This American Family Physician review (September 2026) divides otalgia into primary — arising in the ear — and secondary, referred from elsewhere. Acute otitis media, otitis externa and eustachian tube dysfunction are the common primary causes. Temporomandibular joint disorders, dental disease and cervical spine problems are the common secondary ones.
The approach it recommends is a focused history and examination, targeted treatment for clear infections or structural causes, and further assessment when findings are concerning or symptoms persist. Persistent, severe or unilateral pain is the principal red flag for a serious cause.
For a family physician, the key moment is the patient with ear pain and a normal ear. That is when to examine the teeth, bite and jaw, and the neck — and, in an older smoker or drinker with unilateral pain, the throat, because referred otalgia can be the first symptom of a head and neck cancer.
- Examine the ear first; if the drum and canal are normal, the pain is probably referred.
- Check teeth and gums, press over the temporomandibular joint and ask about clenching or grinding.
- Examine cervical spine movement in patients with neck pain or stiffness alongside the earache.
- Unilateral ear pain with a normal ear in an older smoker or drinker needs examination of the throat and a low threshold for ENT referral.
- Persistent or severe pain despite treatment is a red flag and warrants reassessment.
Why it matters
Antibiotics for 'otitis' with a normal drum miss the real cause, and occasionally a cancer.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for family medicine, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free