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A 45 year-old man comes to your office with a 2-week history of left ear pain. The ear pain began shortly after an upper respiratory infection. He describes the pain as "a pressure" and also notes "crackling" in the ear.

  • What other associated symptoms should you ask about?
  • How does the time course help to distinguish among different causes of ear pain?
  • How does the age of the patient help with narrowing the diagnostic possibilities?

Ear pain is a common complaint in primary care practice, both in pediatric and adult populations. In a random sample of 411 adults in Finland, 7.5% of men and 23.4% of women had experienced ear pain that was not associated with infection in the previous 6 months.1 The cause of ear pain may be in or near the ear, or it may be referred from a distant site. In most cases, a careful history narrows the possible causes considerably. The physical examination is also essential. Most local causes of ear pain produce specific physical findings, whereas the examination of the ear and its immediately surrounding structures is typically normal in cases of referred pain.

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Acute otitis mediaThe presence of infected fluid in the middle ear, caused by bacterial or viral pathogens.
Negative predictive valueThe likelihood, given a negative test (or the absence of a symptom), that the condition of interest is absent.
OtalgiaEar pain.
Otitis externaAn inflammation (usually infectious) of the external auditory canal.
OtorrheaDischarge from the ear canal.
PinnaThe external ear, including the external acoustic meatus.
Positive predictive valueThe likelihood, given a positive test (or the presence of a symptom), that the condition of interest is present.
SensitivityHow frequently a test (or symptom) is positive (present) in those with the condition of interest.
Serous otitisThe presence of uninfected fluid in the middle ear, usually resulting from the blockage of the eustachian tube from an upper respiratory tract infection or from allergy.
SpecificityHow frequently a test (or symptom) is negative (not present) in those without the condition of interest.
TragusThe tongue-like projection of the cartilage of the ear in front of the external acoustic meatus.

In most cases, the cause of ear pain is localized and can be divided into outer ear problems and inner ear problems. Outer ear problems are located external to the tympanic membrane and include otitis externa, ear canal foreign bodies, earwax, and mastoiditis. Occasionally, a furuncle may cause ear pain. Inner ear problems are located at the tympanic membrane or deep to it and include acute otitis media (OM)—the single most common cause of ear pain—and eustachian tube dysfunction. Injuries to the tympanic membrane, which can occur from barotrauma or from direct trauma to the ear, can also cause ear pain.

In children, acute OM is the most common cause of ear pain. ...

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