painful ear

Introduction

tympanic membrane
- auriculotemporal nerve (from the trigeminal nerve (CN V) via the mandibular nerve branch)
  - supplies outer surface ant/inf as well as the temporal region of the scalp
  - has a long, winding path from deep inside the skull up to the side of the head.
  - as it passes through tight muscular spaces, wraps around blood vessels, and travels inside glands, it is highly vulnerable to irritation, entrapment, and compression
- auricular branch of the vagus nerve (CN X)
  - supplies outer surface post/sup
  - may cause a cough or gag reflex if the tympanic membrane is stimulated
- tympanic nerve (from the glossopharyngeal nerve (CN IX) )
  - supplies inner surface
- nervus intermedius
  - the sensory and parasympathetic root of the facial nerve (CN VII)
  - herpes zoster (shingles) of this nerve is also referred to as Ramsay Hunt syndrome
  - supplies:
    - the somatic sensation to the skin lining the posterior and posterosuperior walls of the ear canal
    - sensory supply to a small area of the outer ear bowl (the concha) and a portion of the posterior surface of the pinna
    - minor, variable sensory fibers to the outer (lateral) surface of the eardrum, overlapping with the vagus nerve (CN X)

otitis externa
- usually has pain on moving the tragus and may have conductive deafness
otitis media
- usually has conductive deafness and inflamed TM
mastoiditis
external ear pathology
- chondritis
periauricular pathology
- painful lymph nodes
- skin lesions such as acne / pustules / boils
traumatic causes
- fractures
- ruptured ear drum from barotrauma

due to the overlapping nerve network, pathology in the throat or tonsils (CN IX) or teeth and jaw (CN V) can easily cause referred pain to the eardrum (referred otalgia)
- see under anatomy above
painful throat
jaw pain / TMJ issues
- see temporomandibibular joint disorders
lesser occipital nerve irritation
- supplies parietal area of scalp and peri-auricular areas and can cause pain from base of skull and allodynia of parietal scalp and ear
- see painful scalp

nervus intermedius neuralgia
- irritation at various sites such as:
  - cisternal course:
    - emerges from the brainstem in the cerebellopontine angle, it sits tightly between the main motor root of the facial nerve (CN VII) and the vestibulocochlear nerve (CN VIII)
    - most commonly by aberrance of the anterior inferior cerebellar artery (AICA) or, less frequently, the posterior inferior cerebellar artery (PICA) and vertebral artery or by ass lesions in the cerebellopontine angle, such as acoustic neuromas (vestibular schwannomas) or meningiomas
  - at the internal auditory meatus (canalicular segment)
    - fractures of the temporal bone, localized inflammation or operative injury
  - at the geniculate ganglion (within the facial canal)
    - Ramsay Hunt zoster or multiple sclerosis (MS)
  - at the external auditory canal and tympanic membrane (peripheral terminals)
    - peripheral sensory endings of the nerve supply the skin of the back wall of the ear canal and portions of the eardrum
    - mechanical irritation — such as cleaning the ear with a cotton swab, exposure to cold wind, or a severe outer ear infection can sometimes act as a physical trigger that exacerbates an already irritated nervus intermedius