Otalgia

What is Otalgia?

Otalgia simply means ear pain. It is a symptom rather than a disease itself, indicating that something might be wrong with the ear or the areas around the ear. Ear pain is a condition that can affect anyone at any age, and can range from a mild, dull ache to a sharp, intense pain. However, the source of the pain can vary. Sometimes, the pain originates from the ear itself, known as primary otalgia. Other times, the pain is comes from other areas of the body, meaning the problem isn’t in the ear but feels like it is—this is called referred otalgia. Understanding these two types is crucial in diagnosing and treating the condition. Let's dive deeper into what causes otalgia and how it is connected to the ear's anatomy.

How the Ear Is Connected: The Role of Nerves in Otalgia

The structures of the external and middle ear are connected to several nerves that carry sensations to the brain. That's how pain in the ear can be felt. However, these same nerves that carry sensation of the ear also serve other parts of the head, neck, and even the chest. This shared nerve supply explains how problems in distant areas, like the throat or teeth, can show up as ear pain. We detail the different causes of referred otalgia in the section below. Here's a deeper dive into the nerves involved. To learn more about the intricate structure of the ear, check out our article on the anatomy of the ear and how the hearing system works.

Nerves of the External Ear

The external ear includes the auricle (the visible part of the ear) and the external auditory canal. Sensation in this area here comes from several nerves. Below is an image providing an overview of which nerves cover each area, followed by a more detailed explanation.

• Supplies the front and top portions of the auricle and the ear canal.
  
  
• This nerve also connects to parts of the face and jaw, which is why dental and jaw problems can sometimes cause ear pain.

• Covers the upper part of the auricle and surrounding skin
  
  
• The roots of this nerve (cervical nerves C2) also provide sensation to the neck, which is why cervical problems such as arthritis or tension can cause ear pain.

• Sends small branches to the ear canal and ear, especially around the concha (the bowl-shaped part near the ear canal).
  
  
• The cell bodies of this nerves are located in a structure called the geniculate ganglion which is located at the skull base, and conditions affecting this area (viral infection such as Ramsay Hunt syndrome or benign tumours of the skull base) can cause ear pain. 

• Provides sensation to part of the ear canal and auricle (mainly the concha).
  
  
• This nerve also connects to the throat and chest. Sometimes, cleaning the ear canal can trigger a cough for that reason. This is called the Ear-cough reflex (or Arnold’s reflex).
  
  
• Also explains why throat pain can cause ear pain. A throat infection will often give ear pain, and often leads to the issue being misdiagnosed as otitis but in reality the problem is in the throat. 
  
  

Nerve of the Middle Ear

The middle ear includes the eardrum, the tiny hearing bones, and the Eustachian tube. There is really only one major nerve to consider:

Glossopharyngeal Nerve (CN IX):

• Connects to the middle ear via a branch called Jacobson's nerve. Covers the eardrum’s inner side, the middle ear and the Eustachian tube.
  
  
• It also connects to the throat, which is why throat infections or throat problems can cause ear pain.
  
  

Exploring Primary Otalgia

Primary otalgia refers to ear pain that originates from the ear itself. This can be due to a variety of conditions:

External ear causes

• Otitis externa (known as swimmer's ear): Infection of the ear canal and outer ear. One of the most common causes of ear pain. Usually caused by water being trapped along with accumulated wax and dead skin. Can also be caused by excessive manipulation of the ear (Q-tip, ear flushing, etc.).

• Ear trauma: Ear cuts with a Q-tip or a finger nail are common causes.

• Foreign body in the ear canal: The most common foreign body to get stuck is the cotton tip of a Q-tip! Often patients don't notice the tip is missing after using a Q-tip and seek attention a few days later once it gets infected. General rule: avoid using Q-tips at all! I've also seen insects in the ear canal. In children, it's quite common to see small toys (beads, legos, etc) or organic material such as food. It is more urgent to remove organic material than plastic objects because they swell and it gets much harder to remove. 

• Perichondritis: Infection of the cartilage of the outer ear, often following trauma or piercing.
   
• Impacted Earwax: Excessive or hardened wax (cerumen) can block the ear canal, causing pain and hearing loss.
   
• Furuncule: A bacterial infection of hair follicles in the ear canal, leading to a small access (called "boils") and localized pain. Usually the pain is superficial in the ear canal (as only the out part of the ear canal contains hair follicles). Needs to be drained if forms an abscess. 
   
• Otomycosis: Fungal infections in the ear canal that cause itching and discomfort. Usually caused by excessive use of antibiotic drops, but can also occur in chronically wet ears. 
   
• Herpes Zoster Oticus (Ramsay Hunt Syndrome): A viral infection affecting the facial nerve near the ear, causing severe pain and facial paralysis.
  
  

Middle Ear Causes

• Acute Otitis Media: Infection of the middle ear (behind the eardrum). More common in children but can still occur in adults. Usually happens after a cold, where a build up of stagnant mucus in the middle ear gets infected with a bacteria.

• Chronic Otitis Media: Long-term middle ear infections that may cause intermittent pain and hearing loss.

• Ear Barotrauma: Pain due to pressure changes in the middle ear during activities like flying or diving.

• Tympanic Membrane Perforation: A ruptured eardrum caused by trauma, loud noises, or infections can result in sharp pain and discharge.

• Hemotympanum: Blood accumulation in the middle ear due to trauma or barotrauma. Usually causes more ear pressure than ear pain.
  
  

Mastoid Causes

• Mastoiditis: An infection of the mastoid bone behind the ear, which can occur as a complication of untreated otitis media. Symptoms include swelling, redness, and severe pain behind the ear.
  
  
• Mastoid Abscess: A collection of pus in the mastoid region that may require surgical drainage.

Common symptoms associated with primary otalgia include a feeling of fullness in the ear, hearing loss, and sometimes discharge from the ear. It's important to seek medical attention if you experience these symptoms to prevent complications. If you're concerned about potential hearing loss, you might want to learn more about how to detect hearing loss.

What is Referred Otalgia

Referred otalgia happens when pain from another part of the body is felt in the ear. This is due to shared nerve pathways that we described in the section above. In other words, the pain feels like it's coming from the ear, but in reality it comes from another part of the body close by.

Referred otalgia is probably one of the most common explanation I see in my practice for patients sent to me for ear pain. If you're reading this article, chances are you suffer from ear pain and your doctor told you your ears look normal. In those situations, it's important to look beyond the ear to identify potential causes of ear pain that are referred from other parts of the body. Understanding referred otalgia is crucial for accurate diagnosis and treatment since treating the ear alone won't resolve the pain if the underlying issue lies elsewhere.

Some common sources include: 

• Jaw Disorders: Probably one of the most common causes of referred otalgia. Temporomandibular joint (TMJ) dysfunction often causes referred ear pain. This is very common in individuals who clench or grind their teeth at night (bruxism), or who have habitual chewing (nail biting, chewing the inside of their cheeks, etc.). This causes irritation of the chewing muscles and tendons, leading to myofascial pain that radiates to the ear or that is felt in the ear.
  
  
• Neck Problems: Cervical spine arthritis or strained muscles can result in pain that feels like it’s in the ear. This is also a very common cause of referred otalgia, especially in older individuals.
  
  
• Throat Issues: Tonsillitis, pharyngitis, or even tumors in the throat. 
  
  
• Dental Problems: Cavities, abscesses, or impacted wisdom teeth can send pain signals to the ear.
  
  
• Sinus Infections: Pressure and inflammation in the sinuses can mimic ear pain.

There are some rarer syndromes that can also cause referred ear pain:

• Eagle Syndrome: This is due to a elongated styloid process (a bone on the skull base) that causes irritation in the throat (behind the tonsils) and in the neck and that can also present as ear pain. A CT scan can diagnose this disorder.
  
  
• Geniculate neuralgia: This is caused by inflammation of the facial nerve by either a virus or sometimes irritation by physical pressure (from a blood vessel in the skull base or a tumor). Since the facial nerve supplies sensation to part of the ear canal (see section above), patients will feel a deep ear pain (compared to other disorders which may cause more superficial pain). An MRI would help in making the right diagnosis..
  
  
• Glossopharyngeal neuralgia: This is caused by physical irritation of the glossopharyngeal nerve (CN IX, see section above) typically by a blood vessel in the skull base. Since the glossopharyngeal nerve provides sensation to the middle ear, patients will also report deep ear pain. An MRI would help in making the right diagnosis.

Medical work-up and diagnosis

Diagnosing otalgia involves a thorough medical evaluation. The process typically starts with a detailed history of the patient's symptoms, including the onset, duration, and intensity of the pain. Questions about recent illnesses, injuries, or dental problems are also important. For a better understanding of what to expect during an ear examination, you might find it helpful to read about what happens during a typical audiology appointment.

A physical examination follows, which should include an otoscopic exam to look inside the ear. If the ear examination shows no abnormalities, we must explore all possible causes of referred otalgia: a complete ENT exam is therefore necessary. This includes checking the throat, nose, and neck, in addition to performing a nasopharyngeal endoscopic exam (scope).

Additional diagnostic tests, such as hearing tests and imaging studies may be necessary to pinpoint the exact cause of the pain. Most common imaging studies would include a CT scan of the temporal bones or of the neck (depending on the indication), or if we suspect facial or glossopharyngeal neuralgia, an MRI would be indicated.

Treating Otalgia

The treatment for otalgia depends on whether it is primary or referred. For primary otalgia, treatments might include antibiotics for infections, removal of earwax or foreign objects, and pain relief medications.

For referred otalgia, addressing the underlying cause is key. This might involve dental treatment for tooth issues, physical therapy for TMJ disorders, or antibiotics for throat infections. In both cases, a comprehensive approach ensures that the root cause is treated, providing lasting relief from the pain. If you're experiencing persistent ear-related issues, it's important to consult with the right ear and hearing experts for proper diagnosis and treatment.