Inflammation or irritation of the cranial nerves V (trigeminal nerve), VII (facial nerve), IX (glossopharyngeal nerve), X (vagus nerve), or cervical nerves C1 through C3 may result in ear pain, otherwise known as otalgia.¹ Otalgia can be classified as either primary otalgia or secondary otalgia. Primary otalgia is ear pain that results from the ear itself, and secondary otalgia is ear pain that results from another primary source² (Table 21.1). The ear anatomy includes the auricle, the external auditory meatus and canal, the tympanic membrane, and the middle ear.

In children, primary otalgia is typically the presenting symptom for otitis media or otitis externa.²,³,⁴ Not often present in adults, this diagnosis is found in higher prevalence among children. Otitis media and otitis externa are inflammatory conditions and can be acute or chronic. Acute otitis media presents with a recent history of upper respiratory illness and an inflamed tympanic membrane. Acute otitis media is the most common cause of primary otalgia in children. Otitis externa usually presents with a recent history of water exposure (ie, swimming) with drainage or discharge present from the auditory canal. Primary otalgia can also result following surgery, from trauma, skin pathology or irritation, viral infection, or sunburn.

Secondary otalgia is more common in adults and is referred ear pain as a result of another underlying pathology.⁵ Secondary otalgia may result from temporomandibular jaw (TMJ) syndrome, pharyngitis, tonsillitis, dental causes, cervical spine arthritis, or malignancy involving the head, neck, or chest. TMJ syndrome causes otalgia during chewing or talking and is accompanied by crepitus or tenderness at the joint of the TMJ. Infections to the sinuses, pharynx, and tonsils may also result in secondary otalgia. Similarly, dental infections may also cause secondary otalgia, especially when molars are involved. Investigation of secondary otalgia should include a thorough history as well as examination of the face, mouth, dentition, neck, and pharynx. Special consideration should be taken to rule out malignancy in high-risk patients. For example, malignancy of the chest can cause referred otalgia via the vagus nerve (CN X). Other sources such as gastroesophageal reflux, myofascial pain, salivary gland disorders, sinusitis, myocardial infarction, temporal arteritis, or thoracic aneurysms are atypical possible causes of otalgia.

Inflammation of cranial nerves V, VII, and IX is commonly implicated in otalgia.⁵ Most common neuralgias are trigeminal and sphenopalatine. Pain can be elicited by palpation of the middle ear and mastoid with an otherwise normal ear examination.

Otalgia can occur after surgical procedures involving the ear and mastoid. Surgical procedures such as myringotomy/tube insertion, middle ear, or mastoid procedures may result in postsurgical otalgia.⁶,⁷,⁸,⁹ Pain is commonly seen after mastoidectomy and is characterized by tenderness to the mastoid cavity. In addition to postsurgical pain, these procedures are often accompanied by postoperative nausea and vomiting. Postoperative pain for patients who have undergone a mastoidectomy or tympanoplasty typically have pain for up to 2 weeks. This pain is managed by oral pain medication such as ibuprofen or acetaminophen.⁸ Perioperative pain control for children who are undergoing myringotomy procedures may be treated with either intranasal or intravenous fentanyl.⁷ In addition, local anesthetic or steroidal injections may be used to treat acute postoperative pain.⁶