Ear Pain — Full Text

Everyone thinks that ear pain equals Infection.  In my experience, that’s often not the case.  Infants of course get lots of middle ear infections (Otitis Media), but can’t say “ear hurts” per se.  This website addresses essentially only persons over 5-year-old.  As always, there’s a list of possibilities, & we certainly don’t want to prescribe antibiotics at everyone whose ear hurts.

Causes of Ear Pain

zzzzzzzzzzzRecent Pain Only  
** Otitis Media
** Otitis Externa
** Herpes Zoster (shingles)
** Boil in ear canal
** Sore Throat (see text)

zzzzzzzzzzzzAny Time Frame  
** Wax (Ceruminosis)
** Eustachian Tube Dysfunction
** Mastoiditis (rare)  

zzzzzzzzzzzzzChronic Only  
** Chronic Otitis Media
** TMJ Disorder [???]

Going through the possibilities one by one…

Otitis Media (OM)  —  This is an infection of the middle ear (see Diagram — Ear for explanation of anatomy).  It really hurts.  Somebody would need a pretty good reason [like stuck on a wilderness hike] to wait more than 2-3 days to seek medical care.

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

You’ll hear, “the ear drum is red!”  If you’re ever diagnosed that way, ask, “But, is it bulging?”  Color alone doesn’t prove infection.  The ear drum has to be so swollen that it loses its shape, obscuring the middle ear bones (“bony landmarks”) that are normally visible.  Of course, if you want antibiotics, you won’t argue.

On the other hand, you’ll hear that most Otitis Media is caused by viruses, & doesn’t require antibiotics (see Differences Among Germs).  That depends on how we diagnose it.  But anyone with acute ear pain and a bulging ear drum needs Amoxicillin or something similar.  Maybe not azithromycin (Zithromax®, “Z-Pack®”), because over 40% of strains of the most common bacteria (Pneumococcus) are resistant to it.

If there’s severe ear pain that suddenly gets better, just as the ear starts to drain, it means the ear drum ruptured.  Like any abscess, the best treatment is to open and drain it, so a ruptured ear drum cures the infection.  The person should still get antibiotics; the examiner won’t be able to see a thing in the ear except blood & pus.  Ruptured ear drums usually heal on their own, but need follow-up examinations to be sure.

Otitis Externa (OE)  —  Infection of the ear canal, also called “swimmer’s ear,” because constant water-in-the-ear predisposes to it.  But you can get this even if you can’t swim.

For diagnosis, we don’t even need to look in the ear!!!  Just tug gently on the pinna (big outside ear), and press gently on the tragus (flap of outside ear by opening to ear) [see Diagram — Ear].  Those maneuvers wiggle the canal.  Do this to someone with OE, & they scream.

Well, of course we look in the ear canal, where there’s invariably white gunk.  But I’d never base a diagnosis on what I see, if there’s no tenderness with manipulation of pinna & tragus.  I have, however, followed-up on numerous clinicians who’d given “triple antibiotic” drops & provoked uncomfortable allergies to the neomycin ingredient.

At the other end of spectrum, there’s severe OE (or “malignant,” which isn’t cancer, despite terminology).  It includes infection extending out & around the external ear, maybe a fever.  It requires oral antibiotics, or often IV (especially for persons with severe diabetes & the immunocompromised.

Otitis Media (OM) vs. Otitis Externa (OE)  —  How can we tell the difference when the canal is so full of drainage that we can’t see the ear drum?

  • History of ear pain relieved when drainage began (usually pus/bloody) =  OM
  • Pus / bloody discharge =   OM
  • Chronic pus / bloody drainage =  Chronic OM [usually painless due to ruptured ear drum]
  • Tenderness with manipulation of pinna / tragus =  OE
  • Acute onset pain & no tenderness with manipulation of pinna / tragus =  likely OM
  • Cellulitis around external ear =  severe (“malignant”) OE

Ceruminosis (too much Wax)  —  And if the ear canal is full of wax (cerumen)?  That’s probably the cause of discomfort in & of itself — washing the wax out both makes a diagnosis while providing treatment.  Even though the onset of pain begins once cerumen builds up to a certain point, the severity is much less than acute OM.

“Wax,” by the way, is nothing more than normal dead skin cells accumulating in the ear canal.  Some people just seem to get too much.  It’s normal, so there’s no such thing as “dirty ears.”

We usually wash out the wax, but shouldn’t do this if there’s already a ruptured ear drum.  A history of chronic drainage on & off might suggest this.  Problem is, moist cerumen can ooze on & off, mimicking drainage.  But if it’s mixed with blood or keeps staining the pillow, I’d beware.

Of course, we tug on & wiggle the tragus & pinna to be sure there’s no coincidental OE.  And of course, we stop the ear-wash if it evokes pain, vertigo, or nausea.

Boil  —  A tiny staphylococcal abscess, also called a “furuncle,” can cause ear pain if it occurs in or right near the ear canal.  It’s usually easy to see by looking in the ear.  The boil may well need to be drained by an ENT specialist, though small ones can resolve with oral antibiotics for Staph.

Any growth in the ear canal needs careful follow-up, since skin cancers occur there on rare occasion.

Mastoiditis  —  A complication of acute or chronic Otitis Media, it’s very rare today, I’ve only seen it once.  Tapping the temporal bone right behind the ear would be quite tender; many patients might have fevers (it’s a bone infection).

Sore Throat  —  Pain from the back of the throat can sometimes be felt in the ear (they’re very close in terms of anatomy).  I had one patient who only had right ear pain, nothing else.  His ear was completely normal.  I looked in the throat, there was a tiny blister; when I touched it with a tongue depressor, he screamed & grabbed his ear.

“Everything’s Normal” 

a.k.a. “You don’t have anything.”  That’s not a nice thing to say to a patient, who wouldn’t have spent time / money if they felt well.  Actually, even if the exam is normal, there are a couple of conditions that actually are something.

Eustachian Tube Dysfunction  —  This is quite common, perhaps the most common cause of ear pain of all, caused by pressure in the middle ear if the Eustachian Tube closes off (see our Ear Diagram for the anatomy).  This is usually due to a cold or nasal allergies; all of us have experienced it during airplane take-offs & landings.

If you have ear pain, & your provider says “everything’s normal,” ask “Is the TM retracted?”  [“TM” is common medical jargon: abbreviation for “tympanic membrane,” i.e. ear drum].  A “retracted TM” looks pulled back, almost horizontal, because of negative pressure behind it.  Ear discomfort PLUS a retracted TM almost always signifies Eustachian Tube Dysfunction.

I try treating with allergy medications, which in my own personal experience with patients usually help.  I never recommend decongestant pills (some of which are used to manufacture meth), partly because I’ve seen adverse effects (like stroke), but mostly because I know of absolutely no data to suggest they work. Of course, some people swear by them, but any placebo works at times.

I certainly never recommend over-the-counter decongestants in the nose (Afrin, Neo-Synephrine, etc); they work fine, but after 3-4 days the nose is so accustomed that it can be impossible to stop them (see Rhinitis Medicamentosa).  Actually, all allergy medications are now over-the-counter; fine, but expensive.

Herpes Zoster (“Shingles”)  —  The Varicella Zoster Virus that causes chickenpox can reactivate later in life.  In the ear, it can cause “ear pain.”  There’s usually also a paralysis of the face, vertigo, tinnitus (ringing in the ear), or hearing loss.  Ear pain all by itself makes it virtually impossible to identify.

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

Temporal-Mandibular Joint Disorder (“TMJ”)  —  I hate to say it, but I’ve yet to be convinced that this is a real condition.  Sure, patients with Rheumatoid Arthritis, etc., may have frank TMJ involvement, but that’s quite uncommon.

I know a lot of people are content with the diagnosis they’ve been given, but I’ve never read actual proof that there’s true joint disease.  The various diagnostic criteria you might read about, such as clicks & creaks (“crepitus”), also occur in asymptomatic persons.  The most convincing finding to me is tenderness of facial muscles on just one side.  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.  Lots of money gets spent.  Knowing whether a treatment really works is hard because placebos can be powerful.  I wouldn’t refer to a dentist unless I truly suspected dental disease.

See also Ear Pain for the clinician’s condensed thought-process when face-to-face with a patient.

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