Ear Pain (Otalgia) - Differential Diagnosis Framework



Primary Otalgia 

 - Pain that originates from the ear

 - Pain that is continuous and progressively worsens is more likely to be associated with infection and primary otalgia

Most Common Causes of Primary Otalgia:

	• Otitis media

	• Otitis externa

Mechanical Causes of Primary Otalgia:

	• Barotrauma

	• Eustachian tube dysfunction

	• Foreign object

	• Cerumen impaction

Infectious Causes of Primary Otalgia:

	• Otitis externa - Caused by bacterial infections (90%), Fungal infections (10%)

	• Otitis media:

		- Streptococcus pneumoniae

		- Moraxella catarrhalis

		- Haemophilus influenzae

	• Bullous myringitis

	• Malignant otitis externa

	• Cellulitis of auricle

	• Mastoiditis

	• Viral myringitis

	• Cranial nerve VII:

		- Ramsay Hunt syndrome

		- Herpes zoster

Neoplastic Causes of Primary Otalgia:

	• Cholesteatoma

	• Basal/squamous cell CA

	• Melanoma

Inflammatory Causes of Primary Otalgia:

	• Granulomatosis with polyangiitis

	• Relapsing polychondritis - Relapsing, bilateral, erythematous or violaceous opacification on the external ear, sparing the ear lobes





Secondary Otalgia:

 - Pain that originates outside the ear

 - Intermittent pain is likely to be associated with secondary otalgia

Most Common Causes of Primary Otalgia:

	• Temporomandibular joint syndrome

	• Dental infections		

Cranial Nerve V:

	• TMJ syndrome

	• Dental infections (caries, abscess, pulpitis)

	• Trigeminal neuralgia

	• Sinusitis

	• Mandibular osteomyelitis

	• Tumor

Cranial nerve IX can refer pain:

	• Tonsillitis

	• Pharyngitis

	• Pharyngeal tumor

	• Glossopharyngeal neuromas

Vagus nerve (irritation):

	• Myocardial ischemia causing otalgia

C2 and C3 cervical nerve roots—cervical spine degeneration:

	• Tumor

	• Infection

	• Inflammatory process

Temporal arteritis should be considered in patients 50 years or older who have normal ear examination findings and any of the following symptoms: headache, malaise, weight loss, fever, or anorexia

Other Causes of Secondary Otalgia:

	• Carotidynia

	• Cervical adenopathy

	• Cervical spine arthritis

	• Cricoarytenoid arthritis

	• Gastroesophageal reflux

	• Head and neck tumors

	• Musculoskeletal: myofascial pain, torticollis, cervical disc degeneration, cervical radiculopathy

	• Oral aphthous ulcers

	• Thyroiditis (rarely causes isolated otalgia), thyroid carcinoma

	• Thoracic aneurysms

	• Other rare causes (subdural hematoma, lung cancer, central line placement, carotid artery aneurysm, Pott puffy tumor)

	• Lymph node: lymphadenopathy, lymph node malignancies

	• Gastrointestinal disease: gastroesophageal reflux disease (GERD), esophageal carcinoma

	• Sialadenitis (infection of salivary gland duct), sialolithiasis (salivary duct stones), salivary gland tumor



Clues In History To Narrow Down Ddx:

	• Pain location

	• Duration

	• Aggravating factors

	• Alleviating factors

	• Associated symptoms

	• Previous episodes

	• Medical history

	• Smoking status

	• Alcohol abuse

Red Flags:

	• Dysphagia

	• Odynophagia

	• Dysphonia

	• Hemoptysis

	• Loss of vision or black spots

	• Unintended weight loss

Physical Exam:

	• Traction on the auricle

	• Palpation of the tragus to differentiate disease processes affecting the external ear and ear canal

	• Otoscopic examination

	• Oral exam

	• TMJ

	• Head, neck, nasal, cervical spine



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