What Are the Differential Diagnoses for Chronic Ear Pain?

Judith Shannon Lynch, MS, MA, APRN-BC, FAANP


June 10, 2005


I often see adult patients with acute ear pain but without infection, effusion, or inflammation. What other etiologies could explain this phenomenon? Could it be TMJ?

Response from Judith Shannon Lynch, MS, MA, APRN-BC, FAANP

Chronic otalgia (earache) is a common occurrence for many adults. Although acute otitis media, otitis media with effusion, and chronic eustachian tube dysfunction may be causal, another less accurately diagnosed disorder in adult patients is temporomandibular joint (TMJ) dysfunction.

TMJ dysfunction is a collective term used to describe a group of medical disorders estimated to affect 10.8 million Americans at any given time, with 90% of those seeking treatment being women in childbearing years.[1] Inflammation of, or around, the joint connecting the temporal bones to the mandible often leads to masticatory muscle fatigue and resultant spasm.

Extracapsular etiologies include mechanical injuries that originate in the musculature and often produce secondary myofascial pain.

  • Chronic bruxism -- nocturnal jaw clenching and/or teeth grinding

  • Missing teeth/ill-fitting dentures causing the patient to chew unequally

  • Current orthodontia

  • Frequent gum chewing

  • Stress and other psychological factors

    1. Anxiety

    2. Depression

    3. Posttraumatic stress disorder [2]


Less common etiologies are intracapsular , originating in the joint itself and causing true articular disease resulting in joint deterioration:

  • Connective tissue diseases -- rheumatoid arthritis, osteoarthritis, systemic lupus erythematosus, and Lyme disease may induce synovitis within the capsule

  • Displacement of the cartilage disc

  • Tumors of the joint[3]

  • Cervical injuries (whiplash)

  • Direct trauma to the joint

Symptoms of TMJ Dysfunction

The hallmark symptom of TMJ dysfunction is chronic, unilateral dull, aching jaw, or facial pain exacerbated by joint movement (chewing, talking, or yawning).

Other symptoms include:

  • Surrounding muscle tenderness

  • Pain radiating into temple, cervical area, cheek, or shoulder

  • Clicking or popping of the jaw

  • Jaw locking (dislocation)

  • Trismus -- inability to open the mouth fully

  • Frequent headache, especially temporal

  • Dental pain

  • Otalgia[4]

Connection Between Otalgia and TMJ Dysfunction

Misalignment of the temporomandibular joint can affect ear structures due to pressure on the petrotympanic fissure and tympanic bone that separates the jaw joint from the external auditory canal. Because the chorda tympani nerve (which passes through a fissure in the TMJ capsule) innervates pain sensation to the tongue, there may also be sensitivity in certain areas of that organ. There is some evidence that these pressures may cause certain types of tinnitus, subjective hearing loss, and an increased sensitivity to sound (hyperacusis).[5]

Patient Evaluation

History Clues

  1. Subjective data are often confusing as patient is convinced that the problem is in the ear and otalgia may be the only symptom.

  2. Traditional symptoms of infection (fever, lymphadenopathy, associated nasal symptoms) are lacking.

  3. Look for the following:

    • Recent dental work including root canal, tooth extraction, and braces

    • Positive psychiatric history including trauma

    • Presence of connective tissue disease

    • History of MVA (motor vehicle accident), especially with cervical injury

    • Recent smoking cessation (patients tend to replace cigarettes with gum chewing)

    • Positive history of tooth grinding or clenching, which may be sequelae of increased stress


Physical Examination

The following assessment should be performed. Evaluate:

  • Head and face for signs of trauma or structural abnormalities of the temporomandibular joint

  • Ears for signs of acute or chronic inflammation

  • Cranial nerve assessment, especially if there is comorbid headache

  • Oropharynx for acute tonsillar enlargement and/or inflammation; peritonsillar and retropharyngeal abscesses may radiate pain to the ear

  • Cervical area to rule out lymphadenopathy and myalgias from cervical disease

  • Direct manipulation of the joint; full range of motion will often reveal clicking, crepitus, or incomplete dislocation with or without pain.


Confirmation of internal derangement of the TMJ requires an MRI (magnetic resonance imaging) only of the joint itself. MRI is more sensitive than CT scanning for bony and soft tissue visualization. Usually testing is deferred until conservative measures have failed. If underlying connective tissue disease is suspected, appropriate testing is mandatory.

Management Strategies

A conservative treatment regimen may be 75% successful, especially if the etiology is extracapsular. Strategies include:

  • Dental consultation. This is essential for all patients to rule out malocclusion and bruxism. Many times a mouthguard can be used at night that completely resolves the problem.

  • Soft diet that minimizes hard repetitive chewing of crunchy foods (bagels, steak).

  • Analgesia -- a 2-week course of an anti-inflammatory medication such as ibuprofen or aspirin. Patients should take the medication on a regular basis unless comorbid conditions preclude use.

  • Warm compresses to the affected area twice daily for 10 minutes to decrease pain and increase joint movement.

  • Stop all gum chewing and avoid tooth clenching.

  • Relaxation exercises that emphasize gentle range of motion of the affected joint.

If symptoms persist, a course of physical therapy is often recommended. Patients who are refractory to a comprehensive regimen must be referred to an oral surgeon for possible surgical modalities.


Otalgia is commonly encountered in primary care settings. The clinician who searches beyond the ear itself when there is no inflammation or infection will provide the patient with more accurate diagnosis and treatment of other etiologies. The common problem of TMJ dysfunction will also be discovered in its early stages -- before there is permanent damage to the joint.


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