Ear Pain (Otalgia) - Causes, Tests and Treatment

Earache: Pain Localised to The Ear

Ear ache, Otalgia, Ear Pain, Earache, Primary otalgia, Secondary otalgia
Pain in the ear area is called "otalgia" or "ear pain". The cause of ear pain can be an ear disease; It can occur with dental disease, tonsillitis, infectious diseases related to the nose and throat, diseases related to the temporomandibular joint (TMJ), laryngeal and tongue cancer, and sometimes it can occur as a sensory aura before migraine.

What is Primary Otalgia?

If the cause of ear pain is related to the ear, this condition is called "primary otalgia". Diseases causing primary otalgia may be related to the outer, middle or inner ear. The main diseases that may cause primary otalgia can be summarized as follows:

Related to the outer ear:

- Mechanical causes: due to trauma, foreign objects (insect, hair or cotton swabs)
- Infectious causes (otitis externa): may occur due to bacteria or fungi (ear fungus)

Related to the middle ear:

- Mechanical causes: barotrauma, pressure changes in the middle ear due to eustachian tube defects
- Infectious causes: Middle ear inflammation (acute otitis media) and acute mastoiditis.

Barotrauma (During Airplane Travel)

Barotrauma (During Airplane Travel) Airplane Ear

In the endoscopic examination of the patient who had ear fullness, hearing loss, ear pain and balance problems after the plane flight, retracted tympanic membranes and bleeding areas were found behind the membrane. No perforation was detected in the patient's eardrum.

Generally, during air travel, the external pressure increases as the plane descends. Since the pressure in the cabin is not sufficient to equalize, the eardrum flexes inward if the middle ear pressure cannot be increased sufficiently in the face of the increased external pressure (swallowing, yawning or performing a valsalva maneuver to open the eustachian tube and pump air inside). and the patient should not have an upper respiratory tract infection, nasal polyp, allergic rhinitis ... that may cause nasal congestion). When the aircraft descends for a long time and a rapid amount of descent, the external pressure increase will be rapid, the barotrauma effects may be more and it may even cause nerve type damage in the inner ear due to perforation of the eardrum, severe earache, dizziness or even rapid eardrum collapse.

What is Secondary Otalgia?

If ear pain is due to reasons originating from a region other than the ear, it is called “secondary otalgia / reflected otalgia / reflected ear pain / referenced otalgia”.

Reflected ear pain may occur due to 5 different nerves in this region.

- Trigeminal nerve (V. cranial nerve). Rarely, trigeminal neuralgia can cause otalgia. Oral cavity cancers can also cause ear pain reflected through this route.
- Conditions that can cause reflected pain associated with the facial nerve (VII. Cranial nerve / facial nerve), dental diseases (most often due to the upper molars), temporomandibular joint (temporomandibular joint dysfunction - due to its close relationship with the ear canal) and parotid gland (cheek major salivary gland) diseases.
- Conditions that may cause reflected pain associated with the glossopharyngeal nerve (IX. Cranial nerve), as well as infectious diseases in the throat area such as pharyngitis and tonsillitis; floor of the mouth, tongue root, soft palate, pharynx and tonsil cancers.
- Conditions that may cause reflected pain associated with the vagus nerve (X. cranial nerve X) are infectious diseases of the larynx and pharynx area, cancers and diseases such as reflux related to the esophagus.

Ear pain may also occur in stimuli from the C2 and C3 in the second and third spinal segments.

Differential Diagnosis in Ear Pain

In the ear nose and throat examination, many diseases that can cause ear pain can be detected. After excluding diseases related to the throat and ear, it is continued with jaw joint examination.

Causes of ear pain can be excluded based on the patient's history in the following cases:

- Ear pain that increases while eating may be more related to the jaw joint; rarely, it may be due to impacted teeth or other dental diseases. Since most of the patients who have problems with the jaw joint have tooth clenching (bruxism) at night, they may wake up with pain in the jaw and ear area.
- If there is hearing loss, fever and body malaise in addition to ear pain; Ear pain may be due to otitis media on the painful side.
- If there is an increased pain by pressing on the outer ear canal, the cause may be an external auditory canal infection.
If ear pain increases when you get angry and stressed, this may be part of migraine or tension pain.
- Especially in patients who use tobacco and alcohol, ear pain, which has been present continuously for a long time and gradually increasing, may be due to cancers of the upper part of the throat, tongue root or tonsil region.

Right sided tonsillitis
In the photo above, it was understood that the patient who described right ear pain had reflected ear pain due to right tonsillitis.

General Treatment Principles in Patients With Ear Pain

Treatment for diseases and conditions that cause ear pain should be planned. In addition to a simple external auditory canal inflammation, there are different options available in a wide range of treatment options, including the treatment of migraine or more difficult to treat diseases due to tooth clenching.

Simple questions and answers to identify the causes of earache!

According to the features and questions I have written below, you can simply understand the causes of ear pain:

- Does your earache increase when you open and close your mouth?

If the pain in your ear increases when you open and close your mouth, you should think of a problem with the jaw joint. Patients who grind their teeth, especially at night, may describe a different feeling in the form of pain and cramping in the ear area and jaw area when they wake up in the morning, and there may be an increase in pain, especially when they open their mouths fully while eating. In this case, problems related to the jaw joint may come to mind first. During the examination, we tell our patients to open and close their mouths, and the physician can evaluate the features such as subluxation, dislocation, sound in the temporomandibular joint by placing his index and middle finger in the glenoid fossa area where the temporomandibular joint is, and check whether the patient feels pain or not.

- When you get angry or stressed, does your earache increase, do you feel pain in the temple area or neck at the same time?

If the ear pain you feel increases when you get angry, the underlying cause may be a neurological or psychiatric problem. Especially in patients with tension headaches, migraine tension headaches, panic attacks, there may be an increase in ear pain during anger and stress. In this case, the first thing that comes to our mind is that the patient has ear pain due to an underlying neurological or psychiatric problem. Generally, patients may experience a feeling of numbness or pain in the temple area, neck, and sometimes migraine features. As a simple information, in otitis media or otitis externa, the patient's anger or increased stress is not related to the pain felt.

- Does the earache increase when we press on the anterior region of the external auditory canal with your hand on the cartilage of the tragus?

If the pain increases when we press on this area, that is, if the patient describes a very severe increase in ear pain, otitis externa or any skin infection may have occurred in this area.

- Do you have pain in your tooth or throat at the same time?

When there is an infection in our mouth, in our molar teeth in the back, or in the lateral regions of our throat, tonsils, and lateral pharynx, there may be reflected pain in the ear. Patients often describe simultaneous pain in the tooth on the side of the aching ear, or they may describe a simultaneous pain in their throat when they swallow. During the physical examination, when tonsillitis or pharyngitis is seen, patients can be informed about it. Sometimes, when aphthous lesion occurs in the mouth, on the tonsils or in the soft palate areas close to the ear, patients may date the earache before the pain of the lesion in the mouth.

Cause-Oriented Treatment Approach in the Treatment of Earache

In patients with ear pain, treatment is planned for the cause. If the patient's ear pain is due to a disease related to the outer ear and middle ear, local and systemic treatments can be planned for it. When a patient is examined by an otolaryngologist, external ear inflammation, skin problems in the external ear canal, otitis media can be easily understood and treatments such as local drop therapy and oral antibiotic therapy can be planned for this. Again, during the examination, tonsillitis, aphthous lesions in the mouth, mass lesions can be detected and treatments can be planned for them. Stress control, lifestyle changes, neurologic or antidepressant type drugs, if necessary, can be given to patients for tension-type headaches, migraine, tension-type headaches related to stress. Dentist consultation may be requested from patients who have problems such as tooth infection and tooth abscess. Again, in patients with complaints of nighttime clenching and grinding, which may be related to stress, use of an oral squeezing splint, physical therapy applications for the jaw joint, and osteopathic treatments can be planned. In patients with teeth clenching complaints, the tissues around the temporomandibular joint may be affected in varying amounts, and sometimes there may be damage to the joint capsule. Jaw surgery department in dentistry, maxillofacial surgery department in plastic surgery and physical therapy medicine deal with jaw joint diseases.

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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