What could be causing left ear pain that intensified this morning, is sometimes throbbing, and has spread to the whole left head with a dull pain, accompanied by slight neck ache and normal otoscopic exam results?

Differential Diagnosis: Referred Otalgia with Temporomandibular Joint Syndrome

The most likely diagnosis is temporomandibular joint (TMJ) syndrome presenting as referred otalgia, given the unilateral ear pain radiating to the head and neck with a normal otoscopic examination. 1

Primary Assessment

A normal otoscopic exam with ear pain indicates secondary (referred) otalgia until proven otherwise. 2 This is a critical diagnostic principle that immediately shifts the focus away from primary ear pathology to sources outside the ear canal and middle ear.

Key Clinical Features Supporting TMJ Syndrome

• TMJ syndrome is the most common cause of referred otalgia when the ear canal shows no swelling and there is no middle ear disease. 1

• Patients with TMJ syndrome characteristically complain of pain radiating from the ear to the periauricular area, temple, or neck—exactly matching this presentation of left ear pain extending to the whole left head with neck aching. 1

• The presence of full range of motion of the mouth does not exclude TMJ syndrome, as pain may be present without severe limitation of jaw movement. 1

• History of gum chewing, bruxism, or recent dental procedures with subsequent malocclusion should be specifically elicited, though absence does not rule out TMJ pathology. 1

Physical Examination Priorities

• Palpate directly over the TMJ (anterior to the tragus) to assess for tenderness, which is the hallmark finding in TMJ syndrome. 1

• Listen and palpate for crepitus during jaw opening and closing, which may be present in TMJ dysfunction. 1

• Assess for tragus tenderness and perform pinna traction test, which should be negative in referred otalgia (positive findings would indicate acute otitis externa). 2

Alternative Serious Diagnoses to Consider

Glossopharyngeal Neuralgia

• This condition presents with unilateral pain deep in the ear and/or back of tongue, tonsils, and neck—partially matching this presentation. 1

• The pain is typically paroxysmal (lasting seconds to minutes) rather than continuous dull pain, making this less likely given the described "dull pain 6/10" and "throbbing at times." 1

• Pain is typically triggered by swallowing, coughing, or touching the ear, which should be specifically assessed. 1

• If suspected, MRI is indicated to rule out neurovascular compression or other structural lesions. 1

Upper Aerodigestive Tract Malignancy

• Otalgia may be the only symptom of upper aerodigestive tract cancer, particularly in older patients with tobacco and alcohol use history, or younger patients with human papillomavirus infection. 1

• A complete head and neck examination with visualization of mucosal surfaces, assessment of neck masses, and palpation of the tongue base is mandatory when referred otalgia is suspected. 1

• Palpate for cervical lymphadenopathy, which may indicate infectious or malignant processes. 3

Other Differential Considerations

• Dental pathologies (caries, impacted molars) can present as referred ear pain and should be evaluated. 1

• Giant cell arteritis should be considered if there is scalp tenderness, jaw claudication, or visual symptoms, particularly in patients over 50 years old. 1

• Cerebral venous thrombosis can present with unilateral headache that is dull and throbbing, though typically the headache is more diffuse and progressive over days to weeks. 1

Immediate Management Algorithm

1. Perform TMJ examination with direct palpation for tenderness and assessment for crepitus. 1

2. Complete head and neck examination including visualization of oropharynx, palpation of neck for masses and lymphadenopathy, and tongue base assessment. 1, 3

3. Initiate first-line analgesic therapy with NSAIDs (ibuprofen or naproxen) or acetaminophen for pain control, as NSAIDs demonstrate superior efficacy for pain relief. 2

4. If TMJ syndrome is confirmed, management includes patient education about avoiding aggravating factors (gum chewing, hard foods), jaw rest, heat application, and NSAIDs. 1

5. If examination reveals concerning findings (neck mass, mucosal lesions, severe tenderness), urgent referral to otolaryngology is indicated. 1

6. If pain persists beyond 48-72 hours without improvement or worsens, reassessment is mandatory to exclude serious underlying pathology including malignancy or neuralgic conditions. 2

Red Flags Requiring Urgent Evaluation

• Any palpable neck mass or lymphadenopathy warrants urgent otolaryngology referral. 1, 3

• Mucosal lesions, ulcerations, or induration require biopsy to exclude malignancy. 3

• Progressive neurological symptoms, visual changes, or fever should prompt consideration of more serious pathology including giant cell arteritis or intracranial processes. 1

• Paroxysmal sharp, shooting pain triggered by specific activities suggests neuralgic etiology requiring MRI evaluation. 1