I'm an adult with right ear pain and ringing; what could this be and how is it treated?

Right Ear Pain and Ringing: Diagnosis and Management

You need a thorough ear examination to determine if this is primary otalgia (ear-origin pain with likely abnormal exam findings) or secondary otalgia (referred pain with normal ear exam), and the presence of tinnitus suggests you should obtain a comprehensive audiologic examination to identify underlying hearing loss, which is the most common cause of tinnitus. 1, 2

Initial Diagnostic Approach

Distinguish Primary vs. Secondary Otalgia

Primary otalgia (pain originating from the ear) typically presents with abnormal ear examination findings: 3, 4

• Otitis externa: Ear canal inflammation with pain on tragal pressure or auricular manipulation, canal erythema/edema, possible discharge 3, 4
• Otitis media: Middle ear infection with tympanic membrane abnormalities (erythema, bulging, effusion) 3, 4
• Cerumen impaction: Can cause ear fullness, pain, tinnitus, and hearing loss; look for complete or partial canal occlusion 1

Secondary otalgia (referred pain) presents with normal ear examination: 3, 4

• Temporomandibular joint syndrome: Most common cause of secondary otalgia; assess for jaw clicking, limited mouth opening, tenderness over TMJ 3, 4
• Dental disease: Check for dental caries, periodontal disease, recent dental work 3, 4
• Pharyngitis: Examine oropharynx for erythema, exudates 3
• Cervical spine arthritis: Assess for neck pain, limited range of motion 3

Evaluate the Tinnitus Component

The tinnitus requires specific characterization to guide workup: 2, 5

• Unilateral vs. bilateral: Unilateral tinnitus warrants imaging to exclude vestibular schwannoma or other structural lesions 2, 5
• Pulsatile vs. non-pulsatile: Pulsatile tinnitus (synchronous with heartbeat) requires vascular imaging (CTA or MRA) to identify arteriovenous malformations, dural fistulas, or vascular tumors 2, 5
• Associated hearing loss: Obtain comprehensive audiologic examination if tinnitus is unilateral, persistent ≥6 months, or associated with hearing difficulties 5

Red Flags Requiring Urgent Evaluation

Obtain imaging (MRI with contrast) if any of the following are present: 2, 5, 4

• Unilateral tinnitus with asymmetric hearing loss (concern for vestibular schwannoma) 2, 5
• Pulsatile tinnitus (requires CTA/MRA for vascular evaluation) 2, 5
• Focal neurological abnormalities 5
• Risk factors for malignancy: age >50 years, smoking, alcohol use, diabetes 4
• Severe anxiety or depression with tinnitus (increased suicide risk requiring prompt psychiatric intervention) 2, 5

Management Algorithm

If Ear Examination is Abnormal (Primary Otalgia):

Treat the identified ear pathology: 1, 3

• Otitis externa: Topical antibiotic/steroid drops, pain control 3
• Otitis media: Antibiotics if indicated, pain control 3
• Cerumen impaction: Cerumenolytic agents (if no tympanic membrane perforation or prior ear surgery), manual removal, or irrigation 1

If Ear Examination is Normal (Secondary Otalgia):

Systematically evaluate referred pain sources: 3, 4

• Examine TMJ, dentition, oropharynx, and cervical spine 3, 4
• If diagnosis unclear after targeted examination, consider trial of symptomatic treatment (NSAIDs) for 1-2 weeks 3, 4
• If symptoms persist or red flags present, obtain imaging (CT or MRI) and/or ENT consultation 3, 4

For Persistent Tinnitus Management:

Do NOT routinely order imaging for bilateral, non-pulsatile tinnitus without neurologic abnormalities or asymmetric hearing loss. 5

Evidence-based interventions for bothersome tinnitus: 5

• Cognitive Behavioral Therapy (CBT): Strongest evidence for improving quality of life in persistent, bothersome tinnitus 5
• Hearing aids: Recommended even for mild or unilateral hearing loss when tinnitus is present 5
• Education and counseling: Essential for all patients with persistent tinnitus 5
• Sound therapy: May provide symptomatic relief 5

Avoid these interventions (insufficient evidence, potential harm): 5

• Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary tinnitus treatment 5
• Dietary supplements (Ginkgo biloba, melatonin, zinc) 5

Common Pitfalls to Avoid

• Don't assume tinnitus alone requires imaging: Only image if unilateral, pulsatile, with neurologic findings, or asymmetric hearing loss 5
• Don't overlook cerumen impaction: This simple, treatable cause can present with ear pain, tinnitus, and hearing loss 1
• Don't miss TMJ syndrome: The most common cause of secondary otalgia is often overlooked without specific TMJ examination 3, 4
• Don't ignore psychiatric comorbidity: Screen for severe anxiety/depression due to documented suicide risk in tinnitus patients 2, 5
• Don't prescribe unproven supplements: Patients often request these, but evidence does not support their use 5

Special Consideration: Ménière's Disease

If the patient reports episodic vertigo (lasting 20 minutes to hours) along with fluctuating hearing loss, tinnitus, and aural fullness, consider Ménière's disease: 1

• Obtain comprehensive audiologic examination 1
• Consider vestibular function testing (videonystagmography) 1
• Initial management: low-sodium diet (1500-2300 mg daily), limit caffeine and alcohol 1
• Diuretics and antivertigo medications for symptomatic control 1