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Ear Pain: History Taking and Differential Diagnoses

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Causes

Primary otalgia

Secondary otalgia

History Taking

Overview

With each symptom, always (if relevant) ask about:

  • When did it start?
  • Did it come on suddenly or gradually?
  • Is it continuous or intermittent?
  • Has this ever happened before?
  • Is this one or both ears?

Ear pain

  • Use SOCRATES
  • Associated symptoms:

Review of symptoms

Screen for red flags:

  • Any fever?
  • Any night sweats?
  • Any unexplained weight loss?
  • Any symptoms associated with a stroke? Examples are:
    • Problems with balance?
    • Problems with speech?
    • Weakness or numbness?

Screen for ear symptoms:

  • Tinnitus?
  • Dizziness? – does the room spin?
  • Ear pains?
    • Use SOCRATES
  • Ear discharge?
  • Do they hear any clicking or popping?
  • Do their ears ever feel full?
  • Has anything been inserted into the ear?

Screen for nose symptoms:

Screen for throat symptoms:

Screen for neurological symptoms:

Past Medical History

Questions include:

  • Do they have any other medical conditions?
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
  • Do they take any over-the-counter medications, herbal remedies, or supplements?
  • Have they had a recent infection such as a cold or the flu?
  • Do they take eardrops? – some patients forget these count as regular medications

Family History

  • Is there any family history of anything similar?

Allergy History

  • Are they allergic to anything?
    • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • If so, how much and how long?
  • Do they drink alcohol?
    • If so, how much and how long?
  • Do they use any illicit drugs?
    • If so, how much and how long?
  • What is their occupation?
  • Who’s at home?
    • What support do they have?
  • How has this impacted their activities of daily living?
  • Has there been any recent foreign travel?

Differential Diagnoses

Auricular haematoma

  • A history may reveal:
    • A history of trauma to the ear
    • More common in martial arts, rugby players, wrestlers, and boxers
    • Throbbing ear pain
  • A physical exam may reveal:

Auricular cellulitis

  • A history and examination may reveal:
    • A warm and tender ear, fever, malaise, nausea
    • Ear swelling
  • Diagnosis is clinical

Ramsay Hunt syndrome (herpes zoster oticus)

  • A history may reveal:
  • A physical exam may reveal:
    • Facial nerve palsy
    • Vesicular rash around the ear
  • Diagnosis is usually clinical

Otitis externa

  • A history may reveal:
    • Ear pain, ear itching, and ear discharge
    • Recent swimming
  • A physical exam may reveal:
    • An erythematous/swollen/eczematous canal
    • Otorrhoea may be present
  • Diagnosis is clinical

Necrotising (malignant) otitis externa

  • A history may reveal:
    • A history of diabetes mellitus or immunosuppression
    • Severe, persistent ear pain out of proportion to clinical findings
    • Patients are systemically unwell and headaches
  • Investigations may reveal:
    • Immediate ENT referral
    • CT scan with contrast – may show bony erosions
    • MRI of brain and internal auditory canal – can assess soft tissues

Impacted earwax

  • A history may reveal:
    • The use of cotton buds in the ear or hearing aids
  • A physical exam may reveal:
    • Otoscopy usually identifies impacted earwax
  • Diagnosis is clinical

Otitis media

  • A history may reveal:
    • More common in children
    • Associated earache and fever
    • May perforate leading to foul discharge release from the ear 
  • A physical exam may reveal:
    • A red, bulging, tympanic membrane
  • Diagnosis is clinical

Otitis media with effusion (glue ear)

  • A history may reveal:
    • More common in younger children
    • Hearing loss and problems with speech and language development, or sudden decrease in school performance
    • A previous history of acute otitis media
  • A physical exam may reveal:
    • Otoscopy may show: loss of the right reflex, yellow/amber/blue tympanic membrane, air bubbles or an air-fluid level behind the tympanic membrane, retracted tympanic membrane
  • Diagnosis is clinical

Cholesteatoma

  • A history may reveal:
    • Foul-smelling persistent discharge
    • There may be associated tinnitus and ear pain
  • A physical exam may reveal:
    • Crusting/pus/debris in the attic (upper part of the middle ear) on otoscopy
  • Investigations may reveal:
    • Pure tone audiogram – shows conductive hearing loss
    • CT petrous temporal bone – confirms the diagnosis
    • MRI – considered if soft tissue involvement suspected

Temporal arteritis

  • A history may reveal:
    • Usually older patients (>50 years)
    • Scalp tenderness, jaw claudication
    • There may be painless vision loss
    • There may be a history of polymyalgia rheumatica
  • A physical exam may reveal:
    • Unilateral blindness, temporal tenderness, and fundoscopy may show optic nerve oedema
  • Investigations may reveal:
    • ESR – elevated
    • CRP – may be elevated
    • Temporal artery biopsy – confirms the diagnosis

Sinusitis

  • A history may reveal:
    • Nasal congestion, nasal discharge, post-nasal drip, fever
    • Frontal headache that is worse when bending forwards
  • A physical exam may reveal:
    • Reproducible sinus tenderness when palpating the frontal and maxillary sinuses
  • Diagnosis is clinical

Temporomandibular joint disease

  • A history may reveal:
    • Pain around the jaw, temple, or ear
    • Clicking, popping, or grinding when moving the jaw
    • Difficulty opening the jaw, jaw locking
  • A physical exam may reveal:
    • Pain and tenderness of the masseter, pterygoid, and temporalis muscles
    • Limited range of movement of the mandible
    • Crepitus, clicking, or popping of the temporomandibular joint

Salivary gland disorders

  • A history and examination may reveal:
    • Inflammation and swelling unilaterally or bilaterally
    • Dysphagia and pain
    • Palpable salivary glands

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