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Probability diagnosis

Otitis media (viral or bacterial)

Otitis externa

Boils and furuncles of canal

TMJ arthralgia

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)

Acute mastoiditis


Necrotising otitis externa

Pitfalls (often missed)

Foreign bodies in ear

Hard ear wax

Trauma including barotrauma

Dental abscess

Referred pain: neck, throat (e.g. tonsillitis)

Unerupted wisdom tooth and other dental causes

TMJ arthralgia

Chondrodermatitis nodularis helicus

Facial neuralgias, esp. glossopharyngeal

Post tonsillectomy:

  • from the wound

  • from TMJ due to mouth gag

Masquerades checklist


Spinal dysfunction (cervical)

Is the patient trying to tell me something?

Unlikely, but always possible with pain. More likely in children. Consider factitious pain.

Key history

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.

Key examination

  • 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

Key investigations

Seldom necessary.

  • Consider hearing tests, audiometry

  • Any ear discharge for MC but swabs of no value if the TM is intact

Diagnostic tips

  • 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.

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