What causes severe otalgia (ear pain)?

From the Guidelines

Super sharp ear pain is most likely caused by acute otitis externa (AOE), which can be intensely painful due to the inflammation of the ear canal and the proximity of the highly sensitive periosteum to the ear canal skin. The pain can be severe and may be underappreciated by clinicians, emphasizing the importance of proper pain assessment and management 1.

Possible Causes of Ear Pain

• Ear infections (otitis media or externa)
• Eustachian tube dysfunction
• Barotrauma from pressure changes
• Foreign objects
• Earwax impaction
• Temporomandibular joint (TMJ) disorders
• Referred pain from dental issues

Management of Ear Pain

For immediate relief, over-the-counter pain medications like acetaminophen (Tylenol) 500-1000mg every 6 hours or ibuprofen (Advil, Motrin) 400-600mg every 6-8 hours with food can be taken 1. Applying a warm compress to the affected ear for 15-20 minutes several times daily may also help. However, if the pain is severe, accompanied by fever, hearing loss, discharge, or persists beyond 2-3 days, medical attention should be sought promptly. A healthcare provider can properly diagnose the cause and may prescribe antibiotics like amoxicillin (if bacterial infection is present), ear drops containing antibiotics and/or steroids, or other specific treatments based on the underlying cause.

Importance of Proper Diagnosis

Ear pain occurs because the ear canal and eardrum contain numerous nerve endings that, when irritated or inflamed, can trigger intense pain signals to the brain. Proper diagnosis by a healthcare provider is essential to determine the underlying cause of the ear pain and to provide appropriate treatment. In some cases, topical anesthetic drops may be prescribed for temporary pain relief, but their use should be carefully monitored to avoid masking the progression of underlying disease 1.

Key Considerations

• Pain relief is an essential component of managing AOE, and frequent use of appropriate analgesics at adequate doses is necessary to permit patients to achieve comfort, rest, and resume normal activities 1.
• The use of opioids for pain relief should be guided by the recognition that pain is easier to prevent than treat, and early treatment at an appropriate starting dose is always indicated 1.
• Topical anesthetic drops should not be used if a tympanostomy tube is present or there is uncertainty regarding the integrity of the tympanic membrane 1.

From the Research

Causes of Ear Pain

The causes of ear pain can be divided into two categories: primary otalgia and secondary otalgia.

• Primary otalgia refers to pain that originates from the ear itself, with the most common causes being:
  • Otitis media 2, 3
  • Otitis externa 2, 3
• Secondary otalgia refers to pain that originates from outside the ear, with common causes including:
  • Temporomandibular joint syndrome 2, 3
  • Pharyngitis 2
  • Dental disease 2
  • Cervical spine arthritis 2

Risk Factors for Serious Causes of Ear Pain

Certain factors can increase the risk of a serious cause of ear pain, including:

• Smoking 2, 3
• Alcohol consumption 2, 3
• Age over 50 years 2, 3
• Diabetes 2, 3

Diagnosis and Management of Ear Pain

The diagnosis of ear pain typically involves a physical examination and medical history.

• If the diagnosis is not clear, options may include:
  • Trial of symptomatic treatment without a clear diagnosis 2
  • Imaging studies 2, 3
  • Consultation with an otolaryngologist 2
• Management of ear pain may involve watchful waiting, antibiotics, or other treatments, depending on the underlying cause and severity of the pain 4, 5, 6