What are the possible causes of ear pain and a sensation of a plugged ear when no earwax is present?

Ear Pain and Plugged Ear Without Earwax: Causes

When ear pain and fullness occur without visible earwax, the most likely causes are otitis media with effusion (OME) in children or referred pain from temporomandibular joint dysfunction, dental disease, or Eustachian tube dysfunction in adults.

Age-Based Diagnostic Approach

In Children

The primary concern is otitis media with effusion (OME), which presents as middle ear fluid without acute infection 1. Key diagnostic features include:

• Pneumatic otoscopy findings: Decreased or absent tympanic membrane mobility (fluid blocks normal movement)
• Tympanogram: Flat or nearly flat tracing indicating middle ear fluid
• Associated symptoms: Hearing difficulties, balance problems, or behavioral changes rather than acute pain
• Over 60% of children experience OME by age 2 years 1

Critical distinction: If the child has acute ear pain with bulging tympanic membrane or intense erythema, this represents acute otitis media (AOM), not OME 2. OME is typically painless or causes only mild discomfort.

In Adults

Secondary (referred) otalgia is more common than primary ear disease 3, 4. When otoscopy is normal, systematically evaluate:

Most Common Causes (in order of frequency):

1. Temporomandibular Joint (TMJ) Dysfunction 5, 3

   • Patients reporting ear pain more likely than those with isolated fullness
   • Assess for jaw clicking, limited mouth opening, facial pain
   • Tenderness over TMJ with palpation

2. Intermittent Eustachian Tube Dysfunction (iETD) 5

   • Patients reporting isolated ear fullness more likely than those with pain
   • Symptoms worsen with altitude changes, upper respiratory infections
   • Normal tympanic membrane appearance

3. Dental Disease 3, 6

   • Check for caries, abscesses, impacted molars
   • Percussion tenderness of teeth
   • Pain may worsen with chewing

4. Pharyngitis/Tonsillitis 3, 6

   • Examine oropharynx for erythema, exudates, asymmetry

5. Cervical Spine Arthritis 3, 6

   • Pain worsens with neck movement
   • Palpable cervical tenderness

Red Flags Requiring Urgent Evaluation

Immediately pursue advanced imaging (CT/MRI) or ENT consultation if 3, 6:

• Age >50 years with persistent symptoms
• Smoking history
• Alcohol use
• Diabetes mellitus
• Unilateral symptoms persisting >2-4 weeks despite treatment
• Constitutional symptoms (weight loss, night sweats)
• Cranial nerve deficits

These factors increase risk for malignancy (nasopharyngeal, oropharyngeal carcinoma) or temporal arteritis presenting as otalgia.

Diagnostic Algorithm

1. Perform otoscopy and pneumatic otoscopy (if available)

   • Abnormal findings → primary otalgia (OME, otitis externa, cholesteatoma)
   • Normal findings → proceed to step 2

2. Age stratification:

   • Children: Strongly consider OME even with normal-appearing tympanic membrane; obtain tympanometry 1
   • Adults: Assume secondary otalgia until proven otherwise 4

3. Targeted examination based on symptom pattern 5:

   • Isolated fullness → Eustachian tube dysfunction, migraine
   • Pain predominant → TMJ dysfunction, dental disease
   • Women more commonly present with unexplained ear fullness 5

4. Trial of symptomatic treatment (2-4 weeks) if no red flags 6:

   • NSAIDs for pain
   • Address suspected underlying cause (TMJ exercises, dental referral, nasal decongestants for ETD)

5. If symptoms persist: Consider migraine disorder, anxiety, or functional neurologic disorder 5

   • 94.7% of patients with unexplained ear fullness have identifiable contributing factors when these are considered

Common Pitfalls

• Overdiagnosing AOM in children: Mild tympanic membrane erythema alone without bulging or effusion is not AOM 2
• Stopping evaluation after normal otoscopy in adults: This is when the real diagnostic work begins for secondary otalgia 4
• Missing malignancy: Any adult with risk factors and persistent unilateral symptoms requires imaging regardless of normal examination 3
• Ignoring TMJ/dental causes: These account for the majority of secondary otalgia but are frequently overlooked 3, 6