Pain in the ears can be caused by a number of different problems, both inside the ear and out. I see a lot of patients with ear pain who are convinced that they are having ear infections because their ear hurts. Sometimes they have received several rounds of antibiotics with no help.

Ear infections and problems inside the ear can certainly cause earache, but there are many other problems away from the ear that can cause referred pain to the ear.

Causes of earache:

1. Problems inside the ear:  

• Middle ear infection (otitis media). Caused by fluid buildup behind the eardrum which becomes infected. Will ALWAYS have associated hearing loss because the fluid limits the normal transmission of sound to the inner ear
• Outer ear infection (otitis externa, a.k.a. “swimmers ear”). An infection outside the eardrum within the ear canal.  Can be triggered by water that gets in the ear from swimming or bathing. Usually patients will notice drainage from the ear but not always. There is usually pain with manipulation of the ear.
• Ear wax impaction can sometimes cause pain.
• Eustachian tube dysfunction.  Caused by blockage of the Eustachian tube between the middle ear  and the back of the nasal cavity (usually due to allergy or upper respiratory infection). This causes the pressure behind the eardrum to become different from the atmosphere around you. This sometimes can lead to otitis media if fluid builds up behind the ear drum.
• Tumors or other growths in the ear (fortunately, these are rare).

2. Problems in areas next to the ear

• TMJ pain (temporomandibular joint pain). Caused by arthritis or stress in the jaw joint which sits directly in front of the ear. This is very common.
•  Muscle pain: usually in the chewing muscles, the sternocleidomastoid muscle     (below the ear), or the temporalis muscle (above the ear).
• Fibromyalgia: this is a whole-body pain disorder that can affect the ears and muscles around the ears.

3. Problems in areas remote from the ear. All of these are due to referred nerve pain from other areas:

• Tonsillitis/throat infection/sore throat
• Sinus infection
• Acid reflux
• Tooth pain or infection
• Teething in infants
• Cervical spine problems in the neck
• Cancers in the back of the nose or throat

4. Nerve pain (pain produced by the brain or from abnormal nerve signals)

• Migraines.  A newer concept of migraines is that they are not only headaches but are a “global disorder of sensation.”  Many unpleasant symptoms can be caused by migraines including pain in the ears and throughout the body, nausea/vomiting, dizziness, ringing in the ears, and allergic symptoms in the nose.
• Neuropathic pain: This is pain produced by the nerves themselves.  It can be caused by diabetes or other underlying disorders.

When any patient comes to see me for ear pain, the first step is to take a careful history and perform a head and neck physical exam.  A good clue that the ear pain is not caused by an ear infection is the absence of hearing loss.  In certain patients, further testing such as an audiogram (formal hearing test) or tympanograms (a test to check the pressure behind the eardrum) might be helpful.