Earache (Ear Pain)

Picture of the structures of the ear

• Earache or ear pain may be due to infections and inflammation of the external, middle or inner ear as well as from structures that are located adjacent to the ear itself.
• Earaches are a common symptom and may be due to a variety of illnesses.
• Causes of earaches include Swimmer's ear, middle ear infections, TMJ, infections, bullous myringitis, sunburn, dermatitis, and trauma.
• Signs and symptoms associated an earache depend upon the cause, but may include:
  • Redness and swelling around the outer ear
  • Fever
  • Ear pain
  • Jaw pain
  • Sore throat
  • Itching
  • Draining
  • Ringing in the ears
  • Vertigo
• Earaches often need urgent medical care, and may be treated with natural home remedies, for example, warm compresses; OTC pain relievers like ibuprofen (Advil, Motrin), naproxen (Aleve), and acetaminophen (Tylenol and others); olive oil in the affected ear, and essential oils.
• Medical care should be sought when there is fever, ear drainage, vertigo, loss of hearing or decreased hearing associated with ear pain.
• Evaluation, diagnosis and treatment of earache is usually done in the health-care professional's office and little testing is needed.

The ear has many parts to it, and each may cause ache, pain or other discomfort. Pain may come from one or many parts of the ear, depending on the situation.

The helix and auricle form the outer part of the ear cartilage and may become inflamed and infected. Inflammation may be due many reasons including:

• Skin infection or cellulitis
• Sunburn
• Chronic skin irritations, like atopic dermatitis
• Trauma. An injured auricle is a common wrestling injury. If a hematoma (bruise/blood clot) forms, it can be very painful and may cause damage to the underlying cartilage, resulting in a cauliflower ear.
• The ear canal may be a source of pain due to infection or trauma.

Otitis externa is inflammation of the ear canal, and is often referred to as "swimmer's ear."

• Irritation to the skin that lines the canal may be due to minor trauma, like trying to clean ear wax with a sharp object and causing a scratch that becomes inflamed or infected.
• swimmer's ear describes inflammation caused by retained water in the ear canal. The dark, warm, moist area may promote bacterial growth and predispose to infection.
• Cerumen (ear wax) impaction. Ear wax is part of the body's protective mechanism to lubricate the ear canal and prevent infection. If the wax hardens and builds excessively, it may cause significant pain. This is especially true if the wax presses against the eardrum.
• Foreign body. When a foreign body is inserted in the ear and cannot be removed, pain and inflammation may occur. These may include Q-tips, hair pins, and other narrow objects that are often used to scratch an itch or to remove ear wax. This is never safe, and nothing should be inserted into the ear canal. In addition to irritation of the external canal, the ear drum may also be perforated or damaged.

The middle ear is separated from the external ear canal by the eardrum, and this is the location of nerves involved with hearing. It is a relatively closed space and anything that increases pressure in the middle ear will cause pain.

• Middle ear infections are a common cause of otitis media especially in children. These are commonly caused by a virus or bacteria that invades and infects stagnant fluid in the middle ear.
• Serious otitis media describes fluid collection within the middle ear and is usually due to Eustachian tube dysfunction. This is the tube that drains fluid and equalizes pressure between the middle ear and the back of the throat. Increased pressure may cause pain and fullness but usually resolves over time. However, this fluid may also become infected, causing pain and fever.

• The inner ear is adjacent to the middle ear. The inner ear is the site of the labyrinth system that sends messages to the brain to help with balance. Inflammation of the inner ear is associated with vertigo but not necessarily pain.

The eardrum, or tympanic membrane, separates the external ear canal from the middle ear. It vibrates when sound hits it and transmits that vibration to allow the sense of hearing. Myringitis describes inflammation of the eardrum.

• Bullous myringitis causes inflammation and blistering of the tympanic membrane and can be very painful. Then infection may be due to bacteria, virus, or fungus.
• Myringitis may be due to extension of an infection from the external canal or from the middle ear
• Traumatic myringitis may occur from a direct injury like poking a sharp object into the ear canal.
• Trauma may also cause increased pressure in the area of the eardrum, causing it to rupture. This may include a blow to the ear with the palm of the hand, change in air pressure within an airplane, an explosion or other situations in which air is forced into the ear canal.
• Electrocution injury is often associated with perforation of the eardrum.

Ear discomfort may be due to pain from a nearby structure that that radiates to the ear:

• TMJ pain. The temporomandibular joint, where the jaw attaches to the skull, is located adjacent to the external ear canal, and inflammation of this joint may be associated with ear pain. TM joint pain may be due to trauma or arthritis. Teeth grinding may cause irritation and ear pain as well.
• Sinusitis may be associated with increased pressure within the middle ear, causing pain.
• Dental problems and toothaches may radiate pain to the ear area.
• Mastoiditis. The mastoids are bony prominences of the skull filled with air cells and are located behind the ear. Infection of these areas may cause ear pain.
• Pharyngitis (throat inflammation) and tonsillitis may cause pain that radiates to the ear. A peritonsillar abscess will often result in ear pain in addition to difficulty opening the mouth and difficulty swallowing.
• Thyroid inflammation and carotid artery pain (carotidynia) may also be associated with ear pain
• Trigeminal neuralgia. Inflammation of the fifth cranial nerve may cause significant facial pain including ear pain.
• Tinnitus. While not truly pain, ringing in the ear may cause significant discomfort
• Barotrauma describes injury to the ear because an acute change in pressure within the middle and inner ear. This may include changing pressures from flying in an airplane, scuba diving or snorkeling, or trauma due to a blast injury. Damage may occur to any or all of the eardrum, middle and inner ear.

Aside from pain symptoms of an earache depends upon the underlying cause

Outer ear (helix, auricle) inflammation include:

• Redness
• Swelling
• Fever
• Auricle trauma causes a well-defined hematoma or clot in the outer ear

Otitis externa or swimmer's ear symptoms include:

• Pain, fullness or pressure
• Itching
• Drainage
• Decreased hearing
• Tinnitus or ear ringing

Otitis media (middle ear infection) symptoms include:

• Deep pain
• Decreased hearing
• Fever
• Fullness
• Ear drainage if there is associated ear drum perforation
• Inner ear inflammation (labyrinthitis, vertigo)
• Vertigo (a sense of the room or surroundings spinning)
• Loss of balance
• Nausea and vomiting
• Decreased hearing, tinnitus (these may be symptoms of Meniere's disease or acoustic neuroma)

Myringitis symptoms include:

• Pain
• Decreased hearing
• Ear fullness
• Drainage that may be bloody

Other symptoms associated with other causes of earache:

• When ear pain occurs because of an illness or injury from a structure adjacent to the ear, the specific symptoms will be related to that structure. For example, TMJ inflammation may lead to earache, but most often is associated with pain when opening the mouth or with chewing. Dental issues may cause ear pain, but most likely involve tooth or gum pain.

In most instances, earaches often self-limiting, and don't require extensive medical attention.

• Adults with colds or upper respiratory infections may develop ear pain in association with a runny nose and post-nasal drainage. The ear pain should resolve as the cold gets better. Sometimes ear fullness may last a little longer.
• Middle ear infections in children are often self-limiting and do not need antibiotics, but it is difficult sometimes to determine that fever and fussiness in an infant is caused by an ear infection. It is reasonable to contact a health-care professional to determine whether the infant or child needs to be evaluated.
• Newborns and infants younger than 8 weeks of age should never have a fever, and if this occurs, urgent medical care should be accessed.
• It is not normal to have blood, pus or other fluid draining from the ear, and this should prompt a visit to a health-care professional.
• Pain that lasts for a few hours or increases in intensity should be evaluated by a health-care professional.
• Earache associated with hearing loss, unexplained fever, and general malaise or feeling poorly should be clues that care may be needed.
• Vertigo often requires medical care especially if there also is hearing loss and tinnitus, for these may be the signs of a nerve tumor called an acoustic neuroma.
• People with diabetes or those who are immunocompromised are at risk for malignant otitis externa, a condition that requires aggressive antibiotic treatment. The symptoms include earache, fever, drainage from the ear canal and redness around the ear. These should be warning signs to seek medical care.
• A person complaining of earache, but also has a fever, headache, neck stiffness, lethargy, and may be showing signs of meningitis or encephalitis and should seek emergency medical care immediately.

Earaches and ear pain are very common symptoms, and may be evaluated and cared for by most primary care providers, including family practice specialists, pediatrician, and internal medicine specialists. Urgent care and emergency medicine doctors also evaluate ear pain. Otolaryngologists (ear, nose and throat specialists) are able to care for ear issues and are able to perform surgery on all parts of the ear (externa, middle, internal) and face.

A health-care professional usually diagnoses the cause of an earache by talking to the patient, parent, or caregiver (taking history) and performing a physical examination. In general, X-rays and other tests are unnecessary.

Otoscope

The health-care professional may use an otoscope to look into the ear canal to evaluate the canal and the ear drum.

• If otitis externa is the cause of the earache, the ear canal will look swollen and inflamed. There may be thick drainage visible. Sometimes, the canal may be so swollen and painful that the canal cannot be seen.
• Bullous myringitis is diagnosed by using the otoscope to visualize the ear drum. The tissue will look inflamed and fluid blisters can be seen.
• Otitis media causes inflammation and swelling of the middle ear. The health-care practitioner cannot see the middle ear directly but instead, uses the otoscope to look at the ear drum. Initially, fluid fills the middle ear (serous otitis media), and there may be air and fluid bubbles seen behind the drum. As pressure builds, the ear drum may not move if a small puff of air is pushed through the otoscope. If the eardrum looks red and inflamed, the diagnosis of acute otitis media is made. The presence of fluid is called an effusion and may persist for two to three months after the acute infection has resolved.
• The eardrum may appear scarred if there have been previous infections.
• If tubes have been placed in the ear drum to treat chronic ear infection, these may be seen, if they are still in place.

The health-care professional also may evaluate other parts of the body including the throat (looking for sore throat or tonsillitis), the neck (feeling for swollen lymph nodes and assessing stiffness), and the lungs (looking for signs of pneumonia). This is especially important if the earache persists and there is no apparent reason for ear pain on examination. Referral to an ear, nose, and throat specialist may be necessary to evaluate the structures deeper in the throat with an endoscope (flexible camera) or a mirror.

Hearing tests

• Hearing tests may be recommended if there have been recurrent infections or if there has been a delay in speech development.
• Patients with vertigo may undergo hearing tests.

Laboratory tests

• Laboratory testing is usually not indicated in caring for routine ear infections.
• Rarely, a sample of drainage from the ear is sent to the laboratory in an attempt to identify the specific bacteria causing the infection. Sending the sample to the laboratory is not necessary in most cases and usually is reserved for infections that do not respond to normal treatment.

Imaging

X-ray, CT and other imaging studies are not usually needed for most cases of ear pain. They may be considered if there is concern for tumors or other structural problems in or adjacent to the ear.

Earaches may often be treated at home. The goal is to decrease inflammation and pain.

1. Warm compresses held to the outside of the ear may help with some of the pain. Make certain that water does not get into the ear canal. As well, it is important not to burn the skin.
2. Alternatively, a cool compress may help if warmth does not. Holding a cool compress for 20 minutes at a time against the ear may be helpful. Be careful to not have it too cold to cause frostbite.
3. Over-the-counter pain medications may be helpful. These include ibuprofen (Advil, Motrin), naproxen (Aleve) and acetaminophen (Tylenol, Panadol). It is important to remember that over-the-counter medications may interact with prescription drugs and may also have side effects. Always check with a health-care professional or pharmacist if needed. As well, in infants and children, these medications are dosed based upon weight.
4. Ibuprofen and acetaminophen may also be used for fever control.
5. Keep well hydrated and drink plenty of fluid.
6. Humidity may help sinuses and ears drain. It is important to be careful when using steam or hot water, especially around infants and children, to prevent scald burns.
7. Olive oil may be helpful for pain. A few drops in the ear canal may be soothing.
8. Other over-the-counter ear drops may also be helpful in decreasing pain
9. Herbal oils may be of use in helping with pain. A pharmacist or herbalist may be able to suggest specific herbal products.
10. Chewing or yawning may be helpful in easing pressure within the middle ear. Sometimes one can feel or hear popping sounds, like rice krispies, as the Eustachian tubes open and close to try to equalize pressure.
11. When flying, sucking on candy or having an infant feed on a bottle during take-off and landing may help as the plane changes altitude quickly
12. If the ear fullness is due to sinus pain, in addition to humidity, oxymetazoline (Afrin) nasal spray may be helpful (but should only be used for a maximum of three days). Salt water nasal spray may be used for a longer duration and more frequently.

Swimmer's ear treatment (otitis externa)

• Most cases are treated with prescription eardrops for 7-10 days.
• These drops contain an antibiotic to fight the infection, and often a steroid to reduce inflammation swelling.
• The drops are placed in the affected ear with the individual laying on their side. After the drops are placed, the patient should remain in this position for about 5 minutes to prevent the drops from running out of the ear.
• If the ear canal is very swollen, a wick or small piece of gauze material may be placed into the canal to allow the ear drops to reach the appropriate location.
• Occasionally, the health-care professional may prescribe an oral antibiotic as well as the eardrops. Pain medication either OTC or prescription is often needed for a few days until the infection is under control.
• The ear canal should be kept dry during treatment. An earplug or small cotton ball coated with Vaseline can be used during bathing to keep water out.
• In some cases the drainage in the ear builds up, and the infection won't clear until it is removed. Referral to an otolaryngologist (an ear, nose, and throat specialist) may be required.

Middle ear infection treatment (otitis media)

• There are different ways of approaching the treatment of otitis media. Depending upon the situation, the health-care professional may prescribe antibiotics immediately. This is most often used for adults who develop otitis media.
• Alternatively, in children, observation and comfort care may be appropriate, and if symptoms resolve in 2-3 days, no antibiotics may be necessary. The American Academy of Pediatrics recommends this two-step approach depending upon the age of the child, the certainty of the diagnosis, the severity of illness, and the ability of the child and family to have access to follow-up care.
• The decision about which course of treatment to use will depend upon the discussion between parent and health-care professional. A prescription for antibiotics may be provided to the parents or caregiver with the instructions not to fill the prescription for 2 to 3 days, and then only fill and use the prescription only if the symptoms persist.
• Symptomatic treatment may include pain control with over-the-counter or prescription pain medications, drinking plenty of fluids, and humidifying the air.

Bullous myringitis treatment

• Treatment for infections of the eardrum may include oral antibiotics, antibiotic ear drops, and pain medications.

Most earaches resolve after 1 to 2 days of treatment; however, the ear infection may recur even with appropriate therapy. It is important not to stop the course of treatment even though symptoms are relieved.

• Most often, follow-up with a health-care professional is not required unless complications occur because of the ear infection. These may include recurrent pain, fever, loss of hearing, nausea, or vertigo.
• People with recurrent infections may require hearing tests.
• Ruptured eardrums may require referral to an ear, nose, and throat specialist in case they do not heal on their own, and require surgery to help repair the eardrum defect.
• People who are immunocompromised or who have diabetes should be seen in follow- up care for a recheck.

• Often ear infections resolve without medical intervention.
• Individuals that require antibiotics also resolve the infection quickly, and pain relief should occur within a couple days.
• Associated symptoms, such as hearing loss or the feeling of ear fullness, may take longer to improve.
• Referral to an otolaryngologist (ear, nose, and throat specialist) may be needed for people with continuing infection, or those who get frequent, recurring infections.

Swimmer's ear (otitis externa)

Many cases of otitis externa may be prevented by decreasing the opportunity for water or moisture to enter the ear canal by taking the following measures.

• Carefully dry the ears after swimming or bathing
• Shake out excess water in the ear.
• Hold a hair drier on a low heat setting at least 12 inches from the ear
• Wear earplugs while swimming.

Pain in the outer ear also can be caused by putting objects into the ear canal.

• Do not use objects to clean the ear (for example, paper clips, Q-tips, bobby pins, or fingernails) that may tear the skin. Most people have ears that are self-cleansing, and cleaning with a cotton-tipped swab is unnecessary and potentially harmful. People who have excess wax buildup should have it removed by a health-care professional who can remove the debris under direct vision using an otoscope or with ear irrigation.
• Occasionally, a foreign object such as an insect can cause inflammation and pain, and will need to be removed by a health-care professional.

Middle ear (otitis media)

• Minimize exposure of infants and children to others with colds or upper respiratory infections. This may require altering day care visit patterns.
• Avoid bottle feeding in the supine (lying) position.
• Babies who are breastfed for the first 6 months have a decreased risk of developing ear infections.
• Eliminate pacifier use after 6 months of age.
• Avoid exposure to secondhand smoke.
• Keep immunizations current, including those for influenza.