Ear Pain: Causes and Relief

Types of ear pain

Ear pain is divided into two groups:

• Primary ear pain comes from the ear itself: the ear canal, eardrum, or middle ear. Something is usually visible when a doctor looks inside.
• Referred (secondary) ear pain comes from nearby structures that share nerves with the ear: the jaw joint, teeth, throat, tonsils, sinuses and neck. The ear looks normal on examination. This accounts for about half of earaches in adults.

Common causes of ear pain

Middle ear infection (otitis media)

Acute otitis media is an infection behind the eardrum. It often follows a cold, when the eustachian tube swells and fluid builds up and becomes infected. It is most common between 6 months and 3 years of age. It causes ear pain, fever, irritability, poor sleep, and muffled hearing. Young children may pull at their ears. If the eardrum bursts, pus drains out and the pain often eases quickly. The perforation usually heals within a few weeks.

Swimmer's ear (otitis externa)

Otitis externa is an infection of the ear canal skin. Water, cotton swabs, earbuds and eczema make it more likely. The ear canal becomes itchy, then painful and swollen, and pulling on the earlobe or pressing the tragus (the flap in front of the canal) hurts. There may be discharge and muffled hearing.

Eustachian tube dysfunction

The eustachian tube connects the middle ear to the back of the nose and balances pressure. When it is blocked by a cold or allergy, you feel fullness, popping, muffled hearing and mild pain. Eustachian tube dysfunction usually clears as the cold resolves.

Earwax

A large plug of earwax (cerumen impaction) causes fullness, muffled hearing and sometimes discomfort. Cotton swabs push wax deeper.

Barotrauma

Rapid pressure changes during flying or diving stretch the eardrum, causing pain, fullness and sometimes bleeding. See barotrauma.

Referred causes of ear pain

TMJ disorders

The jaw joint sits just in front of the ear. Temporomandibular joint disorder causes ear pain with chewing, jaw clicking, jaw stiffness and headaches. Teeth grinding and clenching are common triggers. It is one of the most common causes of ear pain in adults with a normal-looking ear.

Throat infections

Tonsillitis, strep throat and peritonsillar abscess cause pain that shoots to the ear when you swallow. A peritonsillar abscess also causes difficulty opening the mouth and a muffled voice.

Dental problems

An infected or impacted molar, especially a wisdom tooth, can cause ear pain on the same side.

Neck and nerve causes

Neck arthritis and muscle tension, trigeminal and glossopharyngeal neuralgia (brief, electric shock-like pain), and shingles affecting the ear (Ramsay Hunt syndrome, with a blistering rash and facial weakness) can all cause ear pain.

Less common but important

Persistent one-sided ear pain with a normal ear in an adult who smokes or drinks heavily can be referred pain from a cancer in the throat, tongue base or voice box. It needs examination by an ENT specialist.

Ear pain in adults vs children

Children get middle ear infections far more often because their eustachian tubes are shorter and more horizontal. In adults, middle ear infections are less common, and swimmer's ear, TMJ problems and referred pain are more likely causes. Adults with recurrent middle ear infections, or fluid in one ear that does not clear, should see an ENT doctor to check the back of the nose.

Complications to know about

• Mastoiditis: spreading infection into the bone behind the ear, with swelling, redness and the ear sticking out. See mastoiditis.
• Malignant otitis externa: a severe ear canal infection that spreads to bone, mainly in older adults with diabetes. It causes severe, constant pain and discharge.
• Hearing loss: usually temporary from fluid, but persistent fluid in children can affect speech development.
• Meningitis: rare.

How doctors diagnose ear pain

A doctor will look in the ear with an otoscope to check the canal and eardrum. A pneumatic otoscope puffs air to test eardrum movement. If the ear looks normal, they examine the jaw, teeth, throat, neck and cranial nerves. Hearing tests, tympanometry or, in persistent cases, a nasal endoscopy or scan may follow.

Treatment and ear pain relief

At home

• Pain relief: acetaminophen (paracetamol) or ibuprofen at the label or weight-based dose. Do not give aspirin to children or teenagers.
• Warm compress: a warm (not hot) cloth over the ear for 10 to 20 minutes.
• Rest upright: sleeping slightly propped up can ease middle ear pressure.
• For flying: swallow, yawn or chew gum during descent. Give babies a bottle or breastfeed.
• Keep the ear dry if you have swimmer's ear or a burst eardrum. Do not put cotton swabs or objects in the ear.

Medical treatment

• Middle ear infection: many children over 6 months with mild symptoms are given 48 to 72 hours of pain relief and watchful waiting, as most improve without antibiotics. Antibiotics are recommended for infants under 6 months, severe pain or high fever, infections in both ears under 2 years, or pus draining from the ear.
• Swimmer's ear: antibiotic ear drops, sometimes with steroid, for 7 to 10 days. A wick may be placed if the canal is very swollen. Oral antibiotics are rarely needed.
• Earwax: softening drops, irrigation or removal by a clinician.
• TMJ disorder: soft diet, jaw rest, heat, anti-inflammatory medicine, a night guard and jaw exercises.
• Throat or dental causes: treating the infection or tooth.
• Recurrent ear infections: ear tubes (tympanostomy tubes) may be recommended for children with frequent infections or persistent fluid.

Prevention

• Keep children up to date with pneumococcal and flu vaccines.
• Avoid exposure to cigarette smoke.
• Breastfeed if possible, and avoid bottle-propping.
• Dry ears after swimming, and do not use cotton swabs.
• Use earplugs for frequent swimming if you are prone to swimmer's ear.

Frequently asked questions

What causes ear pain in adults?

In adults, common causes are swimmer's ear, eustachian tube problems, earwax, TMJ disorders, throat infections and dental problems. About half of adult earaches are referred from nearby structures, so the ear itself may look normal.

Why does my ear hurt when I swallow?

Ear pain on swallowing usually comes from a throat infection such as tonsillitis or pharyngitis, because the throat and ear share nerves. It can also occur with a middle ear infection or eustachian tube problem. A peritonsillar abscess causes severe one-sided pain and needs urgent care.

How long does ear pain last?

Ear pain from a middle ear infection usually improves within 2 to 3 days and clears within a week. Swimmer's ear improves within 2 to 3 days of starting drops. Pain lasting more than 3 days, or getting worse, should be checked.

Do ear infections need antibiotics?

Not always. Many middle ear infections clear on their own, so children over 6 months with mild symptoms often wait 2 to 3 days with pain relief first. Antibiotics are used for young infants, severe infections, or when symptoms do not improve. Swimmer's ear is treated with drops.

What is the fastest way to relieve ear pain?

Acetaminophen (paracetamol) or ibuprofen at the correct dose, a warm compress, and resting upright usually help quickly. Prescription anesthetic ear drops may be used if the eardrum is intact. Avoid putting anything into the ear canal.

Can ear pain be caused by the jaw?

Yes. The jaw joint sits right next to the ear, and TMJ disorders are a common cause of ear pain in adults. Clues include pain when chewing, jaw clicking, stiffness in the morning, and teeth grinding.