Causes
Primary otalgia
- Auricular ear pain:
- Haematoma
- Cellulitis
- Ramsay Hunt syndrome (herpes zoster oticus)
- Auditory canal pain:
- Otitis externa
- Necrotising (malignant) otitis externa
- Wax impaction
- Ear trauma
- Middle and inner ear pain:
- Acute otitis media
- Otitis media with effusion
- Cholesteatoma
- Trauma
- Haemotympanum
Secondary otalgia
- Temporal arteritis
- Sinusitis
- Temporomandibular joint disease
- Salivary gland disorders
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:
- Discharge?
- Blood?
- Itching?
- Hearing loss?
- Tinnitus?
- Double vision (nystagmus)?
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:
- Runny nose?
- Nosebleeds?
Screen for throat symptoms:
- Sore throat?
- Pain or difficulties when swallowing?
- Cough
- Lock-jaw/trismus?
Screen for neurological symptoms:
- Falls?
- Fits?
- Loss of consciousness
- Visual changes?
- Headaches?
- Neck stiffness?
- Photophobia?
- Weakness?
- Tingling?
- Pain?
- Problems with balance?
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:
- A tense, tender, fluctuant, ear
- ‘Cauliflower ear’
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:
- Auricular pain followed by facial nerve palsy
- 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