The ear can be divided into three parts: an outer part of skin, bone and cartilage, an air-filled middle ear and a fluid filled inner ear. It is concerned with hearing and balance and is very sensitive to pain. There are two broad categories of pain: Primary and Secondary pain. When ear pain originates within the ear, it is labeled primary or intrinsic pain. When it originates outside the ear, it is called secondary or extrinsic and more commonly labeled referred ear pain.
Pain (otalgia) is a symptom that makes patients rush to doctors to seek medical help. Primary ear pain due to infections of the outer or middle ear is common and readily diagnosed upon examination by your doctor. But, as noted above, not all ear pain originates within the ear. Referred ear pain poses more of a challenge to properly diagnose and treat since the source of pain is “hidden” at a distance from the ear.
An 18 y/o university student complains of jabbing ear pain with no other symptoms and normal findings upon ear examination. A 53 y/o iron worker complains of a sore throat and left ear pain for several months. The hearing is fine and examination of the ear is normal. A 5 y/o child wakes up in the middle of the night screaming of ear pain after a tonsillectomy. The child needs motherly reassurance and analgesics, the university student requires a dental consultation and the iron worker needs cancer surgery — What’s going on?
The ear is supplied by cervical nerves C2, C3 (located in the back of the neck) and cranial nerves V, VII, IX and X that send pain sensitive nerves to the front, back and inner parts of the ear. (1)
In children, ear infections are primarily the cause of otalgia and the eardrum is abnormal in appearance. In adults, referred ear pain is more often the culprit and with few exceptions the eardrum is normal in appearance.
Many disorders produce referred ear pain because of infections, tumors and trauma. The diffused sensory innervation of the ear is susceptible to such disorders.
Below are: The Ten “T’s” of Referred Otalgia (2)
Teeth: Impacted wisdom teeth, caries, infant teething.
TMJ: Temporomandibular Joint Disease
Tubal Area: Eustachian tube dysfunction, nasopharynx (area behind the nose (rule out tumor).
Tonsils: Infection, tumors.
Throat: Infections, tumors of pharynx, larynx (voice box).
Tongue: inflammation, tumor.
Trachea: (windpipe), Larynx (voice box).
Thyroid gland: infections, tumors.
Temporal Arteritis: inflammation of the artery above the ear.
Trauma
The above is not intended to be a complete list. For example, Gastro-esophgeal Reflux Disease (GERD), Trigeminal Neuralgia, Parotid Tumors can refer pain to the ear.
The majority of ear pain is benign, but the patient and especially the physician must be aware of this “hidden” pain that can be life threatening.
- V (5) Trigeminal nerve; VII (7) Facial nerve; IX (9)Glossopharyngeal nerve; X (10) Vagus nerve.
- Collected Letters of Otolaryngology.