Ear Pain

Common in children & adults alike, & probably sounds like a boring topic.  But that’s one thing I enjoy about our professions — there’s always something interesting to mull over every day, be it big or small.

Infants of course get lots of Otitis Media, but can’t complain of “ear pain” per se.  Our Blog addresses essentially only persons >4 y.o.  Of course, whenever we hear the complaint, we immediately think of Otitis Media.  But there’s more to the differential, & we certainly don’t want to throw antibiotics at everyone whose ear hurts.

Ear Pain  —  Differential Diagnosis

Acute Pain Only

Any Time Frame


Going through the possibilities one by one…

Otitis Media (OM)  —  This really hurts.  Patients would need a really good reason [e.g. stuck on a wilderness hike] to present for care after more than 2-3 days.

Unfortunately, in my opinion OM is one of the most overdiagnosed conditions I’ve seen, regardless of patient age.  I think providers are afraid of missing it, and so, when in even the least bit of doubt, prescribe antibiotics.  I like really having to convince myself.

“Red TM” all by itself doesn’t fly.  I’ve seen a little bit of vascularity generate the Rx.  Ignore the color; what really matters is whether or not the TM is BULGING.  Look for the landmarks.  If the handle of the malleus is sticking right out, there’s no otitis.  An infected  bulging TM occludes this (even if it stays gray).

Here are a few pictures:

Called “incipient OM” by wikimedia; I’m not convinced, though there is some bulging in the upper TM above the quite-prominent landmark (note that the peripheral redness is in canal).


Not completely convinced here below either that the right ear is infected vs. the left.  But it probably is, because the landmark is a little more obscured, & the lower part of the TM seems to bulge.  The redness in photo is primarily the canal wall; in terms of the injected handle of malleus on right TM, I’m unimpressed. [don’t know if these are same patient].


Two Left ears here [different patients, obviously]; the one on our right is bulging out to obscure the landmarks (OM for sure).


Once again, please don’t focus on color.  What really matters is if the TM (or maybe part of the TM) is bulging!  In my mind, no bulging = no otits.

Treatment?  We’ll cover bacterial pathogens in a few postings when we get to I.D. (Infectious Diseases).  But in terms of whether it’s viral vs. bacterial otitis, in my anecdotal experience, the studies I read about antibiotic efficacy never convince me that investigators who disagree are talking about similar types of clinical findings.  In my practice, “otitis media” means bacterial, & I never make the diagnosis unless the TM is frankly bulging.

If the TM ruptures, drainage ensues, but pain disappears (or greatly diminishes.  If you get this sort of history, you’re likely dealing with OM, even if there’s too much gunk in the canal to see the TM.

Bullae on the TM (bullous myringitis) suggests Mycoplasma infection, so say the texts.  However, the entity is likely exceedingly rare.  But if you see it, treat with azithromycin, clarithromycin, or doxycycline.

Otitis Externa (OE)  —  You don’t even need to look in the ear!!!  Just tug gently on the pinna, press gently on the tragus.  Those maneuvers wiggle the canal; if your patient screams, it’s OE.

Well, of course look in the canal.  But I’d never base a diagnosis on what I see, if “manipulation of pinna & tragus non-tender.”  I have, however, followed-up on numerous clinicians who’d given “triple antibiotic” drops & provoked neomycin hypersensitivity reactions.  If an OE is so mild as to not cause tenderness as above, treat with acetic acid or other acidifying drops, not antibiotics.

At the other end of spectrum, there’s severe OE (or “malignant,” which isn’t cancer, despite terminology).  It includes cellulitis around the external ear, fever, & requires systemic antibiotics, often IV (especially for diabetics & compromised hosts).

Microbiologic Diagnosis — The main pathogens causing OE are Pseudomonas & Staph aureus, both covered by the various combination antibiotic drops.  However, quinolone drops won’t cover MRSA.  We’ll address this when we hit I.D. as well

OM vs. OE  —  How can you tell the difference when the canal is so occluded with drainage / exudate that you can’t see the TM?

  • History of ear pain relieved when discharge began = OM
  • Purulent / bloody discharge = Chronic OM [usually painless due to ruptured TM]
  • Tenderness with manipulation of pinna / tragus = OE
  • Cellulitis around external ear (contiguous with canal) = severe OE

Cerumenosis  —  And if the canal is fully occluded with wax?  That’s probably the cause in & of itself; lavage is both diagnostic & therapeutic.  Even though the onset of pain begins at a certain point of cerumen accumulation, severity is much less than acute OM.

Note that we said the canal is “fully occluded.”  If there’s enough space to achieve even a bare glimpse of a part of the TM, the cerumen probably has nothing to do with current symptoms.  It’s not necessary to remove every speck of “wax” from an ear; only lavage it if a) you suspect symptoms are due to impaction; OR b) you can’t (but need to) visualize the TM.

Be sure to emphasize to the patient why you’re cleaning the ear.  Otherwise, they may think it’s important for hygiene, & use their Q-tips even more vigorously [!!!].

Before lavage, inquire about a history of chronic drainage on & off, which could imply a ruptured TM that would contraindicate lavage.  Problem is, moist cerumen can ooze on & off, mimicking drainage to the patient.  So be sure to ask in a way that suggests significant purulence, like “mixed with blood” or “keeps staining the pillow,” versus just a little bit of gunk.

Of course, a ruptured TM is usually completely asymptomatic.  It’s much safer to curette out wax, but that takes getting used to, & takes time.  So we simply lavage it out; best tool is a 20 cc syringe fitted with a 16-18 gauge angiocath.  You don’t have to extract every bit of wax, merely enough to relieve symptoms (diagnostic) & hopefully see the TM.

Do tug on & wiggle the tragus & pinna before lavage, to be sure there’s no coincidental OE.  And of course, stop the lavage immediately if it evokes pain, vertigo, or nausea.  Sometimes we simply have to refer to ENT, who can clean the canal easily under direct vision.

Furuncle  —  A staphylococcal “boil” occurring in or right near the canal can certainly present with ear pain.  The lesion is obvious on otoscopy [unless it happened to be behind the pinna, the patient just says “ear pain,” & the busy & harried clinician just grabs their otoscope].  May well need an I&D by ENT, though small furuncles can resolve with anti-Staph antiobiotics.

Follow-up any canal lesion carefully, since skin cancers occur there on rare occasion.

Mastoiditis  —  A complication of acute or chronic otitis media, very rare today, I’ve never seen it.  But it’s never bad to simply percuss the mastoid process of the temporal bone, right behind the ear.  Significant tenderness warrants a CT scan.


a.k.a. “You don’t have anything.”  That’s not a nice thing to say to a patient.  Actually, there are a couple of conditions that are actually something

Eustachean Tube Dysfunction  —  This is quite common, perhaps most common cause of ear pain of all.  It’s commonly due to a URI or allergic rhinitis; all of us have experienced it during airplane take-offs & landings.  So the next time a patient complains of “ear pain” & you conclude “everything’s normal,” think back to how you felt on that horrible flight!

If you get a history of nasal symptoms, or see a retracted TM, your diagnosis is clinched.  But even if I don’t, & I’m convinced a person’s truly uncomfortable or concerned about “everything’s normal” ear symptoms, I give a trial of non-sedating antihistamine plus nasal steroids, which in my anecdotal experience usually help.  I never recommend sympathomimetic “decongestants,” partly because I’ve seen adverse effects, but mostly because I know of absolutely no data that suggest efficacy.

What’s a “retracted TM”?  When there’s negative pressure trapped in the middle ear, that “sucks” the TM backward.  On 2-D otoscopy [you lose depth perception when looking through the otoscope with just one eye], you can tell because the handle of the malleus looks much more horizontal than usual.  Note only the landmarks (not the colors) on the pictures below, & compare them to the vertical landmark of a normal TM:

Retracted TM



Normal TM


Zoster  —  Varicella zoster virus reactivation in the 7th or 8th cranial nerve (aka Ramsay-Hunt Syndrome) can cause “ear pain.”  There’s usually associated facial palsy, vertigo, tinnitus, or hearing loss.  Isolated ear pain makes it virtually impossible to identify.

Telltale vesicles in the ear canal clinch the diagnosis, but these usually aren’t present.

Temporal Mandibular Joint Syndrome (“TMJ”)  —  I hate to say it, but I’ve yet to be convinced that this is a bona fide pathologic condition.  Sure, patients with rheumatoid arthritis, etc., may have frank TMJ involvement, but that’s uncommon.  The extent to which this entity has become popularized hit home when I read a very respected source abbreviate it just as I have above, without the “S”, & also without quotes.  “I’ve got TMJ” (we all have TMJs, 2 of them!)

Various diagnostic criteria such as clicks & crepitus also occur in asymptomatic persons.  The most convincing finding to me is unilateral masseter or temporal muscle tenderness.  But I prefer to call that non-specific “facial pain,” rather than attach an anatomic or medicalese term to it.  Lots of treatments get tried, a variety of both drug & non-pharmacologic possibilities.  I wouldn’t refer to a dentist unless I found objective evidence of dental disease.

SUMMARY  —  A patient presents with acute ear pain.

1.  Manipulate External Ear  (Tug on the Pinna, Push on the Tragus)
  • Exquisitely tender →  Otitis Externa
  • Peek in canal: full of exudate confirms Dx
2.  Examine TM
  • Bulging, can’t distinguish landmarks, maybe red →  Otitis Media
3.  Canal Full of Cerumen  →  Cerumenosis
  • Clean canal: TM normal & symptoms better confirms Dx

None of Above

4.  Examine canal carefully for Furuncle (especially near meatus)

5.  Consider Zoster, especially if:
  • Vertigo
  • Vesicles on canal
  • Facial (“Bell’s”) Palsy
6.  Tap on mastoid process behind ear: very tender →  ? Mastoiditis
  • very rare; often febrile
  • often there’s a destroyed TM
  • Needs CT

Still None of Above

7.  Diagnose Eustachian Tube Dysfunction
  • Dx confirmed if retracted TM (may not be present)
  • Dx suggested if concurrent nasal Sx
  • Condition common: default Dx if nothing else

Chronic Ear Pain (with normal TM)

a)  Dx Eustachian Tube Dysfunction
  • Treat w/ Antihistamine & Nasal Steroid
  • If no response, consider Dx of:
b)  Atypical Facial Pain Syndrome  (or “TMJ”)
  • Esp. if masseter or temporal muscles tender to palpation

That’s it for the ear.  Next time: Nose.

One response to “Ear Pain

  1. Pingback: Infectious Disease – 2 (Head & Neck Infections) | DiagnosisDude

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