Ear pain: think beyond the ear when the drum looks normal

Design

Clinical review

Population

Patients presenting to primary care with ear pain

Primary outcome

Diagnostic approach to primary and secondary otalgia

Effect

Structured history and examination; red flags are persistent, severe or unilateral symptoms

This American Family Physician review, published in September, sets out a structured approach to ear pain in primary care. It divides otalgia into primary causes, arising in the ear, and secondary causes, 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. A focused history and examination usually separates them; persistent, severe or one-sided symptoms are the red flags that warrant further assessment.

The practical value is in the normal-looking ear. When the canal and drum are normal, examine the jaw, teeth, throat and neck before reassuring — and in an adult who smokes or drinks heavily with persistent one-sided ear pain, consider referred pain from the upper aerodigestive tract.

• When the ear examination is normal, examine the temporomandibular joint, teeth and neck.
• Persistent, severe or one-sided ear pain is a red flag that needs further assessment.
• In adults with persistent unilateral otalgia and a normal ear, consider referred pain from the throat or larynx.
• Treat infective causes specifically rather than with blanket antibiotics.

Why it matters

Referred otalgia is common and a normal ear is often taken as reassurance, when it should prompt a wider look.

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