Cause	History	Physical findings	Comments
Tumors (e.g., parotid, hypopharynx, nasopharynx, base of tongue, tonsillar fossa, larynx, esophagus, intracranial, cervical spine)4	Risk factors include smoking, alcohol use, age older than 50 years, hoarseness, dysphagia, radiation exposure, weight loss	May require fiberoptic nasolaryngoscopy	Consider referral for invasive examination and MRI
Neuralgias (e.g., trigeminal, glossopharyngeal, geniculate, sphenopalatine)1,4	Pain usually brief (seconds), severe, lancing, jabbing, electric-shock–like, episodic	Usually none May have trigger point	Trigeminal neuralgia (tic douloureux) best defined
Bell's palsy 23,24	Retroauricular pain, less severe than Ramsay Hunt syndrome; can precede or follow the palsy	Peripheral facial palsy (involvement of forehead)	Pain occurs in 25 to 50 percent of patients with Bell's palsy
Temporal arteritis25 *	Age older than 50 years Jaw claudication Diplopia	Temporal arteries may be tender, prominent, or beaded	Erythrocyte sedimentation rate usually greater than 50 mm per hour Biopsy and prompt treatment are indicated
Oral aphthous ulcers	Localized pain in mouth as well as ear	Shallow ulcers with gray, necrotic base	Often recurrent Etiology not well defined
Cervical adenopathy	May have recent upper respiratory infection or scalp lesion	Tender cervical or periauricular lymph nodes	Consider CT and fine needle aspiration for lymph nodes > 1.5 cm, lasting longer than six weeks
Myofascial pain, muscle spasm or inflammation of sternocleidomastoid or muscles of mastication26,27	Pain aggravated by chewing or head movement	May have trigger point	Can be caused by clenching, bruxism, TMJ syndrome, and dental or oral disorders
Eagle's syndrome (elongation of styloid process)28	Deep, unremitting pain exacerbated by swallowing, yawning, or chewing May have pain in neck, foreign body sensation in throat	Reproduce pain with tonsillar fossa palpation	Diagnosed with CT Most patients are 3 to 40 years of age and have had a tonsillectomy Styloid process longer than 1 inch (2.5 cm)
Sinusitis/sinogenic referred pain from allergy29	Nasal congestion Pain in maxillary sinuses	Nasal congestion Tender over maxillary sinuses	Sinusitis is common but otalgia from sinusitis is unusual
Carotidynia30	May have dysphagia and throat tenderness	Tender carotid artery	More common in women May have abnormal enhancement on MRI
Thyroiditis	May report pain in thyroid	Thyroid may be tender or enlarged	Referred pain from cranial nerve X (vagus)
Salivary gland disorders (e.g., stones, mumps)	Pain in preauricular area	Prominent, tender parotid glands	There have been recent epidemics of mumps in the United States
Cricoarytenoid arthritis31	Ear pain and hoarseness Pain is worse with speaking, coughing, or swallowing	May have other features of inflammatory arthritis	Often caused by rheumatoid arthritis or systemic lupus erythematosus
Gastroesophageal reflux32,33	Heartburn Acid reflux	Usually none	Pain caused by irritation of oropharynx (cranial nerves IX [glossopharyngeal] and X) or of eustachian tube orifice
Angina pectoris, myocardial infarction34 *	Cardiac risk factors	Usually none	If suspected, obtain electrocardiogram and serum troponin level
Thoracic aneurysms (e.g., innominate artery, thoracic aorta)*	More common in older men May have hypertension and other risk factors for atherosclerosis	May have chest or back pain	Obtain chest CT scan or magnetic resonance angiogram; plain chest radiography is insensitive
Psychogenic (e.g., depression, anxiety)35	History of depression or anxiety	Blunted affect Depressed mood	Consider in patients with idiopathic otalgia
Other rare causes (e.g., subdural hematoma, lung cancer,36,37 * central line placement,38 pillow otalgia,39 carotid artery aneurysm)	Variable	Variable	Lung cancer is the best described of these rare causes