A clinical review sets out a structured approach to otalgia, one of the commoner reasons a patient presents in primary care. It separates primary otalgia, arising from the ear (acute otitis media, otitis externa, eustachian tube dysfunction), from secondary, referred otalgia, where the ear looks normal and the source is elsewhere.
The common referred causes are dental pathology, temporomandibular joint disorders and cervical spine problems, so a normal ear examination should redirect the search rather than end it. A focused history and examination guide benign management, with targeted treatment of the infection or structural cause.
The safety message is in the red flags: persistent, severe or unilateral ear pain, particularly with a normal ear, warrants further assessment for serious causes, including malignancy in older patients with risk factors. The practical habit is to examine the ear, mouth, teeth, jaw and neck, and to escalate rather than re-treat when symptoms persist.
- Separate primary (ear-origin) from secondary (referred) otalgia at the first visit.
- A normal ear exam should redirect the search to teeth, jaw and cervical spine.
- Red flags are persistent, severe or unilateral pain, especially with a normal ear.
- Examine ear, mouth, teeth, jaw and neck in every case of ear pain.
- Escalate persistent symptoms rather than repeating a course of treatment.
Why it matters
A normal otoscopy does not exclude a serious cause; referred otalgia and malignancy are missed when the search stops at the ear.
Don't overread it
This is a narrative review summarising established practice, not new trial evidence.
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