Ear Pain

Ear pain is a common symptom, and requires a trained clinician to examine the ear with an otoscope (the common instrument mounted on exam room walls). Infections can occur in different parts of the ear, and pain can be due to non-infectious causes. Diagnosis can be achieved through a systematic exam and thought process. See also Diagram โ€“ Ear Anatomy.

1.  Manipulate External Ear  (Tug on the Pinna, Push on the Tragus)

  • Exquisitely tender  โ†’  Otitis Externa (OE)
  • Peek in canal: if full of exudate (pus) confirms the diagnosis
  • Fever; or outside of ear red/hot/swollen   โ†’  “Malignant” OE (not cancer), may need IV meds (esp. if patient has diabetes)

2.  Examine Ear Drum (Tympanic Membrane; TM)

3.  Canal Full of Cerumen   โ†’  Ceruminosis

  • Clean the canal ย โ†’ย  TM looks normal & symptoms resolve ย โ†’ย  confirms diagnosis

None of Above

4.  Examine canal carefully for Furuncle (a boil) (especially near the opening)

5.  Consider Herpes Zoster (Shingles), especially if:

  • Vertigo
  • Tiny blisters on ear canal or ear drum
  • Facial Palsy (droopy facial muscles, a.k.a. “Bell’s Palsy”)

6.  Tap on mastoid process behind ear: very tender   โ†’  maybe Mastoiditis

  • very rare; often with fever
  • often has a destroyed TM
  • Needs CT scan

Still None of Above

7.  Look in throat for a sore or infection.

  • Touch it with Q-tip ย โ†’ย  if thereโ€™s ear pain, that’s the cause
  • Nothing thereโ€ฆ

8.  Diagnose Eustachian Tube Dysfunction

  • Diagnosis confirmed if retracted TM on exam (may not be present)
  • Diagnosis suggested if there are also nasal Sx
  • Condition is common: it’s our default diagnosis if nothing else
  • If treatment with allergy medicines helps, either that was the diagnosis, or whatever was got better on its own
  • Treatment no help   โ†’   refer to ENT specialist (“Ear-Nose-Throat;” Otolaryngologist)

Chronic Ear Pain (with normal ear drum)

a)  Diagnose Eustachian Tube Dysfunction

b)  Atypical Facial Pain Syndrome  (or โ€œTMJโ€)

c) Abnormal Ear Drum usually means Chronic Otitis Media

  • Antibiotics can help improve symptoms temporarily
  • Likely needs referral to Ear-Nose-Throat specialist for surgical procedure


Acute Pain (under 3 days)

1.  Fever:  Will need an exam of ear to diagnose & treat

  • Area around ear red/hot/swollen   โ†’   Go to Urgent Care (or ER if necessary)

2.  Have patient tug & push on the ear (pinna & tragus)

3.  Ear feels very painful (but not tender to tugging & pushing on it)

  • Likely Otitis Media (prescription oral antibiotics if this is first time)
    • My colleagues will criticize me here for inappropriate antibiotic use, but as a one-time try to expedite care & save a visit, it’s not a terrible guess
  • If throat also painful, infection there may be causing the pain

4. Ear NOT very painful

Chronic Pain

See Ear Pain โ€” Full Text for more in-depth explanations and discussions.

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