for diagnosis.

Key Points in History 🥼

Onset and Duration

Acute onset: Suggests infectious or traumatic causes.
Chronic pain: May indicate neoplastic, referred pain, or chronic infections such as otitis externa.
Intermittent pain: Often associated with TMJ disorders or referred pain from the throat.

Associated Symptoms

Hearing loss: Points towards otitis media, barotrauma, or neoplasms.
Discharge: Common in otitis externa, acute otitis media with perforation, or cholesteatoma.
Vertigo: Suggests inner ear involvement, such as labyrinthitis or vestibular neuronitis.
Facial weakness: May indicate Ramsay Hunt syndrome or a parotid gland tumor affecting the facial nerve.
Systemic symptoms (fever, malaise): Often associated with infections.

Exacerbating and Relieving Factors

Movement of the jaw: Aggravates pain in TMJ disorders.
Exposure to water: Worsens symptoms in otitis externa.
Pressure changes (e.g., during flight): Worsens pain in barotrauma or eustachian tube dysfunction.

Background

Previous ear infections: Increases likelihood of recurrent otitis media or chronic otitis externa.
History of eczema or dermatitis: Predisposes to otitis externa.
Smoking and alcohol use: Risk factors for head and neck cancers, which may present with otalgia.
Recent travel or swimming: May point towards otitis externa or barotrauma.
Medication use: Aspirin and other NSAIDs may exacerbate TMJ disorder pain.

Possible Investigations 🌡️

Otoscopy

Visualizes the ear canal and tympanic membrane for signs of infection, perforation, or neoplasms.
Helps differentiate between otitis media, otitis externa, and other conditions.

Audiometry

Assesses hearing loss, which can be conductive or sensorineural.
Useful in cases of chronic otitis media, acoustic neuroma, and inner ear disorders.

Imaging

CT scan: Useful for assessing mastoiditis, temporal bone fractures, and neoplastic conditions.
MRI: Preferred for soft tissue evaluation, such as identifying tumors or assessing the extent of cholesteatoma.

Laboratory Tests

Full blood count (FBC): To identify signs of infection or malignancy.
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): Elevated in infections or inflammatory conditions.
Microbiological cultures: From ear discharge or swabs to identify causative organisms in infections.

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