What should I do for a persistent left ear ache, sensation of water in the ear, and tenderness to touch that has lasted for two months?

Evaluation and Management of Persistent Left Ear Pain

You need to see a healthcare provider urgently for examination and likely referral to an ENT specialist, as a two-month duration of ear pain with tenderness suggests either chronic otitis externa, perichondritis/chondritis of the ear cartilage, or less commonly, a referred pain source that requires investigation.

Immediate Clinical Assessment Required

Your symptoms—persistent ear pain for two months, sensation of water in the ear, pain radiating below the ear, and tenderness to touch—exceed the typical timeframe for common ear infections and warrant direct medical evaluation. 1

Key Diagnostic Considerations

Primary ear pathology (most likely):

• Chronic otitis externa: Inflammation of the ear canal lasting beyond 3 weeks, often caused by allergies or underlying inflammatory skin conditions 2
• Perichondritis/chondritis: Infection of the ear cartilage presenting with painful swelling, warmth, and tenderness that characteristically affects the cartilaginous portion while sparing the earlobe 3, 4
• Otitis media with effusion (OME): Fluid behind the eardrum that can persist for months, though typically less painful than your presentation 1

Secondary (referred) pain sources:

• Temporomandibular joint syndrome and dental infections are the most common causes of secondary ear pain in adults 5
• More serious conditions like temporal arteritis or malignancies must be excluded, especially if you have risk factors such as smoking, alcohol use, diabetes, or age over 50 years 5

Critical Warning Signs

Seek immediate evaluation if you have:

• Fever or constitutional symptoms 6
• Swelling and redness of the ear cartilage (not just the canal) 3, 4
• Diabetes or immunocompromised state, as these increase risk of severe infections including malignant otitis externa 1, 3
• Hearing loss, drainage from the ear, or facial weakness 1

Expected Diagnostic Workup

Your provider should:

• Examine the ear canal and tympanic membrane using otoscopy to distinguish between external ear canal infection, middle ear fluid, or cartilage involvement 1, 2
• Check for tenderness when deflecting the auricular cartilage, which indicates deeper perichondrial infection requiring systemic antibiotics rather than just topical therapy 4
• Assess the temporomandibular joint and dental structures if ear examination is normal, as these are common sources of referred pain 5
• Consider hearing testing if middle ear fluid is suspected, especially if present for 3 months or longer 1

Treatment Approach Based on Diagnosis

If Chronic Otitis Externa:

• Topical antimicrobial therapy is first-line treatment, with fluoroquinolone eardrops (such as ofloxacin) providing excellent coverage against Pseudomonas aeruginosa and Staphylococcus aureus, the most common pathogens 1, 2
• Expect improvement within 48-72 hours; if no improvement occurs, reassessment is necessary 1, 3
• Address underlying causes such as allergies or inflammatory skin conditions for chronic cases 2

If Perichondritis/Chondritis:

• Systemic fluoroquinolone antibiotics (not just topical drops) are required because Pseudomonas aeruginosa is isolated in 69% of culture-positive cases 4
• Re-examination within 48-72 hours is essential to ensure response and absence of abscess formation requiring drainage 4
• Never use local anesthesia with epinephrine if surgical intervention is needed, as this compromises blood supply to the cartilage 4

If Otitis Media with Effusion:

• Most OME lasting less than 3 months resolves spontaneously and does not require intervention 1
• Since your symptoms have persisted for 2 months, hearing testing is recommended if fluid persists beyond 3 months 1
• Antibiotics are not recommended for OME, as they have not been shown effective for long-term resolution 1
• Re-examination every 3-6 months is appropriate if watchful waiting is chosen 1

Common Pitfalls to Avoid

• Do not assume this will resolve on its own after 2 months of symptoms—the duration suggests either chronic infection, cartilage involvement, or referred pain requiring investigation 1, 5
• Do not use ear candles, as they have never been shown effective and can cause harm including hearing loss and eardrum perforation 1
• Do not insert cotton swabs or other objects into the ear canal, as this can worsen inflammation 1
• Do not delay imaging or specialist referral if the diagnosis remains unclear after initial evaluation, especially with risk factors for malignancy 5

Why ENT Referral May Be Necessary

Referral to an otolaryngologist is warranted when:

• The diagnosis is unclear after initial evaluation 1, 5
• Symptoms persist despite appropriate treatment 1
• Structural abnormalities of the eardrum or middle ear are suspected 1
• Risk factors for serious disease are present (age >50, smoking, alcohol use, diabetes) 5
• Surgical intervention such as tympanocentesis or drainage may be needed 1, 4

The two-month duration of your symptoms places you beyond the typical self-resolution timeframe for common ear conditions and necessitates professional evaluation to prevent potential complications and ensure appropriate treatment. 1, 5