Ear Pain – January 2013

Every day in my practice, I see several patients whose primary complaint is ear pain.  Very often, these patients are referred to me by a primary care physician who has examined these individuals, and not seen any obvious cause for the symptom, yet the patient is disabled by the pain.  I will try to explain why this seems so often to be a mystery.

Primary Ear Pain

It is vital, of course, for the practitioner to evaluate these patients by physical examination first and foremost.  This exam begins with a thorough exam of the ear structures.  Infections or malignancies of the external ear and ear canal must be suspected.  Foreign objects, or simple earwax impaction in the ear canal, can cause pain.  The eardrum (tympanic membrane) and the space behind the drum (middle ear) are evaluated to rule out infection or inflammation.  It is important to obtain middle ear pressure testing (tympanogram) and hearing test to fully evaluate the health of the ear.

Secondary Ear Pain

Unfortunately, MANY of our patients complaining of ear pain have NO discernable sign of ear trouble at all.  It is at this point the physician must consider sources for what we call “referred ear pain,” meaning other areas of the head and neck that share the same nerve endings as the ear can actually “refer” pain to the ear, even though the disease is located elsewhere.

The most common site that can shoot pain to the ear is the jaw joint (temporomandibular joint –”TMJ”), and surrounding dental structures. Unlike patients with ear disease, TMJ pain sufferers do not complain of hearing loss or ear drainage.  Very often, TMJ ear pain is worse in the morning after a long night of teeth clenching or grinding.  Frequently, TMJ sufferers have a history of orthodontic care, or dental procedures where the mouth is held open for prolonged periods of time.  TMJ-related ear pain is more common in women, and can shift from ear to ear at times.

Patients who have one-sided (unilateral) ear pain, with no sign of ear disease, or TMJ issues, must be carefully evaluated to detect throat and voice box (larynx) disease that can shoot pain to the ear.  An ominous situation arises when a patient complains of unilateral ear pain and throat pain.  Often, malignant tumors of the tonsil, pharynx and larynx, or severe infections of these structures, can refer pain to the ear.  A fiberoptic evaluation of this anatomy is imperative in patients who have no other explanation for their ear pain.

Less commonly, disease of the sinuses, spinal nerves in the neck,  thyroid gland disorders, salivary gland disease can cause ear pain, but these situations are few and far between.

My general advice to patients, then, is that ear pain must be evaluated with all these possibilities in mind.  Unless the source for the pain is diagnosed and treated successfully by the “front-line” primary care physician, it is my opinion that the rest of the patients require an ENT evaluation.

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