Etiology	History	Physical examination	Additional information
Subacute etiologies
Bell palsy	Retroauricular pain that is less severe than with Ramsay Hunt syndrome	Facial weakness that involves the forehead with otherwise unremarkable examination	Pain may occur in only 50% of patients
Carotidynia	May have dysphagia or throat or neck tenderness radiating to the ear	Tender carotid artery	More common in women and often self-limited
Cervical adenopathy	Recent upper respiratory tract infection	Tender cervical lymph nodes	Consider biopsy or imaging for lymph nodes > 1.5 cm and lasting longer than two months
Cervical spine arthritis	Pain with neck movement	Reduced range of motion; tense paraspinal muscles	Referred pain from C2 and C3 cervical nerve roots
Cricoarytenoid arthritis	Pain is worse with talking, swallowing, or coughing	Inflammatory arthritis	Likely caused by rheumatoid arthritis or systemic lupus erythematosus
Dental causes (caries, abscess, pulpitis)	Dental symptoms	Caries; abscess; gingivitis; facial swelling	Caries and abscess are the most common causes
Gastroesophageal reflux	Acid reflux	Unremarkable	Pain from irritation of cranial nerves IX and X
Head and neck tumors	Increased risk: smoking, alcohol use, age ≥ 50 years, radiation exposure, weight loss	Possible painless neck mass, or no unusual findings; consider fiberoptic nasolaryngoscopy	Consider early referral; imaging should be coordinated with the otolaryngologist; pain is worse with swallowing, especially acidic or spicy foods
Idiopathic	Variable	Unremarkable	Often diagnosed as neuropathic pain, TMJ syndrome, or eustachian tube dysfunction
Myofascial pain	Cervical pain may be aggravated by chewing or neck movement	Likely to have trigger point in the neck or mastoid tip at attachment of sternocleidomastoid muscle	Consider TMJ, cervical spine, or dental disorders
Neuralgias (trigeminal, glossopharyngeal, geniculate, sphenopalatine)	Pain usually lasts seconds and is episodic, possibly with a trigger	May have trigger point, but typically the examination is unremarkable	Trigeminal is most common
Oral aphthous ulcers	Localized pain in mouth but may refer to ear	Shallow ulcers inside mouth, usually gray	Recurrent etiology not well understood
Pharyngitis or tonsillitis	Sore throat	Pharyngeal erythema; tonsillar exudate	Ear may not be directly involved
Psychogenic	History of depression or anxiety	Variable affect	May be previously diagnosed as idiopathic
Salivary gland disorders	Pain in preauricular area	Prominent parotid glands	Recent mumps outbreaks in United States; more commonly purulent parotitis associated with dehydration or stone obstruction
Sinusitis	Recent upper respiratory infection	Nasal congestion, purulent nasal discharge, anosmia	Otalgia from sinusitis is unusual
Thyroiditis (rarely causes isolated otalgia)	May have tender thyroid	Enlarged or tender thyroid	Pain is referred from the vagus nerve
TMJ syndrome	Pain/clicking with opening jaw	Tender TMJ; crepitus on motion of mandible	Leading cause of secondary otalgia in adults; risk factors include clenching and biting lips/mouth, gum chewing
Acute etiologies requiring immediate identification
Myocardial infarction	Risk factors for coronary artery disease	Unstable vital signs	If suspected, start immediate acute coronary syndrome workup
Temporal arteritis	Age ≥ 50 years; jaw claudication; diplopia	May be tender along temporal artery; may see prominent artery	Erythrocyte sedimentation rate ≥ 50 mm per hour Biopsy and immediate treatment to prevent blindness Consider early referral
Thoracic aneurysms	Older men; hypertension; risk factors for coronary artery disease	May have unstable vital signs	Computed tomography or magnetic resonance angiography
Other rare causes (subdural hematoma, lung cancer, central line placement, carotid artery aneurysm, Pott puffy tumor)	Variable	Variable	Pott puffy tumor is typically a complication of prolonged sinusitis with no treatment8