Causes of Otalgia
Local Causes
Causes of Referred Pain

Acute otitis externa

Acute otitis media



Ramsay Hunt Syndrome




  • Dental disease
  • Temporomandibular joint disease
  • Arthritis: OA or RA
  • Upper respiratory tract infection
  • Sinisitis
  • Spasm of muscles of mastication
  • Cervical spondylosis
  • Upper airway neoplasia
  • Pharyngeal neoplasia



Cervical nerves, trigeminal, glossopharyngeal and vagal nerves are involved in referred pain to the ear. Mechanism of referred otalgia;
  • C-spine                                                             -> cervical nerves 2 & 3
  • Nose and sinuses                                             -> CN V
  • Teeth                                                                 -> CN V
  • Temporomandibular joint                                  -> CN V
  • Oropharynx                                                       -> CN IX
  • Larynx                                                               -> CN X
  • Oesophagus                                                      -> CN X

Acute otitis externa

  • Common associations with eczema
  • Common after use of cotton buds
  • Common in anything that increases humidity in the ear à ear phone use, swimming etc.
  • 4 main causative agents; streptococcus, staphylococcus, pseudomonas and fungus (secondary fungal infection is common after initial overuse of antibiotics)
  • Sx; itching and pain
  • O/E;   
    • Red and tender ear canal  
    •   Watery discharge  
    •   Accumulation of debris + oedema à hearing loss
  • Rx;  
    • Topical antibiotic OR  
    • Topical steroid drop OR  
    • Antibiotic dressing (if canal severely swollen)  
    • 1% hydrocortisone (for itching)

Acute otitis media

  • Causes severe otalgia
  • Upper respiratory tract infection
    • ascends via and blocks Eustachian tube
    • negative pressure in middle ear
    • exudates
    • otitis media with effusion (OME)
  • N.B Mastoiditis is a severe possible complication
  • Sx;  
    • Pain (due to pressure in middle ear)
    • Hearing loss
    •   Disharge (if tympanic membrane ruptures) à reduced pain
    •   Imbalance (especially in adults)
  • O/E;
    • Injected, congested and bulging ear drum
    • Hearing loss
    • Large tonsils ( + adenoids NB cannot see on normal examination of buccal cavity and pharynx)
    • Tympanometry shows no ear movement and produces a flat trace. (Tympanometry measures how the tympanic membrane moves in relation to an applied pressure and thus pressures in the middle ear can be calculated)
  • Rx;
    • NSAIDs and analgesics
    • Systemic broad spectrum antibiotics
    • Decongenstants
    • Myringotomy and grommet insertion (if recurrent)
    • Adenoidectomy (if recurrent)

Ramsay Hunt Syndrome

  • Infection of the facial nerve ganglion by herpes zoster (shingles)
  • NB can cause permanent damage to facial nerve if not treated promptly
  • Sx;
    • Otalgia
    • Facial palsy
    • Hearing loss
    • Imbalanced.  O/E;
    • Vesicles in ear canal and around pinnae.  Rx;
    • Systemic acyclovir

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