What are the causes of burning and tingling sensations in the ears?

Burning and Tingling Sensations in the Ears: Differential Diagnosis and Evaluation

The most common causes of burning and tingling in the ears are contact dermatitis (allergic or irritant), otitis externa, and less commonly, Red Ear Syndrome or pain hyperacusis, with the diagnostic approach requiring careful examination of the ear canal and consideration of recent exposures to potential allergens or irritants. 1

Primary Dermatologic Causes

Contact Dermatitis

• Allergic contact dermatitis affects susceptible individuals exposed to metals (nickel in earrings affects ~10% of women with pierced ears), cosmetics, soaps, shampoos, hearing aid materials, or topical medications 1
• Neomycin is the most common otic preparation causing sensitization, affecting 5-15% of patients with chronic external otitis, with patch testing showing 13% of normal volunteers are hypersensitive 1
• Irritant contact dermatitis results from direct chemical damage (acids/alkalis), causing inflammatory mediator release that produces erythema, edema, scaling, itch, and occasional pain in a dose-dependent manner affecting all individuals 1
• A maculopapular or eczematous eruption on the conchal bowl and ear canal, with an erythematous streak extending down the pinna where drops contact skin, indicates allergic reaction to a topical agent 1

Acute Otitis Externa

• Inflammatory mediator release from damaged epidermal cells leads to erythema, edema, and pain that can manifest as burning sensations 1
• Furunculosis (infected hair follicle in outer third of ear canal) presents with otalgia, localized tenderness, focal swelling, and pustular lesions 1

Viral Etiologies

Herpes Zoster Oticus (Ramsay Hunt Syndrome)

• Causes vesicles on the external ear canal and posterior auricle surface, accompanied by severe otalgia (which can present as burning pain), facial paralysis, loss of taste on anterior two-thirds of tongue, and decreased lacrimation 1
• Requires prompt systemic antiviral therapy and systemic steroids 1

Neurologic Pain Syndromes

Red Ear Syndrome

• Characterized by episodic attacks of ear erythema with burning ear pain 2, 3
• Triggers include touch, exertion, heat/cold, stress, neck movements, hair washing/brushing, and dietary triggers (orange juice documented in one case) 2
• Can occur as isolated episodes or in association with migraine, particularly in younger patients 3
• Pathophysiology may involve trigeminal autonomic reflex activation 3

Pain Hyperacusis (Noxacusis)

• Causes physical pain in response to sounds that don't bother most people 4
• 80.77% report burning sensations, along with stabbing (76.92%), throbbing (73.08%), and pinching (53.85%) sensations occurring in or around the ear 4
• Pain can last weeks to months after sound exposure 4
• Symptoms consistent with trigeminal nerve involvement 4

Ototoxic Medication Effects

Drug-Induced Symptoms

• Ibuprofen can cause tinnitus as a common adverse effect (3-9% of patients), with rare reports of hearing loss and paresthesias 5
• Azithromycin post-marketing reports include hearing disturbances, tinnitus, and paresthesias 6
• Multiple ototoxic medications can produce burning or tingling sensations as part of their adverse effect profile 1

Critical Diagnostic Approach

Initial Examination Priorities

• Otoscopic examination is essential to identify external ear canal pathology, vesicles (herpes zoster), or signs of contact dermatitis 1
• Assess for recent exposures: new earrings, hearing aids, otic drops (especially neomycin-containing), cosmetics, or hair products 1
• Evaluate for triggers: sound sensitivity (hyperacusis), stress, dietary factors, or physical activities 2, 4

When to Suspect Serious Pathology

• Unilateral symptoms with focal neurological deficits require imaging and specialty referral to exclude underlying pathology 1, 7
• Facial paralysis with ear pain and vesicles mandates immediate antiviral therapy for herpes zoster oticus 1
• Severe anxiety or depression accompanying ear symptoms requires prompt psychiatric evaluation due to suicide risk 1, 8

Management Algorithm

First-Line Interventions

• Remove sensitizing agents (discontinue suspected topical medications, remove nickel earrings, change hearing aid materials) and apply topical steroids or calcineurin inhibitors (tacrolimus 0.1% ointment or pimecrolimus 1% cream) for contact dermatitis 1
• Trigger avoidance for Red Ear Syndrome (dietary modifications, stress management) provides symptomatic improvement 2
• For pain hyperacusis, benzodiazepines and nerve blockers emerged as most effective analgesic options in patient surveys, though evidence is limited 4

Common Pitfalls to Avoid

• Missing neomycin allergy in patients using otic drops who develop worsening symptoms—switch to non-neomycin preparations 1
• Overlooking herpes zoster oticus in patients with severe burning ear pain—look carefully for vesicles and assess facial nerve function 1
• Dismissing sound sensitivity as psychological when it may represent pain hyperacusis requiring specific management 4
• Failing to identify medication-induced symptoms—review all current medications for ototoxic potential 5, 6