Can gastroesophageal reflux disease (GERD) cause referred ear pain?

Can GERD Cause Referred Ear Pain?

Yes, gastroesophageal reflux disease can cause referred ear pain, though establishing causation is challenging and requires careful diagnostic evaluation. 1

Understanding the Association

Ear disease is recognized as a possible extraesophageal manifestation of GERD by the American Gastroenterological Association. 1 The relationship between acid reflux and ear symptoms operates through two proposed mechanisms:

• Reflux pathway: Micro-aspiration of gastric contents (acid or non-acid) reaching the upper aerodigestive tract 1
• Reflex pathway: Vagally-mediated neurogenic signaling triggering inflammation without direct contact 1

Critical Diagnostic Challenges

The absence of typical GERD symptoms does not rule out reflux as the cause of ear pain. 1 Patients with extraesophageal reflux may not complain of heartburn or regurgitation, placing the diagnostic burden on the clinician. 1

Causation versus association is difficult to establish because:

• Variable responses to PPI therapy occur even with confirmed reflux 1
• Up to 50-60% of patients with extraesophageal symptoms do not have GERD as the underlying cause 2
• Symptom improvement on PPIs may result from mechanisms other than acid suppression and should not be regarded as confirmation of GERD 1

Diagnostic Approach

Perform objective testing before initiating PPI therapy in patients with ear pain but without typical GERD symptoms. 1, 2 The diagnosis requires a global clinical impression incorporating:

• pH/impedance monitoring off PPI to detect both acid and non-acid reflux episodes (most valuable test) 2
• Upper endoscopy to identify erosive esophagitis or alternative diagnoses 2
• Patient symptoms and response to therapy 1

Do not rely on PPI trials as a diagnostic tool - there is no single gold standard test for extraesophageal reflux. 1

Treatment Algorithm

For patients with suspected reflux-related ear pain:

1. Initial evaluation: Rule out primary otologic causes (otitis media, Eustachian tube dysfunction from other causes) 3

2. If typical GERD symptoms are present alongside ear pain: Start once-daily PPI for 4-8 weeks 4

3. If no typical GERD symptoms: Consider diagnostic testing (pH/impedance monitoring) before empiric PPI therapy 1, 2

4. If one PPI trial fails (up to 12 weeks): Pursue objective testing for pathologic reflux rather than trying additional PPIs 1, 2

5. For confirmed reflux with inadequate PPI response: Consider pH-impedance monitoring while on acid suppression to evaluate ongoing acid or non-acid reflux 1

6. Alternative treatments may include lifestyle modifications, alginate-containing antacids, prokinetic agents, or neuromodulators 1

Multidisciplinary Collaboration Required

Engage otolaryngology early in the evaluation. 1 Extraesophageal reflux manifestations are often multifactorial, requiring input from both gastroenterology and ENT specialties. 1 Results from otoscopy, tympanometry, and other ENT diagnostic testing should be incorporated when considering reflux as a cause. 1

Key Clinical Pitfalls

• Both acid and non-acid reflux can cause ear symptoms, so standard pH monitoring may miss non-acid reflux events requiring pH-impedance testing 2
• Pediatric populations: In children presenting with ear pulling, irritability, and normal otoscopic exams, consider reflux-induced referred otalgia, particularly if there is a pattern of "recurring otitis media" without objective findings 3
• Lack of response to PPI therapy predicts lack of response to anti-reflux surgery and should be incorporated into surgical decision-making 1