Otitis media (viral or bacterial)
Boils and furuncles of canal
Eustachian tube dysfunction
Serious disorders not to be missed
Neoplasia of external ear
Cancer of other sites (e.g. tongue, throat)
Herpes zoster (Ramsay—Hunt syndrome)
Necrotising otitis externa
Trauma including barotrauma
Referred pain: neck, throat (e.g. tonsillitis)
Unerupted wisdom tooth and other dental causes
Chondrodermatitis nodularis helicus
Facial neuralgias, esp. glossopharyngeal
Spinal dysfunction (cervical)
Is the patient trying to tell me something?
Unlikely, but always possible with pain. More likely in children. Consider factitious pain.
Assess the site of pain and radiation, details of the onset of pain, nature of the pain, aggravating or reliving factors and associated features such as vertigo, tinnitus, sore throat and irritation of the external ear. Ask about trauma, especially the use of a cotton bud to clean the ear.
The external ear with manipulation of the ear
Check helix for chondrodermatitis nodularis helicus
Palpate the face and neck to include the parotid glands, regional lymph nodes and skin and temporomandibular joint (TMJ)
Inspect both empty ear canals and tympanic membrane (TM) with the auroscope using the largest possible earpiece
Look for causes of referred pain: cervical spine, nose, postnasal space and mouth including teeth
Consider hearing tests, audiometry
Any ear discharge for MC but swabs of no value if the TM is intact
The pain of otitis media may be masked by fever in babies and young children.
If an adult presents with ear pain but normal auroscopy, examine possible referral sites, namely TMJ, mouth, throat, teeth and cervical spine.