The cause of otalgia in adults may be simple and straightforward in many cases with an obvious ear infection, injury or foreign body. This is known as primary otalgia and the diagnosis is usually straightforward and the problem usually responds to standard treatments.
Unlike children, many adults with ear pain, however, present with a normal ear exam. When the source of the ear pain is not obvious, a thorough history of the ear pain as well as an ear, nose and throat exam is needed. Ear pain in the absence of an obvious infection or injury can be due to many possible etiologies. The complexity of the diagnosis is related in part to the number of nerves that supply the ear with sensation. There are six nerves that supply sensation to the ears. Problems along the courses of any of these nerves can present as ear pain, when the problem actually has nothing to do with the ear itself. This is called “referred otalgia” and one of the most common causes of ear pain. In up to 50% of adults complaining of ear pain, the pain is the result of referred otalgia arising from non-otological disease.
It is not that the ear pain does not exist in referred otalgia, it is that the pain is not coming from the ear. For example, if an adult presents with bilateral ear pain, this is rarely due to bilateral ear infections and usually is a form of referred otalgia. In adults, middle ear infections are often over-diagnosed and patients receive unnecessary prescriptions for antibiotics and steroids. These may help temporarily ease the pain, but if the underlying cause of the ear pain is not a middle ear infection, then the ear pain will return.
The possible causes for referred pain are numerous, ranging from benign conditions such as TMJ, tonsillitis or sinus disease to significant problems such as reflux or nasopharyngeal cancer. If otalgia is due to a problem that is not revealed by the history or direct exam, diagnostic imaging (for example, dental X Rays, CT or MRI) or other testing/procedures may be useful.