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Causes of the Mystery Ear Pain (Otalgia)

by , last modified on 6/25/21.

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There are many possible causes of pain in or around the ear although most patients and even physicians can think of only a few causes. Those causes being allergies, earwax or ear infection, whether it be a middle ear infection (otitis media) or Swimmer's ear (otitis externa). A few may even think of eustachian tube dysfunction as a possible cause of ear pain. As such, patients are often put on repeated doses of antibiotics, anti-histamines, nasal decongestants, and nasal sprays. In a certain percentage of patients, these medications do NOTHING to help with their ear pain/discomfort. Even tube placement in the ears fail to help. Out of desperation, some patients resort to unproven homeopathic medications.

Why does treatment targeting the ear not help? What most people do not realize is that otalgia (medical term for ear pain) may be due to problems totally remote from the ear itself. Indeed, many new parents realize that at least in children, new teeth coming out causes a child to dig or tug on his/her ears, though the ears themselves are completely normal. Indeed, this particular cause of otalgia is due to Cranial Nerve 5 that transmits pain involving the jaw to the ear itself. Sometimes the pain/discomfort is due to a non-biologic trigger, like cell phone use (read more about this here). There are many other examples of non-ear causes of otalgia.

How is it possible that a problem elsewhere in the head and neck causes ear pain??? The main reason is due to referred pain secondary to the numerous nerves that go to the ear from problems found elsewhere in the head and neck. Listed below are the nerves and the most common reasons that produce a particular type of ear pain/discomfort. As one may realize from reading the descriptions, the precise area where the ear pain is felt can lead one to focus on a particular region of the head and neck.

Nerve Where Discomfort Usually Felt Diagnosis of the Ear Pain
C2, C3, C4 spinal nerves (Great Auricular & Lesser Occipital Nerve) Discomfort mainly over the mastoid cervical spine disc disease (ie, sciatica), whiplash, cervical meningiomas, tendonitis of the sternocleidomastoid muscle
Cranial Nerve 7 (Posterior Auricular Nerve) Discomfort mainly behind the ear cerebellar pontine angle tumors, geniculate neuralgia
Cranial Nerve 5 (Auriculotemporal Nerve) Discomfort mainly in the front aspect of the ear TMJ, dental problems, parotid gland tumors/infection
Cranial Nerve 9 (Jacobson's Nerve) Discomfort directly deep in the ear Tonsillitis, Sinusitis, pharyngeal tumor, adenoiditis, eustachian tube dysfunction
Cranial Nerve 10 (Arnold's Nerve) Discomfort directly in the ear, but more ear canal type pain GERD (reflux), throat tumors, lingual tonsillitis

At least 40% of patients presenting to our ENT office with the chief complaint of ear pain is found NOT to have ear infections, but rather some other non-ear issue causing their otalgia. In a primay care office, that number is probably lower.

The most common causes of non-ear otalgia overall are:

  • Musculoskeletal involving either the sternocleidomastoid muscle or cervical spine arthritic changes
  • TMJ (Watch Video): Interestingly, 55.1% of patients with TMJ specifically describe ear pain
  • Tonsillitis
  • Eustachian Tube Dysfunction
  • Throat problems (infection or tumor)

When it comes to a pinched nerve of the cervical spine causing ear pain, the culprit level can be determined by the pain distribution. Take a look at the pictures below. Each color corresponds to a specific nerve involvement, but the key point is that cervical levels C2-5 is responsible for pain in these regions. Other hints that point towards a cervical spine etiology include presence of posterior neck pain, increased pain with head movement, pain that is worst during the night and may even wake from sleep, pain worst first thing in the morning, and/or pain that can be triggered by pressing along the cervical spine. Keep in mind that absence of these symptoms do not rule-out cervicogenic ear pain.

The best doctor to see if this constellation fits your symptoms is a neurologist or cervical spine specialist.

SO, how does one go about figuring out a patient's ear pain if he/she does not appear to have an ear infection on exam? Really, one needs to perform a comprehensive head and neck exam, including examination of the nasal cavity, oral cavity, neck, cervical spine and TMJ. Finger palpation of the tonsil and base of tongue region is a quick and dirty way to figure out hidden oral cavity and throat causes of ear pain. Your ENT may perform fiberoptic endoscopy to more closely examine the nose and throat hidden from direct view. Radiologic exams such as CT or MRI may even be ordered as well.

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The key thing to remember, however, is that not all ear pain is caused by ear problems and that pretty much any problem of the head and neck may produce ear pain as a patient's ONLY complaint. Key questions on history that are helpful to guide diagnosis include:

  • When did it start?
  • How long does the pain last (all the time, a couple hours, a couple seconds, etc)?
  • Is it intermittent or continuous?
  • What does the pain feel like exactly (sharp, pressure, itchy, burning, etc)?
  • Exactly where in/around the ear does the pain occur (deep in ear, behind ear, below ear, etc)?

If a thorough workup by your primary care as well as general ENT has been obtained and still no cause for ear pain has been found, an evaluation by an experienced rheumatologist, neurologist, spine specialist, and neuro-otologist may be the next steps to take. Not uncommonly, the ear pain may end up being due to a condition called trigeminal migraine, an atypical migraine headache centered over the ear region. Check out this video on all the different possible causes of pain involving the face including the ear.

Recognized experts in the mystery ear pain are neuro-otologic surgeons. Click here to see a list.

Watch Time-Lapse Video of an Ear Infection


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