What are the possible causes and treatments for unilateral ear pain, scalp tingling, and arm tingling?

Unilateral Ear Pain with Scalp and Arm Tingling: Differential Diagnosis and Management

This symptom complex requires urgent evaluation for glossopharyngeal neuralgia, cervical radiculopathy with referred otalgia, or less commonly, a posterior circulation stroke, with immediate neuroimaging (MRI) indicated if any focal neurologic deficits are present.

Critical Red Flags Requiring Immediate Evaluation

• Focal neurologic symptoms (weakness, dysarthria, ataxia, facial numbness) accompanying unilateral ear pain and paresthesias suggest central nervous system pathology, particularly brainstem involvement 1
• Stroke or TIA rarely presents as isolated ear pain but should be considered when ear pain occurs with arm tingling and scalp paresthesias, especially involving the lateral pontomedullary region 1
• Giant cell arteritis presents with temporal region pain, scalp tenderness, and jaw claudication; requires immediate ESR/CRP and temporal artery biopsy within 2 weeks if suspected 1

Most Likely Diagnoses

Glossopharyngeal Neuralgia

This is the primary consideration given the unilateral deep ear pain with radiating symptoms. 1

• Presents as unilateral deep ear pain radiating to back of tongue, tonsils, and neck with paroxysmal attacks lasting seconds to minutes 1
• Pain is sharp, shooting, electric shock-like and moderate to very severe 1
• Triggered by swallowing, coughing, or touching the ear 1
• Syncope rarely occurs as an associated feature 1
• Management: MRI to exclude structural lesions, followed by anticonvulsants (first-line) or surgical intervention 1

Cervical Radiculopathy with Referred Otalgia

Cervical nerve root compression can cause neck pain radiating to the ear/head region with arm paresthesias. 2

• Neck pain radiating to head/ear region potentially mimicking or coexisting with ear symptoms 2
• Associated dizziness may occur from cervical proprioceptive dysfunction 2
• Arm tingling follows dermatomal distribution corresponding to affected nerve root 2

Temporomandibular Joint Dysfunction

TMJ disorders are among the most common causes of secondary otalgia in adults. 3, 4, 5

• Unilateral ear pain worsening with jaw movements due to close anatomical relationship between TMJ and ear structures 6, 7, 2
• May coexist with neck pain and associated cervical muscle tension 2
• Dedicated MRI of TMJ should be considered when jaw symptoms are present 7

Diagnostic Workup Algorithm

Step 1: Immediate Assessment

• Comprehensive neurologic examination looking for focal deficits, cranial nerve palsies, ataxia, or dysarthria 1
• Otoscopic examination to differentiate primary vs. secondary otalgia (normal exam suggests referred pain) 3, 4, 5
• Assess for temporal artery tenderness and jaw claudication if age >50 years 1

Step 2: Targeted History

• Characterize pain quality: Sharp/shooting suggests neuralgia; dull/aching suggests TMJ or musculoskeletal 1
• Identify triggers: Light touch, swallowing, jaw movement, or neck position 1, 6
• Associated symptoms: Syncope (glossopharyngeal neuralgia), visual changes (giant cell arteritis), or hearing loss (retrocochlear pathology) 1

Step 3: Imaging Strategy

• MRI head and internal auditory canal with contrast is first-line for unilateral ear pain with neurologic symptoms to exclude vestibular schwannoma, stroke, or structural lesions 1, 7
• CT temporal bone if pulsatile component or suspected bony abnormalities 6, 7
• Cervical spine MRI if arm tingling follows dermatomal pattern suggesting radiculopathy 2

Step 4: Laboratory Testing

• ESR and CRP if age >50 with scalp tenderness to rule out giant cell arteritis 1
• Audiologic testing including pure tone audiometry for unilateral symptoms 2

Management Based on Etiology

For Glossopharyngeal Neuralgia

• Anticonvulsants (carbamazepine or oxcarbazepine) as first-line pharmacotherapy 1
• Surgical intervention (microvascular decompression) for refractory cases 1

For Cervical Radiculopathy

• Address underlying cervical pathology through physical therapy, NSAIDs, or epidural steroid injections 2
• Neurosurgical consultation if progressive neurologic deficits 2

For TMJ Dysfunction

• Dental/jaw therapies including occlusal splints, physical therapy, and NSAIDs 6, 2
• Avoid hard foods and excessive jaw movements 6

Critical Pitfalls to Avoid

• Never dismiss unilateral ear pain with normal otoscopy without investigating referred pain sources 3, 4, 5
• Do not delay imaging in patients with risk factors: age >50, smoking, alcohol use, diabetes, or persistent symptoms despite symptomatic treatment 3, 4
• Recognize that intermittent symptoms do not exclude serious pathology—vestibular schwannomas and vascular abnormalities can produce intermittent symptoms 7
• Symptoms changing with position or jaw movement strongly suggest mechanical or vascular etiology rather than sensorineural causes 6, 7
• Persistent unilateral ear pain warrants otolaryngology consultation to exclude occult malignancy, especially in high-risk patients 3, 5