Ear Pain (Otalgia) — Causes and When to Worry

Why Does My Ear Hurt?

Otalgia is the medical term for ear pain. It can be sharp, dull or burning, affect one ear or both, and last anywhere from a few hours to many weeks.

The single most useful thing to understand about ear pain is that it does not always come from the ear. Clinicians divide it into two categories, and which one you have completely changes what needs to be done:

• Primary otalgia — the pain originates from a disease within the ear itself.
• Referred (secondary) otalgia — the ear is entirely healthy, and the pain is coming from somewhere else in the head or neck.

This matters more than it might appear. If your ear is examined and looks completely normal, that is not a dead end — it is a significant clinical finding that redirects the search to the teeth, jaw, throat or neck. And in adults, persistent one-sided ear pain with a normal ear examination is a recognised warning sign that must be taken seriously.

Primary Otalgia — Problems Inside the Ear

Primary ear pain is best organised by anatomy, working from the outside inward.

The pinna (outer ear)

The visible ear is cartilage covered by thin skin, and is exposed to everything.

• Trauma — tears and lacerations from injury or sport
• Haematoma — a collection of blood under the covering of the cartilage after blunt trauma, which needs prompt drainage to prevent permanent deformity
• Perichondritis — infection of the ear cartilage, often following a high piercing or an untreated outer ear infection. It causes severe pain and redness while characteristically sparing the earlobe, which contains no cartilage
• Frostbite or sunburn — the upper rim of the ear is highly exposed and easily burned
• Tumour

The external auditory canal

Warm, narrow and dark — an environment that rewards infections and punishes interference.

• Impacted ear wax — excessive or hardened wax, very often pushed deeper by cotton buds. Causes a dull ache, blocked sensation and muffled hearing. See our guide to safe ear wax removal
• Foreign body — cotton bud tips, beads and seeds in children, insects in adults. What to do is covered in foreign body in ear, nose or throat
• Furunculosis — a boil in a hair follicle in the outer canal. Small, but disproportionately painful, especially when the ear is touched or pulled
• Otitis externa — diffuse bacterial infection and inflammation of the canal skin, classically after swimming. Intense pain, swelling and discharge
• Otomycosis — fungal infection of the canal, common in humid climates. Intense itching with a thick, velvety discharge
• Herpes zoster oticus — viral infection producing severe burning pain with blisters in the canal or on the pinna, often with facial weakness
• Tumour

Both bacterial and fungal canal infections are covered in more detail in ear infections — otitis media and externa explained.

The middle ear

Behind the eardrum, connected to the back of the nose by the eustachian tube.

• Acute otitis media — acute bacterial infection of the middle ear, usually following a cold. Intense throbbing pain and fever
• Secretory otitis media — fluid collection behind the eardrum from eustachian tube dysfunction. More pressure and dullness than sharp pain
• Chronic otitis media — long-standing middle ear disease, often with chronic ear discharge
• Otitic barotrauma — injury from rapid pressure change, typically during air travel or diving
• Traumatic perforation — rupture of the eardrum. See ear drum perforation
• Haemotympanum — blood collected in the middle ear
• Neoplasm

The mastoid

The honeycomb of bone directly behind the ear.

• Mastoiditis — infection spreading from the middle ear into the mastoid bone. Deep throbbing pain with redness, swelling and tenderness behind the ear, sometimes pushing the pinna forward. This is a serious complication requiring urgent treatment
• Mastoid abscess — a collection of pus behind the ear
• Neoplasm

The inner ear

• Noise injury — excessive noise exposure damages the inner ear
• Neoplasm

Inner ear conditions more often cause dizziness, tinnitus or hearing loss than frank pain.

Referred Otalgia — When the Ear Is Not the Problem

Referred ear pain is labelled as such when the ear examination is entirely normal. The pain is real; its source is elsewhere.

The reason this happens is anatomical. The ear receives sensory supply from an unusually large number of nerves — branches of the trigeminal, facial, glossopharyngeal and vagus nerves, plus the upper cervical nerves. Each of these also supplies other structures in the head and neck. Irritation anywhere along those shared pathways can be interpreted by the brain as pain in the ear.

Common sources of referred otalgia:

Reflux is another frequent contributor — laryngopharyngeal reflux irritates the throat and eustachian tube openings and can produce persistent dull ear discomfort alongside throat clearing and hoarseness.

Jaw-related causes are among the most common of all. If your ear pain is worse when chewing, talking or yawning, and there is clicking or tenderness in front of the ear, the temporomandibular joint is the more likely culprit than the ear itself.

Red Flags — When Ear Pain Needs Urgent Assessment

Most ear pain is benign and settles with appropriate treatment. Some does not, and the following pattern deserves particular attention.

The key red flag: persistent one-sided ear pain in an adult, with a completely normal ear examination.

The vagus and glossopharyngeal nerves supply both the ear and the deep structures of the throat — the tongue base, tonsil, pharynx and larynx. A tumour in any of those sites can, in its early stages, produce ear pain as its only symptom, long before anything is visible or felt in the throat.

This risk is substantially higher in people who smoke, chew tobacco or gutka, or drink heavily — which is why tobacco use and ENT health is directly relevant here.

Seek prompt ENT assessment if ear pain is accompanied by any of:

• Difficulty or pain on swallowing — food sticking, or sharp pain when swallowing
• Hoarseness lasting more than two to three weeks
• A neck lump, even if painless
• Unexplained weight loss
• A non-healing mouth ulcer
• Difficulty opening the mouth fully
• Persistent, unexplained nosebleeds

Also seek urgent care for severe pain with swelling and redness behind the ear, high fever with severe ear pain, sudden hearing loss, facial weakness, or severe pain following head injury.

None of this means ear pain is usually sinister — it is usually not. It means that persistent one-sided pain with a normal-looking ear should be examined properly rather than treated blindly with drops.

Risk Factors

Several habits and circumstances make ear problems considerably more likely:

• Inserting unclean or sharp articles into the ear — cotton buds, hairpins, keys. These scratch the canal, push wax deeper and can perforate the eardrum
• Instillation of contaminated solutions — including unprescribed oils and home remedies
• Swimming in polluted water — a leading cause of otitis externa
• Upper respiratory tract infections — colds cause eustachian tube swelling and middle ear fluid
• Eustachian tube dysfunction
• Allergy

How Ear Pain Is Diagnosed

Diagnosing ear pain often requires only a careful history and physical examination. Imaging and blood tests are needed less often.

History. Expect questions about what the pain feels like, whether it is constant or intermittent, and whether there are associated symptoms — fever, hearing loss, balance problems or dizziness, discharge, or tinnitus. You will also be asked about recent illness and any trauma to the face or ear.

Examination. A detailed examination of the ear, nose and throat — not just the ear. Where the ear looks normal, examination of the teeth, jaw joint, tonsils, tongue base and neck becomes the priority.

Endoscopic examination. A thin flexible endoscope allows the back of the nose, eustachian tube openings, tongue base and larynx to be seen directly. This is the investigation that most often identifies the cause of referred otalgia.

Hearing and balance testing. Audiometry and balance assessment where there is associated hearing loss or giddiness.

Imaging. X-ray, CT or MRI when a deep structural problem, bone infection or tumour is suspected.

Treatment

The underlying cause must be identified first — treating the symptom alone risks allowing the real problem to progress.

Medical treatment includes painkillers and anti-inflammatories, antibiotics for bacterial infection, treatment of the associated cold or allergy, and targeted antibiotic, antifungal or steroid ear drops. Micro-suction under a microscope safely clears impacted wax, debris and fungal discharge — considerably safer than syringing or self-cleaning.

Surgery is considered in specific situations:

• Severe infection of the middle ear and mastoid
• Eardrum perforation requiring repair
• Persistent fluid in the middle ear — grommet insertion
• Tumours or neoplasms

Where the pain is referred, treatment targets the actual source — dental treatment, TMJ management, reflux control or throat treatment as appropriate.

Ear Care at THANC

Ear conditions at THANC are managed through the otology and neuro-otology service, with on-site audiology for hearing and balance assessment.

Because referred ear pain so often originates in the teeth, jaw or throat, assessment is shared where needed with our head and neck surgery and oral and maxillofacial surgery teams — which matters most in exactly the cases where the ear looks normal and the cause lies elsewhere.

Book a consultation if you have ear pain that is persistent, one-sided, or accompanied by any of the red flags above.