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By Douglas J Lanska MD MS MSPH

In this clinical article, Dr. Lanska of the Great Lakes VA Healthcare System at the VA Medical Center in Tomah, Wisconsin explains the clinical presentation, pathophysiology, diagnostic workup, and management of otalgia. Primary otalgia results from pathologic conditions of the ear, whereas secondary otalgia results from nonotologic pathologic conditions usually in the distributions of cranial nerves V, VII, IX, or X, or the cervical plexus in the distribution of C2 and C3. If no ear disease is identified, secondary otalgia is likely, but unfortunately no simple diagnostic algorithm is available.

Key points

  • Primary otalgia is ear pain resulting from pathologic conditions of the ear itself, whereas secondary otalgia is pain referred to the ear from nonotologic sites, usually in the distributions of cranial nerves V, VII, IX, or X, or the cervical plexus.
  • Primary otalgia is often accompanied by abnormalities of the mastoid, external ear, ear canal, or tympanic membrane that are evident with inspection, palpation, and otoscopy; however, mild redness of the tympanic membrane or mild swelling of the external auditory canal are common findings and may not indicate the source of ear pain.
  • In most cases of otalgia in children, the otalgia is primary, whereas less than half of the cases of otalgia in adults are primary.
  • The cause of secondary otalgia may be difficult to identify because of the complex innervation of the ear and the many potential sources of referred pain.
  • Neurologic disorders causing secondary otalgia include Herpes zoster oticus (Ramsay Hunt syndrome); trigeminal neuralgia (typically a facial pain, but pain can also radiate to the ear); malignancies of the trigeminal nerve; Slude (sphenopalatine) neuralgia (typically with ear and nasal pain with radiation to the ear); intermedius, glossopharyngeal, and vagus neuralgias; and chronic paroxysmal hemicrania.