What is the possible cause and diagnosis of left ear pain, muffled sound, and radiating jaw pain with a pulsating nature in a 49-year-old female?

Differential Diagnosis and Management of Left Ear Pain with Muffled Hearing and Jaw Radiation

Most Likely Diagnosis

The most likely diagnosis is temporomandibular joint (TMJ) disorder with referred otalgia, though primary ear pathology (otitis media or externa) must be ruled out first through otoscopic examination. 1, 2

Algorithmic Diagnostic Approach

Step 1: Determine Primary vs. Secondary Otalgia

Perform otoscopic examination immediately - this single step differentiates between primary ear pathology (abnormal exam) and referred pain (normal exam). 1, 2

• If tympanic membrane is erythematous, bulging, or cloudy: Acute otitis media is the diagnosis 3
• If external auditory canal shows erythema, edema, or drainage: Otitis externa is the diagnosis 3
• If otoscopic exam is completely normal: Secondary otalgia from referred pain is most likely 1, 2

Step 2: Assess for Pulsatile vs. Non-Pulsatile Quality

The pulsating nature described requires specific evaluation:

• If truly synchronous with heartbeat (pulsatile): This represents a vascular etiology requiring urgent imaging evaluation, as over 70% have identifiable structural abnormalities including life-threatening causes like arterial dissection or dural arteriovenous fistula 4
• If pulsating but not synchronous with pulse: More consistent with TMJ dysfunction or muscular tension 5

Step 3: Evaluate TMJ as Primary Source

Given the jaw radiation and muffled hearing with normal ear exam, TMJ disorder is the leading diagnosis:

• Palpate the TMJ bilaterally (lateral and dorsal aspects) - severe pain on palpation strongly suggests TMJ pathology 5
• Assess mandibular range of motion - limitation below 40mm opening suggests TMJ dysfunction 5
• Check for TMJ crepitation or clicking during jaw movement 5
• Palpate masseter and temporalis muscles for trigger points and tenderness 5

TMJ-related osteoarthritis and myofascial pain can cause tensor tympani muscle dysfunction, producing ear fullness and hearing impairment (hypoacusis) even with normal otoscopic findings. 5

Step 4: Consider Dental Pathology

Dental disease is among the most common causes of secondary otalgia:

• Examine for carious teeth, particularly molars on the affected side 1, 2
• Assess for periodontal disease or dental abscess 1
• Note any recent dental procedures - sudden hearing loss and tinnitus can rarely occur after dental treatment 6

Critical Red Flags Requiring Urgent Evaluation

Order immediate CT angiography (CTA) of head and neck if:

• Pulsatile tinnitus is truly synchronous with heartbeat (suggests vascular pathology) 4
• Patient has risk factors: smoking, alcohol use, diabetes, or age >50 years 1, 2
• Any focal neurologic deficits are present 2
• Symptoms persist despite symptomatic treatment 1, 2

These red flags increase risk for serious occult causes including arterial dissection, dural arteriovenous fistula, or malignant neoplasms. 4, 2

Recommended Management Algorithm

If Otoscopic Exam is Normal (Secondary Otalgia):

1. Trial of TMJ-directed therapy for 2-4 weeks:

   • Self-applied physical therapy with jaw stretching exercises 5
   • Thermal packs to affected TMJ 5
   • NSAIDs for pain control 2
   • Soft diet and avoidance of jaw clenching 5

2. If no improvement after conservative therapy:

   • Consider full-arch stabilization splint (occlusal guard) 5
   • Refer to dentist for evaluation of dental pathology 1, 2
   • Consider panoramic radiograph or maxillary CT to assess TMJ degenerative changes 5

3. If symptoms persist or worsen:

   • Order MRI if malignancy concern exists (especially with risk factors) 2
   • Refer to otolaryngology for fiberoptic nasolaryngoscopy 1
   • Consider ESR if temporal arteritis suspected (age >50, new headache) 1

If True Pulsatile Tinnitus:

Order high-resolution CT temporal bone (non-contrast) OR CT angiography of head and neck with contrast as first-line imaging - do not delay with symptomatic treatment alone. 4

Common Pitfalls to Avoid

• Dismissing pulsatile tinnitus as benign - nearly all cases require imaging due to identifiable vascular causes in >70% of cases 4
• Missing TMJ dysfunction when focusing solely on ear pathology - TMJ disorders commonly present with isolated ear symptoms including fullness and hearing changes 5
• Inadequate otoscopic examination leading to inappropriate imaging selection 4
• Overlooking dental pathology - pharyngitis and dental disease are among the most common causes of secondary otalgia 1
• Failing to recognize high-risk patients (smokers, diabetics, age >50) who warrant more aggressive evaluation for malignancy 1, 2