Earache is any pain felt, or perceived to be felt, in the ear. Primary earache is due to some form of inner or outer ear disease. Secondary earache is due to, or associated with, problems elsewhere in the body, in which the pain is felt in the ear (referred pain).  

Causes and associated conditions 

Earache is common in children, whose Eustachian tube anatomy predisposes them to more infections. Incidence also peaks in summer, when allergies and swimming play a role. Smoking also predisposes to ear infection, and affects children as passive smokers. 

Primary earache may be due to conditions affecting the

  • Outer ear canal – trauma, foreign bodies, infection, (otitis externa), impacted wax, malignancies, allergies;
  • Middle or inner ear – (otitis media) acute or chronic infection, ruptured eardrum, Eustachian tube dysfunction

Secondary earache is associated with

  • Tooth infection
  • Temporo-mandibular (jaw)joint problems
  • Parotid (salivary) gland disorders
  • Tonsillitis, pharyngitis, sinusitis
  • Cancer of the tongue, pharynx or oesophagus
  • Neck vertebrae C2 &C3 lesions

Diagnosis and tests


  • Adults can describe earache, but small children cannot. In them, earache may need to be inferred from head-shaking, losing balance, crying, irritability, refusing feeds (infants), clutching at the ear, or other unusual behaviour.
  • Older children and adults may describe the type of pain, for example ache or sharp, when it started, previous history of earache, what makes it worse, and other associated symptoms such as nausea, fever, abnormal noises, vertigo, hearing loss, fluid discharge from the ear or pain elsewhere.

Examination of the ear usually provides the diagnosis.

  • Pulling the ear slightly upwards will cause pain in nearly all cases of otitis externa, and examining the ear canal may reveal for instance a foreign body, impacted wax or infection as the cause.
  • Inspecting the ear canal and drum with an otoscope may show drum abnormalities, middle ear infection, or fluid discharge. Tympanometry and audiology can measure the flexibility of the eardrum and assess hearing loss.

General examination may find signs of associated disorders, such as jaw problems, tooth infection, oral cancers, These will need investigating on their own merits, for instance X-rays or scans, or referral to other specialists.


  • Perforation of the eardrum
  • Mastoiditis – may be a medical emergency
  • Long-term hearing loss


General steps include

  • Stop smoking, and keep children away from environmental cigarette smoke
  • Control allergies
  • Keep the ear canals dry – for example after swimming, or hair-washing
  • Avoid putting foreign objects like cotton-tipped buds in the ears
  • Infants must not be lying down when fed
  • Older children may relieve Eustachian tube discomfort by chewing gum

Otitis externa management involves

  • Treating any infection (antibiotics)
  • Treating inflammation
  • Relieving pain – avoid aspirin in children
  • Microbiological culture of resistant organisms in recurrent or non-responsive cases.
  • Problems here are usually limited to the ear canal, so topical medication – drops or creams – may be enough.

Otitis media, or middle ear infections, may need systemic (oral) treatment for pain, fever and infection, as described for otitis externa. They may also need surgical intervention to drain fluid behind the eardrum (refer to 'Glue ear').

Any complications such as mastoiditis must immediately be referred to an ear, nose & throat specialist for urgent attention.

Medications such as antihistamines and cortisone are not recommended, unless used for a specific indication and prescribed by a specialist.

(Dr AG Hall)

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