What could be causing facial pain near the left ear?

Facial Pain Near Left Ear: Differential Diagnosis and Management

Facial pain near the left ear requires systematic evaluation to distinguish between primary ear pathology, temporomandibular disorders, neuralgias, and serious conditions like giant cell arteritis or malignancy—with the specific characteristics of the pain (timing, quality, triggers) guiding diagnosis and treatment.

Initial Diagnostic Approach

The key to diagnosis lies in determining whether the ear examination is abnormal (suggesting primary otalgia) or normal (suggesting secondary/referred otalgia) 1, 2. When ear examination is normal, the pain is almost always referred from another source 1.

Critical History Elements to Obtain

• Pain timing: Continuous vs. paroxysmal attacks (lasting seconds to minutes) 3
• Pain quality: Sharp/electric shock-like vs. dull/aching vs. burning 3
• Triggers: Light touch, chewing, swallowing, cold wind, jaw movement 3
• Associated symptoms: Autonomic features (tearing, rhinorrhea), jaw clicking, dental symptoms 3
• Age and risk factors: Age >50 years, smoking, alcohol use, diabetes 1, 2

Most Common Causes by Category

Temporomandibular Joint (TMJ) Disorders

TMJ syndrome is the most common cause of referred pain to the ear region 3, 1, 4. Look for:

• Pain radiating to periauricular area, temple, or neck 3
• History of gum chewing, bruxism, or recent dental procedures 3
• Tenderness over the TMJ with possible crepitus on examination 3
• Management: Early diagnosis with reassurance and simple physiotherapy is often effective; dentists may provide night splints 3

Glossopharyngeal Neuralgia

This condition specifically presents with unilateral deep ear pain and is frequently confused with TMJ disorders 3:

• Paroxysmal attacks lasting 2 seconds to minutes 3
• Sharp, shooting, electric shock-like quality 3
• Triggered by swallowing, coughing, or touching the ear 3
• May involve back of tongue, tonsils, or neck 3
• Rarely associated with syncope due to vagal proximity 3
• Requires MRI imaging 3
• Treatment: Anticonvulsants (same as trigeminal neuralgia); microvascular decompression for refractory cases 3

Trigeminal Autonomic Cephalgias (SUNA/SUNCT)

These can mimic ear pain with distinctive features 3:

• Rapid attacks lasting seconds to several minutes, up to 200 attacks daily 3
• Sharp, stabbing quality 3
• Key distinguishing feature: Autonomic symptoms including tearing, red eye, rhinorrhea, nasal blockage, or ear fullness 3
• Mostly spontaneous but can be triggered by light touch 3
• Treatment: Lamotrigine 3

Acute Otitis Externa

If ear examination is abnormal 3:

• Predisposing factors: Water exposure, trauma, hearing aid use 3
• Furunculosis (localized otitis externa) presents with focal swelling and pustular lesions in outer third of ear canal 3
• Treatment includes local heat, incision/drainage, or systemic antibiotics covering S. aureus 3

Herpes Zoster Oticus (Ramsay Hunt Syndrome)

A critical diagnosis not to miss 3:

• Vesicles on external ear canal and posterior auricle 3
• Severe otalgia with facial paralysis/paresis 3
• Loss of taste on anterior two-thirds of tongue 3
• Requires prompt systemic antiviral therapy and systemic steroids 3

Red Flag Conditions Requiring Urgent Evaluation

Giant Cell Arteritis

Must be considered in any patient over age 50 with temporal/ear region pain 3:

• Continuous dull aching pain 3
• Aggravated by chewing (jaw claudication) 3
• Associated with visual symptoms, malaise, fever, myalgia 3
• Absent temporal pulse, scalp tenderness 3
• Check ESR and C-reactive protein urgently 3
• Refer for temporal artery biopsy within 2 weeks 3
• Start high-dose corticosteroids (minimum 40 mg daily) immediately to prevent blindness 3

Malignancy

Otalgia may be the only presenting symptom of upper aerodigestive tract cancer 3, 2:

• High-risk patients: Smokers, alcohol users, age >50, diabetes, human papillomavirus infection 3, 1, 2
• Requires complete head and neck examination with visualization of mucosal surfaces 3
• Palpation of tongue base and assessment for neck masses 3
• Consider CT, MRI, or fiberoptic nasolaryngoscopy if suspicion exists 1, 2

Management Algorithm

1. Perform ear examination first: Abnormal findings suggest primary otalgia; normal examination suggests referred pain 1, 2

2. If age >50 years: Rule out giant cell arteritis with ESR/CRP before other workup 3

3. Characterize pain pattern:

   • Paroxysmal with ear triggers: Consider glossopharyngeal neuralgia; obtain MRI and trial anticonvulsants 3
   • Paroxysmal with autonomic features: Consider SUNA/SUNCT; trial lamotrigine 3
   • Continuous with TMJ tenderness: Diagnose TMJ disorder; provide reassurance, physiotherapy, consider splint 3

4. If diagnosis unclear after history/examination: Options include trial of symptomatic treatment, imaging studies, or otolaryngology consultation 1, 2

5. Persistent symptoms or high-risk features: Proceed with MRI, fiberoptic nasolaryngoscopy, or specialist referral 1, 2

Common Pitfalls to Avoid

• Do not perform unnecessary dental procedures when dental examination is normal—this can worsen persistent idiopathic facial pain 4, 5
• Do not miss giant cell arteritis in patients >50 years, as this can lead to irreversible blindness 3
• Do not assume TMJ disorder without examining for neuralgic features or autonomic symptoms 3
• Recognize that referred trigeminal pain from occipital neuralgia can present as preauricular pain years before occipital symptoms develop 6
• Chronic facial pain patients benefit from multidisciplinary team management including consideration of cognitive behavioral therapy 3