externa swimming psoriasis seborrheic dermatitis q-tips in the ear bilateral pain scaling itching pain exacerbated when ear is pulled may see granulation tissue in canal on exam necrotizing/malignant otitis externa* diabetes immuno-compromised constant pain with increasing severity at night* purulent discharge* pain out of proportion to exam findings* biopsy granulation tissue for culture chondritis vs perichondritis recent ear trauma (i.e. ear piercing) external ear appears inflamed chondritis more likely than perichondritis if ear shape is distorted referred causes diagnosis features gerd bilateral pain neuralgia pain described as tingling/sharp/burning sensation; episodes can start with light touch malignancy* weight loss* arthritis of the neck pain exacerbated by neck movement eagle syndrome swallowing exacerbates pain infected 3rd molar extreme food temperatures exacerbate pain temporal arteritis* patient age > 50* chewing exacerbates pain* tmj dysfunction patient grinds teeth bilateral pain pain + crepitus with tmj palpation jaw clicking *indicates a "can't miss" diagnosis or a red flag. other causes diagnosis features barotrauma recent ear trauma recent scuba diving or flying (+/- onset of pain coinciding with event) hearing loss eustachian tube dysfunction pain described as ear pressure or "plugged up" sensation in ears unilateral hearing loss crackling/gurgling sounds in ear history of seasonal allergies poor light reflex and tm mobility air-fluid levels present cerumen impaction q-tips in the ear pain described as ear pressure or "plugged up" sensation in ears may need to remove any ear wax present to rule this out as the underlying etiology management management of ear pain depends on the underlying cause. antibiotics while not all causes of ear pain are treated with antibiotics, those caused by bacterial infections of the ear are usually treated with antibiotics known to cover the common bacterial organisms for that type of infection. many bacterial ear infections are treated with cleaning of the area, topical or systemic antibiotics, and oral analgesics for comfort. some types of bacterial ear infections can benefit from warm compresses included in the treatment. some of the causes of ear pain that are typically treated with either a topical or systemic antibiotic include: uncomplicated acute bacterial otitis externa (aoe). for symptoms that are not responsive to treatment within 10 days, a physician should evaluate for necrotizing external otitis. acute otitis media (aom) self-resolves within 24–48 hours in 80% of cases. if it does not self-resolve, aom thought to be caused by bacteria is treated with systemic antibiotics. if symptoms do not respond to a week of treatment, a physician should evaluate for mastoiditis. acute folliculitis. auricular cellulitis. suppurative otitis media. there is also a risk for tympanic membrane rupture. perichondritis. an otorhinolaryngologist should also evaluate it and if a foreign body is present in the cartilage, this foreign body should be removed. if there is cartilage involvement, then more advance care with hospitalization is needed. sinusitis can cause secondary ear pain. treating the underlying sinusitis will treat the ear pain. (see sinusitis.) some bacterial infections may require a more advanced treatment with evaluation by otorhinolaryngology, iv antibiotics, and hospital admission. necrotizing external otitis is potentially fatal and should be evaluated by an otorhinolaryngologist with admission to the hospital and iv antibiotics.(see otitis externa.) acute mastoiditis is treated with admission to the hospital, otorhinolaryngology consultation and empiric iv antibiotics. cases with intracranial involvement are treated with a mastoidectomy with myringotomy. chondritis. procedures some causes of ear pain require procedural management alone, by a health professional, or in addition to antibiotic therapy. keratosis obturans is treated with removal of impacted desquamated keratin debris in the ear canal. chronic perichondritis and chondritis that continues to be symptomatic despite appropriate antibiotic management may require surgical debridement. surgical drainage could be required. bullous myringitis leads to the development of bullae on the tympanic membrane that can be punctured to give pain relief. foreign body in the ear canal can cause pain and be treated with careful removal. infected sebaceous cyst is treated with incision and drainage of the cysts, oral antibiotics and otorhinolaryngology assessment. other given the variety of causes of ear pain, some causes require treatment other than antibiotics and procedures. relapsing polychondritis is an autoimmune disease treated with immunomodulating medications (medications that help modulate the immune system). temporomandibular joint dysfunction can lead to secondary ear pain and can be initially treated with a soft food diet, nsaids, application of a heat pack, massage of local area, and a referral to a dentist. myofascial pain syndromes are initially treated with nsaids and physical therapy. local anesthetic injection into the muscle trigger point can be considered in severe cases. glossopharyngeal neuralgia is treated with carbamazepine. epidemiology 2/3 of people presenting with ear pain were diagnosed with some sort of primary otalgia and 1/3 were diagnosed with some sort secondary otalgia. a common cause of primary otalgia is ear infection called otitis media, meaning an infection behind the eardrum. the peak age for children to get acute otitis media is ages 6–24 months. one review paper wrote that 83% of children had at least one episode of acute otitis media by 3 years of age. worldwide, there are 709 millions cases of acute otitis media every year. hearing loss globally due to ear infection is estimated to be 30 people in every 10,000. around the world there is around 21,000 to 28,000 deaths due to complications from ear infections. these complications include brain abscesses and meningitis. otitis externae peaks at age 7–12 years of age and around 10% of people has had it at least once in their lives. cerumen impaction occurs in 1 out of every 10 children, 1 in every 20 adults and 1 in every 3 elderly citizens. barotrauma occurs around 1 in every 1000 people. of people presenting with ear pain, only 3% was diagnosed with eustachian tube dysfunction. history professor anton friedrich von tröltsch 1869 o. roth, inventor of the otoscope not much was known about ear pain and acute otitis media before the 17th century. it was a common phenomenon with no treatment. that changed when the otoscope was invented in the 1840s by anton von troeltsh in germany. another shift came with the invention of antibiotics. before antibiotics was introduced there use to be a high rate of ear infections spreading to the bone around the ear, but that is now considered a rare complication. society and culture there was previously a strong tradition of treating acute otitis media with amoxicillin. one quote from the 1980s shows this sentiment by saying "any child with an earache has an acute amoxicillin deficiency". however, people started realizing that using antibiotics too much can cause bacteria to gain resistance. increasing resistance makes antibiotics less effective. the term antibiotic stewardship is then used to describe the systematic effort to educate antibiotic prescribers to only give these medications when they are warranted. in particular to children, most ear pain resolves by itself with no complications. there are guidelines in place to help determine when antibiotics for ear pain are needed in children. the ear itself played a role in treatment via acupuncture, also known as auriculotherapy. it was believed that acupuncture of the ear could be used to correct other pain or disorders in the body. such practices may have started as far back as the stone age. the first documentation of auriculotherapy in europe was in the 1600s. one physician described stimulating the ear by burning or scarring to treat sciatic pain, while another physician applied this treatment for toothache. paul nogier is known as the father of ear acupuncture for his theory that parts of the ear corresponds to other areas of the body in a reliable fashion. research there are currently studies going on delivering antibiotics directly into the middle ear.