What is the possible diagnosis for a patient with intermittent sharp unilateral ear pain, without tinnitus, vertigo, or remarkable findings on physical exam, and a normal otoscopic exam?

Intermittent Sharp Unilateral Ear Pain with Normal Exam

The most likely diagnosis is secondary (referred) otalgia from temporomandibular joint (TMJ) dysfunction or cervical spine pathology, given the intermittent sharp pain, normal otoscopic examination, and absence of otologic symptoms like tinnitus or vertigo. 1, 2

Primary vs. Secondary Otalgia

When the physical examination is unremarkable and the otoscopic exam is normal, you are dealing with secondary (referred) otalgia rather than primary ear pathology. 1, 2

• Primary otalgia (pain originating from the ear itself) typically shows abnormal findings on examination, such as signs of otitis media, otitis externa, or other visible ear pathology 1
• Secondary otalgia (referred pain) presents with normal ear examination findings and originates from structures outside the ear that share common neural pathways 1, 2
• The absence of tinnitus and vertigo further argues against primary otologic causes like Menière's disease or vestibular pathology 3, 4

Most Likely Diagnoses

Temporomandibular Joint (TMJ) Dysfunction

TMJ dysfunction is the most common cause of secondary otalgia in adults. 1, 2

• The TMJ shares innervation with the ear through the auriculotemporal nerve (branch of cranial nerve V) 5, 2
• TMJ-related otalgia can cause unilateral tinnitus that worsens with jaw movements, though tinnitus is absent in this case 6, 4
• Key diagnostic features to assess: jaw clicking, limited jaw opening, pain with chewing, temporal headaches, or tenderness over the TMJ 1, 2

Cervical Spine Degenerative Disease

Cervical spine pathology is an increasingly recognized cause of referred otalgia, particularly in aging populations. 7

• Cervical spine disease causes referred otalgia through irritation of spinal nerves C2 and C3, which contribute to ear innervation 5, 7
• In one study, 88% of patients with cervical spine disease-referred otalgia had degenerative cervical spine disease 7
• Key diagnostic features to assess: neck pain, limited neck range of motion, pain radiating to the head/ear region, or history of cervical spine problems 4, 7

Dental Pathology

• Dental infections or pathology can cause referred ear pain through the mandibular division of the trigeminal nerve (cranial nerve V) 1, 2
• Key diagnostic features to assess: dental pain, recent dental work, tooth sensitivity, or gingival inflammation 1

Diagnostic Approach

Perform a targeted history focusing on:

• Jaw symptoms: clicking, locking, pain with chewing, or temporal headaches 1, 2
• Neck symptoms: pain, stiffness, limited range of motion, or radicular symptoms 7
• Dental symptoms: toothache, recent dental procedures, or gum problems 1, 2
• Temporal pattern: relationship to jaw movement, neck position, or chewing 6, 4

Physical examination should include:

• Palpation of the TMJ during jaw opening and closing 1
• Assessment of cervical spine range of motion and tenderness 7
• Oral cavity and dental examination 1, 2
• Cranial nerve examination to rule out neurologic pathology 5

Red Flags Requiring Further Workup

Be vigilant for alarm symptoms that warrant imaging or specialist referral:

• Age 50 years or older with risk factors (smoking, alcohol use, diabetes) suggesting possible malignancy 1
• Persistent unilateral ear pain lasting more than 4 weeks despite conservative management 2
• Focal neurologic deficits suggesting cranial nerve involvement 4
• History of malignancy or recent trauma 4

Management Strategy

Initial management should target the most likely underlying cause:

• For TMJ dysfunction: Trial of soft diet, NSAIDs, warm compresses, and jaw rest; consider dental/TMJ specialist referral if symptoms persist 6, 1
• For cervical spine pathology: Cervical spine physical therapy has shown subjective pain relief in documented cases 7
• For dental pathology: Dental referral for definitive treatment 1, 2

If diagnosis remains unclear after targeted history and physical examination:

• Consider a trial of symptomatic treatment with NSAIDs 1
• If symptoms persist beyond 4 weeks or red flags are present, proceed with imaging (CT or MRI) or otolaryngology consultation 1, 2

Important Caveats

• Do not assume benign etiology in patients over 50 with risk factors for malignancy (smoking, alcohol, diabetes), as otalgia may be the only presenting symptom of head and neck cancer 1
• Secondary otalgia is more common in adults, while primary otalgia is more common in children 1
• The complexity of ear innervation (involving cranial nerves V, VII, IX, X and cervical nerves C2-C3) means referred pain can originate from multiple distant sites 5, 2