What is the best course of action for a female adult patient presenting with right ear fullness and intermittent sharp nerve-like pain preauricular extending down to her jaw, with a normal physical exam, no jaw tenderness, and no pain to percussion over the preauricular facial nerve area?

Evaluation and Management of Preauricular Pain with Ear Fullness

This presentation most likely represents temporomandibular joint (TMJ) dysfunction or referred pain from the trigeminal nerve distribution, and should be managed with a trial of NSAIDs, TMJ-directed therapy, and close follow-up rather than immediate imaging, unless red flags emerge.

Initial Diagnostic Considerations

The combination of ear fullness with sharp, intermittent nerve-like pain extending from the preauricular area to the jaw, in the absence of physical exam findings, strongly suggests a non-otologic cause. The normal physical examination effectively rules out acute otitis externa, which would show canal inflammation, tenderness, or debris 1. The absence of facial nerve tenderness on percussion makes Bell's palsy or facial nerve pathology unlikely 1.

Most Likely Diagnoses

Temporomandibular Joint Dysfunction (TMJD) is the leading consideration because:

• Patients with isolated ear fullness and pain radiating to the jaw are more likely to have TMJ dysfunction than other causes 2
• The auriculotemporal nerve (a branch of the mandibular division of the trigeminal nerve) supplies the TMJ and can produce preauricular pain extending to the jaw 3
• TMJ dysfunction commonly presents with ear fullness, otalgia, and referred pain without objective ear abnormalities 4, 5
• Women are more likely to present with unexplained ear fullness and pain, with TMJ dysfunction being a primary contributor 2

Secondary Otalgia from Trigeminal Nerve Distribution is also possible:

• Secondary otalgia (pain originating outside the ear) is more common in adults than primary otalgia 5
• The complex innervation of the ear through cranial nerves V, VII, IX, and X can produce referred pain from distant sites 5
• Sharp, nerve-like pain suggests neuropathic quality rather than inflammatory ear disease 6, 7

Critical Red Flags to Exclude

Before proceeding with conservative management, actively assess for these concerning features:

Immediate Imaging Required If Present:

• Sensory deficits in the trigeminal distribution (test light touch, pinprick in V1/V2/V3 regions) 6, 7
• Continuous pain from onset without pain-free intervals, which suggests secondary causes like tumors or demyelinating disease 6, 7
• Autonomic features such as tearing, conjunctival injection, rhinorrhea, or nasal congestion, which indicate trigeminal autonomic cephalgias (SUNCT/SUNA) rather than simple neuralgia 6, 8
• Bilateral symptoms, which are atypical for classical neuralgia and warrant expanded differential 7

Age-Related Concerns:

• Patients over 50 years with new-onset pain require consideration of temporal arteritis, especially if accompanied by scalp tenderness, jaw claudication (pain worsening with chewing), visual disturbances, or systemic symptoms like fever or malaise 8, 5
• Check ESR and CRP if temporal arteritis is suspected; markedly elevated values warrant immediate high-dose corticosteroids to prevent vision loss 8

Distinguish from Classical Trigeminal Neuralgia:

This patient's presentation does not fit classical trigeminal neuralgia because:

• Classical trigeminal neuralgia requires paroxysmal attacks lasting only seconds to minutes with mandatory refractory periods where pain cannot be re-triggered 6, 7
• The pain should be sharp, shooting, electric shock-like, triggered by light touch, washing, eating, or brushing teeth 7, 8
• Continuous or prolonged pain suggests Type 2 trigeminal neuralgia, post-traumatic neuropathy, or alternative diagnoses 6

Recommended Management Algorithm

Step 1: Targeted Physical Examination

Perform specific maneuvers to identify TMJ dysfunction:

• Palpate the TMJ (place fingers just anterior to the tragus) during jaw opening and closing; pain or crepitation suggests TMJ-OA 4
• Assess mandibular range of motion (normal opening is >40mm); limitation suggests TMJ dysfunction 4
• Palpate masticatory muscles (masseter, temporalis) for tenderness or trigger points 4
• Examine dentition for malocclusion, bruxism, or recent dental work 5

Step 2: Initial Conservative Management (No Imaging Yet)

If examination suggests TMJ dysfunction and no red flags are present:

Pharmacologic therapy:

• NSAIDs (e.g., ibuprofen 400-600mg three times daily) provide superior pain relief compared to acetaminophen for musculoskeletal pain 1
• Avoid opioids for this presentation; reserve for severe, refractory cases only 1

TMJ-directed therapy:

• Self-applied physical therapy including jaw stretching exercises and thermal packs 4
• Soft diet to reduce mechanical stress on the TMJ 4
• Consider dental referral for stabilization splint if symptoms persist beyond 2 weeks 4

Follow-up timing:

• Reassess in 48-72 hours if pain is severe 1
• Routine follow-up in 2 weeks if symptoms are tolerable 2, 4

Step 3: Imaging Indications

Do NOT routinely image patients with suspected TMJ dysfunction or secondary otalgia without red flags 1.

Obtain MRI with contrast if:

• Symptoms persist beyond 2-4 months despite appropriate treatment 1
• Any red flags develop (sensory deficits, continuous pain, autonomic features) 6, 7
• Atypical features emerge suggesting secondary causes 1

MRI specifications when indicated:

• High-resolution sequences through the trigeminal nerve course to evaluate for neurovascular compression, multiple sclerosis plaques, or tumors 1, 6
• Include pituitary fossa views if SUNCT/SUNA is suspected based on autonomic features 6

Step 4: Alternative Diagnoses to Consider

If TMJ-directed therapy fails, consider:

Intermittent Eustachian Tube Dysfunction (iETD):

• More likely if isolated ear fullness predominates without significant pain 2
• Trial of nasal decongestants or nasal corticosteroids may be diagnostic and therapeutic 2

Migraine-Associated Ear Pain:

• Consider if patient has history of headaches or photophobia/phonophobia 2
• Trial of migraine prophylaxis may be warranted 2

Anxiety-Related Symptoms:

• Up to 94.7% of patients with unexplained ear fullness have contributing TMJ dysfunction, iETD, migraine, anxiety, or combinations thereof 2
• Screen for anxiety and depression, as these significantly impact symptom perception 2

Common Pitfalls to Avoid

1. Do not diagnose acute otitis externa without visible canal inflammation, edema, or debris on examination 1

2. Do not assume Bell's palsy without facial weakness; pain alone is insufficient for this diagnosis 1

3. Do not order CT temporal bone as a first-line study for this presentation; it is indicated for suspected vascular causes of pulsatile tinnitus, trauma, or when middle ear pathology is suspected—none of which apply here 1

4. Do not prescribe topical otic antibiotics for secondary otalgia; they are ineffective and may mask progression of underlying disease 1

5. Do not overlook temporal arteritis in patients over 50 with new-onset pain, even without classic symptoms; this is a vision-threatening emergency 8, 5

6. Do not immediately refer to neurosurgery for suspected trigeminal neuralgia without first confirming the characteristic paroxysmal pattern with refractory periods and attempting medical management with carbamazepine 8, 9

When Symptoms Remain Unexplained

If comprehensive evaluation and trials of targeted therapy fail to identify or improve the cause:

• Approximately 5.3% of patients with ear fullness have completely unexplained symptoms 2
• Consider counseling in the framework of functional neurologic disorders 2
• Reassure the patient that serious pathology has been excluded while validating their symptoms 2