Earache (Otalgia) is pain in the external, middle, or inner ear, commonly caused by infection, obstruction, or trauma. Severity ranges from mild fullness or pressure to deep, boring pain. Earaches can be intermittent or continuous and may develop suddenly or gradually, sometimes radiating to the jaw, throat, or head.

Pathophysiology

Otalgia results from irritation, inflammation, or injury of the ear structures. Mechanisms include:

• Infection: Bacterial, viral, or fungal infection of the external or middle ear stimulates sensory nerves, causing pain.

• Obstruction: Impacted cerumen, foreign bodies, or tumors create pressure on ear structures.

• Barotrauma: Sudden changes in pressure can cause tympanic membrane ecchymosis or bleeding.

• Inflammatory/neurological causes: Herpes zoster oticus, Ménière’s disease, or referred pain from teeth, jaw, sinuses, or pharynx.

Pain location and character help differentiate underlying causes: external ear involvement often worsens with pressure on the tragus, while middle ear disorders may produce deep, throbbing pain.

Signs and Symptoms

• Ear pain: dull, sharp, throbbing, burning, or full sensation

• Hearing loss or tinnitus

• Ear drainage (purulent, bloody, or serous)

• Vertigo, dizziness, or imbalance

• Fever or malaise (with infection)

• Facial paralysis or taste disturbance (herpes zoster oticus)

• Redness, swelling, or tenderness of auricle or mastoid

Clinical Assessment

History

• Characterize onset, duration, intensity, location, and timing of pain

• Associated symptoms: hearing loss, discharge, vertigo, tinnitus, fever

• Precipitating events: trauma, swimming, high-altitude exposure, diving

• Recent infections: upper respiratory tract, sinus, dental, or throat

• Past history: ear surgery, foreign body insertion, chronic otitis media

• Medication and allergy history

Physical Examination

• Inspect external ear: erythema, swelling, drainage, deformity

• Palpate tragus and mastoid for tenderness

• Otoscopic examination:

  • External auditory canal: lesions, foreign bodies, cerumen impaction, discharge, swelling

  • Tympanic membrane: color, landmarks (cone of light, umbo, pars tensa, malleus), perforation

• Hearing assessment: watch tick, whispered voice, Rinne, Weber tests

• Neurological assessment if facial nerve involvement suspected

Medical causes of Otalgia

Special considerations

• Administer analgesics and apply heat for comfort

• Instill prescribed eardrops correctly

• Monitor for systemic signs of infection

• Educate patient/caregiver on adherence to antibiotics and avoiding ear trauma

• Evaluate for referred pain from dental, sinus, or throat disorders

Pediatric pointers

• Common causes: acute otitis media, foreign bodies in the ear canal

• Nonverbal clues: crying, tugging at ear, irritability

• Examination: child in supine position, securely held; otoscopic examination last to minimize distress

Patient counseling

• Correct instillation of eardrops

• Avoid water exposure during active infection

• Report persistent pain, fever, or discharge promptly

• Educate about preventing vertigo and trauma

References

1. Brehm JM, Celedón JC, Soto-Quiros ME, Avila L, Hunninghake GM, Forno E, et al. Serum vitamin D levels and markers of severity of childhood asthma in Costa Rica. Am J Respir Crit Care Med. 2009;179:765–771.

2. Peters BS, dos Santos LC, Fisberg M, Wood RJ, Martini LA. Prevalence of vitamin D insufficiency in Brazilian adolescents. Ann Nutr Metab. 2009;54:15–21.

3. Van Belle TL, Gysemans C, Mathieu C. Vitamin D in autoimmune, infectious and allergic diseases: A vital player? Best Pract Res Clin Endocrinol Metab. 2011;25:617–632.