What causes a burning sensation in the ear?

Burning Sensation in the Ear: Causes and Management

Most Likely Causes

A burning sensation in the ear most commonly results from acute otitis externa (swimmer's ear), allergic contact dermatitis, or eczematous dermatitis of the ear canal. 1, 2

Primary Otologic Causes

Acute Otitis Externa (AOE)

• Presents with rapid onset (within 48 hours) of ear canal inflammation causing pain, itching, fullness, and burning sensations 3
• Nearly all cases (98%) in North America are bacterial, with Pseudomonas aeruginosa (20-60%) and Staphylococcus aureus (10-70%) as the primary pathogens 3
• Examination reveals swelling of the ear canal, erythema, and tenderness when manipulating the pinna 1

Allergic Contact Dermatitis

• Characterized by erythema, edema, scaling, and a maculopapular or eczematous eruption on the conchal bowl and ear canal 4
• An erythematous streak may extend down the pinna where drops or allergens contact the auricular skin 1
• Nickel is the most common contact allergen, affecting approximately 10% of women with pierced ears 4
• Neomycin causes hypersensitivity in 13-30% of patients with chronic external otitis 1, 3

Atopic/Eczematous Dermatitis

• Presents with chronic pruritus, erythema, xerotic scaling, lichenification, and burning sensations 2
• Distinguished from AOE by chronic course and lack of acute bacterial infection signs 2

Seborrheic Dermatitis

• Marked by greasy yellowish scaling with itching, burning, and secondary Malassezia yeast inflammation 2

Serious Conditions Requiring Immediate Recognition

Auricular Perichondritis

• Presents with painful swelling, warmth, and redness in the auricular area that typically spares the earlobe 4
• Acute tenderness when deflecting the auricular cartilage distinguishes this deeper perichondrial infection from superficial skin infections 4
• Delaying treatment leads to devastating focal cartilage necrosis and permanent ear deformities 4, 5
• Requires immediate systemic fluoroquinolone antibiotics (ciprofloxacin or levofloxacin) to cover Pseudomonas aeruginosa and Staphylococcus aureus 4

Herpes Zoster Oticus (Ramsay Hunt Syndrome)

• Causes vesicles on the external ear canal and posterior surface of the auricle with severe burning otalgia 1
• Associated with facial paralysis or paresis, loss of taste on the anterior two-thirds of the tongue, and decreased lacrimation 1, 4
• Requires prompt systemic antiviral therapy and systemic steroids 1, 4

Secondary (Referred) Otalgia Causes

When ear examination is normal but burning pain persists, consider:

• Temporomandibular joint (TMJ) syndrome: Most common cause of referred otalgia with pain radiating to periauricular area, temple, or neck; tenderness over the affected TMJ with possible crepitus 1, 6
• Upper aerodigestive tract cancer: Particularly in older patients with tobacco and ethanol use history, or younger patients with human papillomavirus infection 1, 7
• Dental pathologies: Caries, impacted molars causing referred pain 1
• Red ear syndrome: Painful, burning, red ear associated with third cervical root irritation, TMJ dysfunction, or occurring without obvious structural cause in response to touch or heat 8

Diagnostic Algorithm

Step 1: Examine the ear canal and tympanic membrane

• If abnormal findings present (erythema, edema, discharge, vesicles): Primary otalgia 1, 3
• If normal examination: Secondary otalgia requiring head and neck evaluation 1, 6

Step 2: Distinguish the specific condition

• Acute onset (<48 hours) with canal swelling and tenderness: AOE 3
• Maculopapular eruption with scaling: Contact dermatitis 1, 4
• Chronic pruritus with xerotic scaling: Atopic dermatitis 2
• Greasy yellowish scaling: Seborrheic dermatitis 2
• Auricular swelling sparing the earlobe with cartilage tenderness: Perichondritis 4
• Vesicles with facial paralysis: Herpes zoster oticus 1, 4

Step 3: Assess for modifying factors

• Non-intact tympanic membrane or tympanostomy tubes 1, 3
• Diabetes, immunocompromised state, or prior radiotherapy 1, 3

Treatment Approach

For Acute Otitis Externa

Topical antimicrobials are the mainstay of treatment, delivering concentrations 100-1000 times higher than systemic therapy 3

• Use fluoroquinolone otic drops (ciprofloxacin 0.2% or ofloxacin 0.3%) twice daily for 7 days 3, 9, 10
• Proper technique: Patient lies with affected ear upward, fill canal with drops, maintain position for 3-5 minutes with gentle to-and-fro movement of pinna 3
• Expect improvement within 48-72 hours; if no improvement, consider treatment failure, allergic contact dermatitis, or misdiagnosis 3
• Avoid oral antibiotics for uncomplicated cases—they add cost without improving outcomes 3

For Allergic Contact Dermatitis

Remove the sensitizing agent immediately (jewelry, topical medications, cosmetics) and apply topical corticosteroid or calcineurin inhibitor 1, 4, 2

• Use tacrolimus 0.1% ointment or pimecrolimus 1% cream 1, 4
• Apply topical corticosteroid drops or ointments for 7-10 days, potentially extending to 2 weeks if symptoms persist 2
• Avoid neomycin-containing products due to high sensitization risk (13-30% in chronic cases) 1, 2, 3

For Atopic/Eczematous Dermatitis

• Apply topical corticosteroids for 7-10 days with proper technique 2
• Use emollients after bathing to provide surface lipid film and retard water loss 2
• Employ soap substitutes rather than traditional soaps 2
• Keep nails short to minimize trauma from scratching 2

For Seborrheic Dermatitis

• Add topical antifungal medications to reduce Malassezia yeast burden 2
• Combine with topical corticosteroids as above 2

For Auricular Perichondritis

Start fluoroquinolone antibiotics immediately (ciprofloxacin or levofloxacin) systemically—topical therapy alone is insufficient 4

• This is a medical emergency requiring systemic antibiotics to prevent cartilage destruction 4, 5

For Herpes Zoster Oticus

• Initiate prompt systemic antiviral therapy and systemic steroids 1, 4

Critical Pitfalls to Avoid

• Confusing perichondritis with simple otitis externa results in inadequate antibiotic coverage for Pseudomonas and leads to permanent deformity 4, 5
• Using neomycin-containing products in patients with dermatitis or chronic otitis externa due to 13-30% sensitization risk 1, 2, 3
• Prescribing oral antibiotics for uncomplicated AOE when topical therapy is superior 3
• Using ototoxic preparations (neomycin, aminoglycosides) in patients with non-intact tympanic membranes or tympanostomy tubes 3, 9
• Failing to perform complete head and neck examination in patients with normal ear findings, especially those with tobacco/alcohol use or age >50 years, missing occult malignancy 1, 6, 7
• Dismissing persistent otalgia after appropriate treatment without reassessing for allergic contact dermatitis from topical medications or considering patch testing 2, 3