Differential Diagnosis for Sharp Pain Behind the Ear

The patient presents with sharp pain behind the ear, but the ear exam is normal. This scenario requires a broad differential diagnosis to cover various potential causes. The differential diagnoses can be categorized as follows:

• Single Most Likely Diagnosis

  • Temporomandibular Joint (TMJ) Disorder: This is a common cause of sharp pain behind the ear, especially if the pain is exacerbated by jaw movement or if there is a history of teeth grinding or clenching. The normal ear exam supports considering TMJ disorder as the pain can be referred from the joint.

• Other Likely Diagnoses

  • Occipital Neuralgia: Inflammation of the occipital nerve can cause sharp, stabbing pain in the back of the head and behind the ear. This condition can be diagnosed based on clinical presentation and response to treatment.
  • Cervicogenic Headache: Referred pain from the cervical spine, particularly from the C2-C3 facet joint, can cause pain behind the ear. This diagnosis should be considered if there is a history of neck trauma, strain, or if the pain is accompanied by neck stiffness.
  • Mastoiditis: Although the ear exam is normal, mastoiditis (inflammation of the mastoid part of the temporal bone) can cause pain behind the ear. Early in the disease, the ear exam might not show significant abnormalities.

• Do Not Miss Diagnoses

  • Meningitis: Although less likely with a normal ear exam, meningitis can cause severe headache and neck stiffness. It's crucial to consider this diagnosis, especially if the patient has fever, confusion, or severe headache.
  • Temporal Arteritis (Giant Cell Arteritis): This condition can cause headache and pain in the temple area, which might be referred behind the ear. It's essential to consider this diagnosis in older adults, especially if there are symptoms like jaw claudication or visual disturbances.
  • Stroke or Transient Ischemic Attack (TIA): Pain behind the ear can be an atypical presentation of a stroke or TIA, especially if accompanied by other neurological symptoms like weakness, numbness, or difficulty with speech.

• Rare Diagnoses

  • Eagle Syndrome: This is a rare condition caused by an elongated styloid process or calcified stylohyoid ligament, leading to sharp pain in the side of the face and behind the ear.
  • Otosclerosis: A condition that affects the middle ear, leading to hearing loss, but in some cases, can cause pain behind the ear due to involvement of the otic capsule.
  • Trigeminal Neuralgia: Although typically causes facial pain, in rare instances, the pain can be referred behind the ear, especially if the third division of the trigeminal nerve is involved.