A review in American Family Physician, published on 1 September 2026, sets out a structured approach to otalgia in primary care. Ear pain is either primary, arising in the ear, or secondary, referred from elsewhere.
The common primary causes are acute otitis media, otitis externa and eustachian tube dysfunction. The common secondary causes are temporomandibular joint disorders, dental disease and cervical spine problems. A normal ear examination in a patient with ear pain should turn attention to those referred sources.
The authors stress red flags: pain that is persistent, severe or one-sided, particularly with a normal ear, warrants further assessment, because referred pain from the throat or larynx can be the presentation of head and neck cancer. In a short consultation, the structure is what prevents both unnecessary antibiotics and a missed diagnosis.
- Examine the ear first; a normal drum and canal point to a referred cause.
- Check the temporomandibular joint, teeth and neck in ear pain with a normal ear.
- Treat persistent, severe or unilateral ear pain with a normal ear as a red flag.
- Ask about smoking, alcohol, dysphagia, hoarseness and weight loss in older adults with unexplained ear pain.
- Avoid antibiotics for ear pain without signs of infection.
Why it matters
Referred ear pain is often treated as an ear infection, which can delay both a dental diagnosis and a cancer one.
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A narrative review of established practice rather than new evidence.
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