What is Otalgia?
Otalgia is ear pain, which can originate from the ear itself (primary otalgia) or from structures outside the ear (secondary/referred otalgia), and in the context of unilateral post-auricular lymphadenopathy, you must urgently evaluate for serious infections like mastoiditis, herpes zoster oticus, or malignancy. 1, 2
Definition and Classification
Otalgia is the sensation of pain in the ear, divided into two distinct categories 3, 4:
- Primary (otogenic) otalgia: Pain originating from ear pathology itself, most commonly acute otitis media in children and acute otitis externa in adults 1, 2
- Secondary (referred) otalgia: Pain felt in the ear but originating from non-otologic sources, transmitted through cranial nerves V, IX, X and spinal nerves C2-C3 3, 5
Critical Context: Unilateral Post-Auricular Lymphadenopathy
When otalgia presents with unilateral swollen post-auricular lymph nodes, you must immediately consider these serious etiologies:
High-Priority Diagnoses
Herpes zoster oticus (Ramsay Hunt syndrome): Look for vesicles on the external ear canal and posterior auricle, severe otalgia, facial paralysis/paresis, loss of taste on anterior two-thirds of tongue, and decreased lacrimation—this requires prompt systemic antiviral therapy and systemic steroids 6
Mastoiditis: Post-auricular swelling with lymphadenopathy, fever, and ear pain suggests mastoid involvement requiring urgent imaging and possible surgical intervention 2
Malignancy: Upper aerodigestive tract cancers can present with otalgia as the only symptom, particularly in patients with tobacco/alcohol use history, age >50 years, or diabetes mellitus—perform complete head and neck examination with visualization of mucosal surfaces, assessment of neck masses, and tongue base palpation 6, 1, 2
Common Infectious Causes
Acute otitis externa: Presents with otalgia, tragal tenderness, ear discharge, and canal edema, caused by Pseudomonas aeruginosa and Staphylococcus aureus in 98% of bacterial cases 1, 2
Furunculosis: Infected hair follicle in outer third of ear canal with localized tenderness, focal swelling, and pustular lesions, most commonly caused by S. aureus 6, 2
Common Pitfalls to Avoid
Missing malignancy is the most critical error: Failure to recognize referred pain from non-ear sources in high-risk patients with persistent otalgia and normal ear examination can delay cancer diagnosis 1, 2. The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that older patients with tobacco/ethanol use history presenting with otalgia require thorough head and neck evaluation even when ear examination is normal 6.
Inadequate pain management: Pain relief must be addressed immediately, as analgesics provide relief within 24 hours while antibiotics do not provide symptomatic relief in the first 24 hours for acute otitis media 1.
Inappropriate antibiotic selection: Systemic antibiotics should NOT be prescribed as initial therapy for uncomplicated otitis externa when topical antimicrobials are superior 1, 2.
Examination Approach
When evaluating otalgia with post-auricular lymphadenopathy, systematically assess 6, 4:
- Ear examination: Look for canal edema, discharge, vesicles, tympanic membrane abnormalities, and test for tragal tenderness
- Facial nerve function: Check for facial weakness suggesting Ramsay Hunt syndrome or malignancy
- Skin examination: Inspect for vesicular lesions on external ear canal and posterior auricle
- Head and neck examination: Visualize oropharynx, palpate tongue base, assess for neck masses beyond the post-auricular nodes
- Temporomandibular joint: Palpate for tenderness and crepitus, as TMJ syndrome is the most common cause of referred otalgia 6, 1
Age-Related Patterns
Primary otalgia is more common in children, whereas secondary otalgia is more common in adults 4, 7. In adults presenting with otalgia and post-auricular lymphadenopathy, you should have a higher index of suspicion for referred pain from serious pathology including malignancy 2, 4.