[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [ENT](https://durgical.com/en/ent/) › [Ear: approach to complaints](https://durgical.com/en/ent/areas/ear/) › Approach to earache: from the ear or referred

# Approach to earache: from the ear or referred

- Approach to a complaint

If otoscopy is normal, earache usually comes from elsewhere: the teeth, the jaw joint, the throat or the larynx.

Updated Nov 5, 2026

## Key points

- Otoscopy separates primary from referred earache.
- The ear receives branches of nerves V, VII, IX and X and of C2 and C3, so dental, throat and laryngeal problems can hurt there.
- Pain on pulling the auricle or pressing the tragus: otitis externa.
- An older diabetic with severe earache and granulation tissue in the canal: necrotising otitis externa.
- Persistent earache with a normal ear in a smoker: laryngoscopy to rule out cancer.

## What it is

Earache is primary when it arises in the outer, middle or inner ear, and secondary or referred when it comes from another organ that shares nerves with the ear: the trigeminal, facial, glossopharyngeal and vagus nerves and the C2 and C3 roots. Otoscopy is the deciding step. With an abnormal ear, think of otitis externa, acute otitis media and their complications; with a normal ear, look for dental, temporomandibular, pharyngeal, laryngeal or cervical causes. In an adult who smokes or drinks, persistent earache with a normal ear means ruling out cancer of the pharynx or larynx.

## Key questions in the history

- Since when? Fever or a recent cold?
- Swimming, ear instrumentation or hearing aids?
- Discharge, hearing loss, vertigo or facial weakness?
- Diabetes or immunosuppression?
- Pain on chewing, teeth grinding, toothache?
- Painful swallowing, hoarseness, trouble swallowing, weight loss, tobacco or alcohol?

## Causes and classification

- Primary earache: otitis externa, acute otitis media, bullous myringitis, foreign body, impacted wax, trauma, mastoiditis and herpes zoster oticus.
- Referred through the trigeminal nerve (V): teeth, temporomandibular joint, paranasal sinuses and parotid.
- Through the glossopharyngeal (IX) and vagus (X) nerves: tonsils, pharynx, pain after tonsillectomy, larynx and hypopharynx, including cancer.
- Through C2 and C3: the cervical spine.
- Others: giant cell arteritis.

## Step-by-step approach

- Do otoscopy in every earache: it decides whether the pain is primary or referred.
- Pain on pulling the auricle or pressing the tragus, with a swollen canal: otitis externa.
- Bulging eardrum with effusion, fever and a recent cold: acute otitis media.
- Check behind the ear: redness, tenderness and a displaced auricle suggest mastoiditis.
- Look for vesicles on the auricle or in the canal and facial weakness: herpes zoster oticus.
- With normal otoscopy, examine the teeth, temporomandibular joint, pharynx, larynx and neck.
- In an adult smoker or drinker with persistent earache and a normal ear, arrange laryngoscopy.

## Primary versus referred earache

| Cause | Key clue | Otoscopy |
| --- | --- | --- |
| [Acute otitis externa](https://durgical.com/en/conditions/otitis-externa/) | Pain on pulling the auricle; water or instrumentation | Swollen canal with discharge |
| [Acute otitis media](https://durgical.com/en/conditions/acute-otitis-media/) | Fever, cold, irritable child | Bulging, dull eardrum |
| Necrotising otitis externa | Older diabetic, severe pain | Granulation tissue in the canal |
| [Mastoiditis](https://durgical.com/en/conditions/acute-mastoiditis/) | After otitis media; pain behind the ear | Abnormal eardrum, displaced auricle |
| Temporomandibular disorder | Pain on chewing, teeth grinding, clicking | Normal |
| Dental cause | Pain on biting or with cold | Normal |
| Tonsillopharyngitis or post-tonsillectomy | Painful swallowing | Normal |
| [Cancer of the pharynx or larynx](https://durgical.com/en/conditions/laryngeal-cancer/) | Smoker, hoarseness, trouble swallowing, neck node | Normal |

## Red flags

- A diabetic or immunosuppressed patient with severe earache, discharge and granulation in the canal: necrotising otitis externa.
- Tender swelling behind the ear or a displaced auricle: mastoiditis.
- Associated facial palsy, vertigo or sensorineural hearing loss.
- Severe headache, neck stiffness or reduced consciousness: intracranial complication.
- Persistent referred earache with hoarseness, trouble swallowing, weight loss or a neck lump.
- Over 50 with temporal headache and jaw claudication: giant cell arteritis.

## Next step / Initial management

- Acute otitis media: pain relief (paracetamol or ibuprofen); if treating, amoxicillin is first line; watchful waiting in selected mild cases.
- Otitis externa: canal cleaning, antibiotic ear drops (with or without a corticosteroid) and pain relief.
- Mastoiditis or necrotising otitis externa: urgent same-day referral to hospital for imaging, intravenous antibiotics and ENT.
- Referred earache: treat the cause (dentistry, temporomandibular care); priority ENT referral if it persists with a normal ear in a smoker or drinker.

## Test yourself

Think of the answer, then tap the question to see it.

## A 70-year-old diabetic man has 3 weeks of severe right earache, discharge and granulation tissue in the canal. What do you suspect?

Necrotising otitis externa, almost always Pseudomonas aeruginosa. It needs urgent referral, imaging and intravenous antipseudomonal antibiotics.

## A 60-year-old smoker has had left earache for 2 months, hoarseness and normal otoscopy. What must you rule out?

Earache referred from cancer of the larynx or hypopharynx (through the vagus nerve): laryngoscopy and priority ENT referral.

## Which nerves explain referred earache?

The trigeminal (V), facial (VII), glossopharyngeal (IX) and vagus (X) nerves and the cervical roots C2 and C3.

## A child with acute otitis media develops tender swelling behind the ear and the auricle is pushed forward. What do you do?

Suspect mastoiditis: under IMCI (AIEPI) the child is referred urgently to hospital for intravenous antibiotics, imaging and ENT.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/ent/approach-to-earache-from-the-ear-or-referred/)

## Connections

## Related 4

- [Otoscopy: technique and the normal eardrum](https://durgical.com/en/ent/otoscopy-technique-and-the-normal-eardrum/)
- [External and middle ear: applied anatomy](https://durgical.com/en/ent/external-and-middle-ear-applied-anatomy/)
- [Otitis media in children: watchful waiting and ear tubes](https://durgical.com/en/ent/otitis-media-in-children-watchful-waiting-and-ear-tubes/)
- [Head and neck cancer: red flags and urgent referral](https://durgical.com/en/ent/head-and-neck-cancer-red-flags-and-urgent-referral/)

## Related conditions 2

- [Acute otitis media](https://durgical.com/en/conditions/acute-otitis-media/)
- [Otitis externa](https://durgical.com/en/conditions/otitis-externa/)

[← All of ENT](https://durgical.com/en/ent/)

Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.

Sources: [Otalgia](https://www.ncbi.nlm.nih.gov/books/NBK549830/) (StatPearls Publishing (NCBI Bookshelf), 2024); [Acute Otitis Media](https://www.ncbi.nlm.nih.gov/books/NBK470332/) (StatPearls Publishing (NCBI Bookshelf), 2026); [Otitis Externa](https://www.ncbi.nlm.nih.gov/books/NBK556055/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Necrotizing (Malignant) Otitis Externa](https://www.ncbi.nlm.nih.gov/books/NBK556138/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Mastoiditis](https://www.ncbi.nlm.nih.gov/books/NBK560877/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Outpatient Clinical Care for Pediatric Populations](https://www.cdc.gov/antibiotic-use/hcp/clinical-care/pediatric-outpatient.html) (Centers for Disease Control and Prevention (CDC), 2024); [Cuadro de procedimientos: Atención Integrada a las Enfermedades Prevalentes de la Infancia (AIEPI)](https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/PP/cuadro-procedimientos-atencion-integrada-enfermedades-prevalentes-infancia.pdf) (Ministerio de Salud y Protección Social, Colombia, 2018).

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/ent/approach-to-earache-from-the-ear-or-referred/