Referred Ear Pain

Marcello Cherchi, Ph.D, MD • Page last modified: March 6, 2021

Otalgia means pain that is located in or about the ear. While ear pain most commonly comes from the external, middle or inne ear, it can also be referred from elsewhere in the body. There are many nerves that go to the ear, which means that there are many potential sources of pain. This complexity is reflected in the figure below.

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Anatomy of otalgia from Jaberet al, 2008.

Despite what is shown in the diagram above, there is actually considerable variation between individuals in the ear’s somatosensory innervation (4).

The table below summarizes the anatomy, innervation, and sources of referred pain (1, 2), with pathologies drawn from the statistics of a case series of 123 patients (1).

Part of ear innervated	Nerve	Frequency in case series (1)	Organs from which referred pain may arise	Pathologies to consider (with percentage frequency in case series (1))
• Tragus • Anterior auricle • Anterior wall of external canal • Anterior portion of the lateral tympanic membrane	Auriculotemporal nerve (branch of the mandibular division of CN V) and meningeal nerve (branch of the maxillary division of CN V)	46%	Temporomandibular joint Dentition Face Mastoid Anterior two-thirds of tongue	• Temporomandibular joint disease (28%) • Dental disease (9%) • Trigeminal neuralgia (3%) • Mandibular osteomyelitis/tumor (3%) • Parotid infection or tumor (3%)
• Posterior wall of external auditory canal • Posterior lateral surface of tympanic membrane • Posterior skin of auricle	Posterior auricular nerve (part of tympanic plexus, chorda tympani branch, and an unnamed branch of CN VII)	2%		• Vestibular schwannoma (2%) • Herpes zoster affecting facial nerve (1%)
• Middle ear • Upper Eustachian tube • Medial surface of tympanic membrane	Jacobson’s nerve and part of tympanic plexus (CN IX)	7%	Nasal cavity Nasopharynx Paranasal sinuses Palatine tonsils Tonsillar fossa Soft palate Oropharynx Posterior one-third of tongue Infratemporal fossa	• Sinusitis (3%) • Tonsillitis/pharyngitis (2%) • Pharyngeal tumor (1%) • Glossopharyngeal neuroma (1%) A separate case series (n=615) found that 3% of patients with a primary complaint of otalgia had a malignant tumor in the infratemporal fossa (3).
• Inferior and posterior aspects of the external auditory canal • Concavity of concha • Lateral surface of tympanic membrane	Inferior branch of Arnold’s nerve (auricular branch of CN X)	3%	Thyroid Infratemporal fossa Hypopharynx Larynx Trachea Esophagus Lung Abdominal viscera	The following can irritate the superior division of the laryngeal nerve (a branch of CN X) and be referred to the ear: • Gastroesophageal (laryngeal/pharyngeal) reflux (2%) • Cricopharyngeal spasm (1%) • Vagal stimulator (1%) Others: • Thyroiditis • Thyroid tumor • Laryngeal carcinoma
• Posterior auricle • Skin overlying the mastoid bone and parotid gland	Greater auricular nerve (C2 and C3) and lesser occipital nerve (C3) roots of the cervical plexus	42%	Cervical spine	Cervical spine degenerative disease (37%), including: • Osteoarthritis • Cervical facette disease • Spondylosis • Disc herniation • Spinal stenosis Other: • Whiplash (2%) • Cervical meningioma • Arnold-Chiari type I (1%) • Vascular (1%) • Fibromyalgia (1%) • Cervical nerve root cysts (1%)

Of note, most referred ear pain arises in cervical spine disease, followed closely by temporomandibular joint dysfunction.

References

1.         Charlett, S. D., and A. P. Coatesworth. 2007. Referred otalgia: a structured approach to diagnosis and treatment. Int J Clin Pract 61:1015-21.
2.         Jaber, J. J., J. P. Leonetti, A. E. Lawrason, and P. J. Feustel. 2008. Cervical spine causes for referred otalgia. Otolaryngol Head Neck Surg 138:479-85.
3.         Leonetti, J. P., J. Li, and P. G. Smith. 1998. Otalgia. An isolated symptom of malignant infratemporal tumors. Am J Otol 19:496-8.
4.         Shah, R. K., and N. H. Blevins. 2003. Otalgia. Otolaryngol Clin North Am 36:1137-51.