Acute Epiglottitis: This condition is characterized by inflammation of the epiglottis, which can cause severe pain when swallowing, referred pain to the ear due to the common nerve supply, and hoarseness due to the proximity of the epiglottis to the vocal cords. The combination of these symptoms makes acute epiglottitis a strong candidate for the single most likely diagnosis.

Peritonsillar Abscess: Although more commonly associated with tonsillar pain, a peritonsillar abscess can cause referred pain to the ear and, if large enough, can affect the swallowing mechanism and vocal cord function, leading to hoarseness.
Strep Throat (Streptococcal Pharyngitis): Severe cases can lead to significant throat pain, difficulty swallowing, and, less commonly, hoarseness. The referred pain to the ear can occur due to the involvement of the nerves that supply both the throat and the ear.
Laryngitis: Inflammation of the larynx can cause hoarseness and, if severe, can lead to pain when swallowing. Referred pain to the ear is possible due to the shared nerve pathways.

Laryngeal Cancer: Although less common, laryngeal cancer can present with hoarseness, pain when swallowing, and referred ear pain. Given the potential severity of this diagnosis, it is crucial not to miss it.
Epidural Abscess: A collection of pus in the epidural space surrounding the spinal cord can lead to severe pain, including pain when swallowing, and neurological deficits. The referred pain to the ear and potential for hoarseness due to nerve involvement make this a critical diagnosis not to overlook.
Retropharyngeal Abscess: An abscess in the retropharyngeal space can cause severe pain when swallowing, referred pain to the ear, and, due to its proximity to the airway, can lead to respiratory distress and potentially affect vocal cord function.

Glossopharyngeal Neuralgia: A rare condition characterized by recurrent episodes of severe pain in the tongue, throat, ear, and area of the jaw, which can be triggered by swallowing. It's less likely but should be considered in the differential diagnosis of painful swallowing with referred ear pain.
Stylohyoid Syndrome: Involves the stylohyoid ligament and can cause pain when swallowing, referred ear pain, and, in some cases, hoarseness due to the anatomical relationship with the hyoid bone and surrounding structures. It is relatively rare and often overlooked.