Earache [Otalgia]

Earaches usually result from disorders of the external and middle ear associated with infection, obstruction, or trauma. Their severity ranges from a feeling of fullness or blockage to deep, boring pain. At times, it may be difficult to determine the precise location of the earache. Earaches can be intermittent or continuous and may develop suddenly or gradually.

History and physical examination

Ask the patient to characterize his earache. How long has he had it? Is it intermittent or continuous? Is it painful or slightly annoying? Can he localize the site of the pain? Does he have pain in any other areas, such as the jaw?

Ask about recent ear injury or other trauma. Does swimming or showering trigger ear discomfort? Is discomfort associated with itching? If so, find out where the itching is most intense and when it began. Ask about ear drainage and, if present, have the patient characterize it. Does he hear ringing, “swishing,” or other noises in his ears? Ask about dizziness or vertigo. Does it worsen when the patient changes position? Does he have difficulty swallowing, hoarseness, neck pain, or pain when he opens his mouth?

Find out if the patient has recently had a head cold or problems with his eyes, mouth, teeth, jaws, sinuses, or throat. Disorders in these areas may refer pain to the ear along the cranial nerves.

Finally, find out if the patient has recently flown, been to a high-altitude location, or been scuba diving.

Begin your physical examination by inspecting the external ear for redness, drainage, swelling, or deformity. Then apply pressure to the mastoid process and tragus to elicit any tenderness. Using an otoscope, examine the external auditory canal for lesions, bleeding or discharge, impacted cerumen, foreign bodies, tenderness, or swelling. Examine the tympanic membrane: Is it intact? Is it pearly gray (normal)? Look for tympanic membrane landmarks: the cone of light, umbo, pars tensa, and the handle and short process of the malleus. (See Using an otoscope correctly.) Perform the watch tick, whispered voice, Rinne, and Weber’s tests to assess for hearing loss.

Medical causes

Abscess (extradural)

Severe earache accompanied by a persistent ipsilateral headache, malaise, and recurrent mild fever characterizes this serious complication of middle ear infection.

Barotrauma (acute)

Earache associated with barotrauma ranges from mild pressure to severe pain. Tympanic membrane ecchymosis or bleeding into the tympanic cavity may occur, producing a blue drumhead; the eardrum usually isn’t perforated.

Cerumen impaction

Impacted cerumen (earwax) may cause a sensation of blockage or fullness in the ear. Additional features include partial hearing loss, itching and, possibly, dizziness.

Chondrodermatitis nodularis chronica

Chondrodermatitis nodularis chronica produces small, painful, indurated areas along the auricle’s upper rim.

Ear canal obstruction by an insect

An insect lodged in the ear canal may cause severe pain and distressing noise.

Frostbite

Prolonged exposure to cold may cause burning or tingling pain in the ear, followed by numbness. The ear appears mottled and gray or white; it turns purplish blue as it’s warmed.

Furunculosis

Infected hair follicles in the outer ear canal may produce severe, localized ear pain associated with a pus-filled furuncle (boil). The pain is aggravated by jaw movement and relieved by rupture or incision of the furuncle. Pinna tenderness, swelling of the auditory meatus, partial hearing loss, and a feeling of fullness in the ear canal may also occur.

Herpes zoster oticus (Ramsay Hunt syndrome)

Herpes zoster oticus causes burning or stabbing ear pain that’s commonly associated with ear vesicles. The patient also complains of hearing loss and vertigo. Associated signs and symptoms include transient ipsilateral facial paralysis, partial loss of taste, tongue vesicles, and nausea and vomiting.

Keratosis obturans

Mild ear pain, otorrhea, and tinnitus are common in keratosis obturans. Inspection reveals a white glistening plug obstructing the external meatus.

Mastoiditis (acute)

Mastoiditis causes a dull ache behind the ear accompanied by low-grade fever (99° F to 100° F [37.2° C to 37.8° C]). The eardrum appears dull and edematous and may perforate, and soft tissue near the eardrum may sag. A purulent discharge is seen in the external canal.

Ménière’s disease

Ménière’s disease is an inner ear disorder that can produce a sensation of fullness in the affected ear. Its classic effects, however, include severe vertigo, tinnitus, and sensorineural hearing loss. The patient may also experience nausea and vomiting, diaphoresis, and nystagmus.

Middle ear tumor

Deep, boring ear pain and facial paralysis are late signs of a malignant tumor.

Myringitis bullosa

Myringitis bullosa is a rare bacterial infection that causes sudden, severe ear pain that radiates over the mastoid and lasts for up to 48 hours. Small serous or blood-filled vesicles may dot the reddened tympanic membrane. Transient hearing loss and a serosanguineous discharge may also occur.

Otitis externa

Earache characterizes both acute and malignant otitis externa. Acute otitis externa begins with mild to moderate ear pain that occurs with tragus manipulation. The pain may be accompanied by low-grade fever, sticky yellow or purulent ear discharge, partial hearing loss, and a feeling of blockage. Later, ear pain intensifies, causing the entire side of the head to ache and throb. Fever may reach 104° F (40° C). Examination reveals swelling of the tragus, external meatus, and external canal; eardrum erythema; and lymphadenopathy. The patient also complains of dizziness and malaise.

Malignant otitis externa causes sudden ear pain that’s aggravated by moving the auricle or tragus. The pain is accompanied by intense itching, purulent ear discharge, fever, parotid gland swelling, and trismus. Examination reveals a swollen external canal with exposed cartilage and temporal bone. Cranial nerve palsy may occur.

Otitis media (acute)

Otitis media is a middle ear inflammation that can be serous or suppurative. Acute serous otitis media may cause a feeling of fullness in the ear, hearing loss, and a vague sensation of top-heaviness. The eardrum may be slightly retracted, amber colored, and marked by air bubbles and a meniscus, or it may be blue-black from hemorrhage.

Acute suppurative otitis media is characterized by severe deep, throbbing ear pain; hearing loss; and fever that may reach 102° F (38.9° C).The pain increases steadily over several hours or days and may be aggravated by pressure on the mastoid antrum. Perforation of the eardrum is possible. Before rupture, the eardrum appears bulging and fiery red. Rupture causes purulent drainage and relieves the pain.

Chronic otitis media usually isn’t painful except during exacerbations. Persistent pain and discharge from the ear suggest cancer or osteomyelitis of the skull base.

Perichondritis

Perichondritis can cause ear pain accompanied by warmth and tenderness in the outer ear and a reddened, doughlike auricle.

Petrositis

The result of acute otitis media, this infection produces deep ear pain with headache and pain behind the eye. Other findings are diplopia, loss of lateral gaze, vomiting, sensorineural hearing loss, vertigo and, possibly, nuchal rigidity.

Temporomandibular joint infection

Typically unilateral, temporomandibular joint infection produces ear pain that’s referred from the jaw joint. The pain is aggravated by pressure on the joint with jaw movement; it commonly radiates to the temporal area or the entire side of the head.

Special considerations

Administer an analgesic, and apply heat to relieve discomfort. Instill eardrops if necessary. Teach the patient how to instill drops if they’re prescribed for home use.

Pediatric pointers

Common causes of earache in children are acute otitis media and insertion of foreign bodies that become lodged or infected. Be alert for nonverbal clues to earache in a young child, such as crying or ear tugging.

To examine the child’s ears, place him in a supine position with his arms extended and held securely by his parent. Then hold the otoscope with the handle pointing toward the top of the child’s head, and brace it against him using one or two fingers. Because an ear examination may upset the child with an earache, save it for the end of your physical examination.

Pictures

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

Other Book Chapters Related to Ear sounds

Read excerpts from these other book chapters related to Ear sounds:

Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

More About Causes of Ear sounds

• Back to symptom: Ear sounds: Introduction (review 109 causes)
• Next Book Extract About Ear sounds: Hearing Loss (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
• All Book Extracts: All Online Book Extracts for Ear sounds

More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

 » Next page: Hearing Loss (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

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