Ear pain (otalgia) is a common complaint for adults and is seen even more often in children. It is important for the cause of ear pain to be uncovered, because this symptom can be due to many conditions ranging from mild to very serious.

Pain presenting in the ear can have a direct cause or be due to referred pain from another area that radiates to the ear. Some of the more common direct causes of ear pain include:

• Middle-ear infections
• Swimmer’s ear (outer-ear infection)
• An infected cyst
• Pressure, often from flying or diving
• Trauma
• Tinnitus (ringing in the ears)
• A foreign object lodged in the ear canal

Indirect causes include:

• Dental problems
• TMJ disorder
• Cranial neuralgias
• Sinus problems
• Temporal arteritis
• Osteoarthritis in the jaw

Treatment for ear pain depends on the cause. For bacterial infections, antibiotics are often prescribed along with pain relievers. For more serious problems, an ear, nose and throat (ENT) physician may need to be consulted. At times, procedures such as surgery or injections are needed.

Many causes which result in ear pain may be difficult to prevent. However, it is important to take precautions in loud environments, such as concerts, and to keep objects out of the ear canal, including cotton swabs.

Ear pain (otalgia) can be a common problem for adults and children alike. However, children are much more prone to developing ear pain than adults because of the anatomy of their developing ear structure.

Ear pain is not a disease, but rather a symptom that can result from numerous causes. It is important to identify the underlying cause of ear pain, rather than simply taking antibiotics or analgesics to alleviate the pain.  

The ear can be anatomically divided into three main areas – the outer ear, the middle ear and the inner ear. They all work together to provide proper hearing and balance.  The outer ear captures sound waves, which are converted to vibrations (energy) and then are passed to the inner ear. The inner ear, in turn, converts the energy into nerve impulses, which then travel to the brain.

The middle ear has a small canal that opens up in the back of the nose. This tiny passageway is known as the eustachian tube. Its purpose is to equalize pressure between the middle ear and the surrounding environment. At times, bacterial or viral infections develop by spreading through this eustachian tube into the middle ear. When this occurs, the infected area may fill with pus or fluid and lead to a buildup of pressure, which causes pain and sometimes a temporary loss of hearing.

Ear pain can have a direct cause or an indirect cause (pain from another region of the body is referred to the ear). For instance, direct causes of ear pain may include acute otitis externa (swimmer’s ear), which occurs when water becomes trapped inside the external portion of the ear canal resulting in inflammation, or injury to the ear (e.g., from use of cotton swabs). Indirect causes of ear pain may include dental problems, tonsillitis or sinusitis.

It is not uncommon to have associated symptoms, such as vertigo, disequilibrium or dizziness, with ear pain in adults.  

Ear pain is not a disease, but rather a symptom that can result from numerous etiologies (causes). To determine the underlying cause of the ear pain, a physician will review the patient’s medical history and perform a physical examination. This may include the use of an otoscope, which is a device that can visualize the external ear canal and the tympanic membrane.

The causes of ear pain are often divided into two general categories – direct and indirect (referred pain from another region of the body that radiates to the ear). Common direct causes of ear pain include:

• Acute otitis media. This infection of the middle ear is a common complaint, especially among children. Often the ear pain is severe and may be accompanied by fever and hearing deficits. Although this pain can be intense, it often lasts less than 48 hours. According to the American Academy of Pediatrics, acute otitis media is the most common form of bacterial illness in children.

Recent research suggests that many of these infections involve viruses (which do not respond to antibiotics), as well as bacteria. Repeat ear infections that become resistant to conservative treatment in children may require surgery by an ear, nose and throat (ENT) physician. 

Acute otitis media in rare cases can cause osteomyelitis, an infection that spreads into the skull’s mastoid bone (mastoiditis). Mastoiditis was once a leading cause of death in children; however, this has diminished significantly since the development of antibiotics, according to the National Institutes of Health.

• Acute otitis externa (acute external otitis). Also known as swimmer’s ear, this is the result of water trapped inside the external portion of the ear canal which leads to inflammation and infection, resulting in pain. It can also be due to skin conditions such as eczema, psoriasis or acne.
  
  
• Malignant otitis externa (malignant external otitis). When ear pain continues despite treatment, it may indicate a persistent infection that has spread beyond the ear canal into the skull (osteomyelitis). Malignant otitis externa can occur more commonly in people with diabetes and in those with impaired immune systems due to conditions such as acquired immune deficiency syndrome (AIDS). It is a rare but serious form of external otitis that is potentially fatal.
  
  
• Barotrauma. Ear pain caused by differences in pressure between the inside and the outside of the eardrum (tympanic membrane). Painful pressure can build up in the middle ear during flying or scuba diving, for example. This pressure causes the eardrum to stretch, leading to moderate to severe ear pain.
  
  
• Infected cyst within the ear canal. An infected cyst inside the ear canal is often due to a clogged hair follicle or gland. These cysts can grow large enough to block the entire ear canal.
  
  
• A foreign body lodged in the ear. Countless objects have been found lodged in the external part of the ears (e.g., beads, paper clips, insects), usually by a child. The treatment is careful removal of the object.
  
  
• Injury to the ear. A trauma injury to the ear can lead to swelling, tenderness, pain and possibly a ruptured eardrum. Although swelling normally continues to increase over the next 24 to 48 hours after the injury, it usually subsides afterward.
  
  
• Tinnitus (ringing in the ears). Though more annoying than painful, this condition can disrupt a person’s life. The American Tinnitus Foundation estimates that 12 million Americans have tinnitus severe enough to seek medical help. Causes include noise, buildup of earwax (cerumen), infections, TMJ disorder, Meniere’s disease (vertigo) and certain medications, including aspirin. 
  
  
• Cancer of the ear or its structures. Skin cancers can occasionally occur within the ear canal, namely squamous cell carcinoma or basal cell carcinoma. Although they rarely cause pain during their initial stages of growth, these cancers can spread (metastasize) to the skull or other nearby structures, which may result in severe ear pain.

Some common indirect causes of ear pain include:

• TMJ disorder. This condition can cause a number of symptoms, including ear pain, headache, neck pain, upper back pain, shoulder pain and pain in the temporomandibular joint of the jaw.
  
  
• Dental problems. Often, an early sign of dental problems can be pain in one or both ears, as toothaches and other dental disorders can occasionally radiate into the ears.
  
  
• Eustachian tube dysfunction.  This tube is a connection between the ear and throat.   Any dysfunction or swelling, such as from a sore throat, can cause a blockage in this tube, increasing the pressure in the ear and thus causing pain.
  
  
• Neuralgia. Disorders of certain nerves in the region of the ear can result in pain in and around the ears. These include certain cranial neuralgias, such as laryngeal neuralgia or nervous intermedius neuralgia. The most common form of neuralgia is postherpetic neuralgia, which is caused by the same virus responsible for chickenpox and shingles (varicella-zoster virus). It can damage the cranial nerves (Herpes zoster oticus) and result in ear pain. Occipital neuralgia can cause neck pain, headache and pain behind the ears.
  
  
• Bell’s palsy. Damage to a facial nerve can result in temporary paralysis or weakness, which usually occurs on only one side of the face. Bell’s palsy sometimes causes tinnitus or pain behind the ear. Risk factors for Bell’s palsy may include meningitis, sarcoidosis, diabetes and autoimmune disorders such as lupus. For more information, see Bell’s Palsy.
  

• Sinusitis. This condition involves inflammation of the membrane within the sinus cavities that are in the facial bones. Although headaches and eye pain are more common, at times sinusitis can lead to moderate or severe ear pain as well.
  
  
• Arthritis. Osteoarthritis, infectious arthritis or another form of arthritis in the articulating joints of the jaw could be a cause of ear pain.

• Surgery for tonsillitis. When tonsils are removed, ear pain is a common complaint for the first few days after the procedure.
  
  
• Ramsay Hunt syndrome. Ear pain is a common sign of this syndrome, which is caused by a facial nerve infection. The pain is caused by fluid-filled blisters on the eardrum, external ear canal, external ear and, at times, the roof of the mouth. This neurological disorder is the result of the herpes zoster (shingles) virus.
  
  
• Temporal arteritis. This is an inflammation of the large arteries, most often the temporal arteries of the side of the head. Patients experience facial pain and may also suffer eye, ear or dental pain.  If this disorder is suspected, urgent medical treatment is necessary.
  
  
• Cancer of the oropharynx or larynx. Cancer in the oropharynx (the part of the throat located below the soft palate) or larynx (voice box) may cause symptoms of a sore throat or ear pain. Bone cancer in a nearby structure could also be a cause of referred ear pain.

Most of the conditions causing ear pain can be diagnosed by a medical history and a physical examination. The physician will likely use a hand-held otoscope to inspect the ear canal.

Ear secretions may be collected on a swab for analysis. Usually inflammation and infection of the middle and external ear can be identified visually with the otoscope. Rarely, blood tests such as sedimentation rate or complete blood count may be performed to reveal inflammation or infection.

If a nerve condition such as cranial neuralgia is suspected, tests such as electromyography or nerve conduction studies may be ordered. A tissue biopsy or imaging tests such as a CAT scan (computed axial tomography), MRI (magnetic resonance imaging) bone scan or x-rays may be used to diagnose uncommon conditions such as cancer or malignant otitis externa.

If necessary, a primary care physician can refer a patient to an ear specialist (otologist) or an ear, nose and throat (ENT) specialist (otolaryngologist).

The relief options for ear pain depend on the underlying cause. A physician should be consulted if the ear pain increases, is accompanied by other symptoms such as hearing loss and dizziness, or radiates into the temple or neck. Depending on the cause of the ear pain, possible treatment methods may include:

For many indirect causes, there is no way to prevent ear pain. However, for some direct causes, steps can be taken to decrease the likelihood of ear pain. Precautions in loud environments, such as concerts and noisy workplaces, as well as keeping objects out of the ear canal, can help to decrease the risk of subsequent pain in the ear. Workers exposed to loud noises, such as at construction sites or airports, should use adequate ear protection.

To help reduce the incidence of ear pain due to ear infection in children, parents may want to consider the following suggestions:

• Choose a child-care facility with fewer children.
  
  
• Avoid exposure to secondhand smoke.
  
  
• Choose breastfeeding over bottle feeding.
  
  
• Avoid bottle feeding young children while they are lying on their back.
  
  
• Reduce or eliminate the use of a pacifier.
  
  
• Control a child’s allergies as much as possible.
  
  
• Ensure that vaccinations, including the flu vaccine, are up to date.
  
  
• Have the child wash hands frequently, especially during cold and flu season.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients (or parents) may wish to ask their doctor the following questions about ear pain:

1. What do you think is causing my ear pain?
   
   
2. Are there any other possible causes for my ear pain?
   
   
3. What is the expected course of my condition?
   
   
4. What medication may be prescribed for my ear pain?
   
   
5. How and when do I take this drug?
   
   
6. What are the possible side effects of my medication?
   
   
7. Can I take a pain reliever with the prescribed medication?
   
   
8. Could I need surgery or other invasive treatments?
   
   
9. Will I need to see an ear specialist?
   
   
10. Is there any home treatment method I can use instead of medication?
    
    
11. Is the cause of my ear pain preventable?