Case study: It is a quiet Wednesday afternoon in clinic. You are winding down for the day and open the chart for your last patient. You see that your patient is an otherwise healthy 18-year-old woman who is presenting to clinic with a chief complaint of “right ear pain.” When you walk into the exam room, you see a young woman in no distress flipping through her phone. She greets you warmly and tells you her name is Tracy. She says she is here because her right ear has been hurting for the past three days. What do you ask Tracy?
You ask the patient to describe her ear pain and to tell you if she has any associated symptoms. Tracy tells you she has always been in good health except for the occasional cold. However, three days ago, she began having pain in her right ear. The pain is dull and nothing seems to make it better or worse. You ask her if she has any additional symptoms, and she denies any recent fever, upper respiratory infection, sore throat, or rashes. On physical exam, her vital signs are normal, her heart rate and rhythm are normal, breath sounds are clear bilaterally, and she does not have any abdominal tenderness. You look in both ears with your otoscope and do not appreciate any erythema or drainage. You can see her tympanic membranes clearly and there does not appear to be any fluid behind them. She does not have any tenderness when you press on the tragus or pull on the auricle. The patient does not have any palpable lymphadenopathy. You look in her mouth and do not see any carries, ulcers, or signs of dental infection. However, you do feel popping along her jaw when she moves her jaw up and down, and she has tenderness at her right temporomandibular joint. What do you do next?
You ask Tracy if she has any history of grinding her teeth at night. She says her roommate was recently complaining that she could hear Tracy grinding her teeth at night in their shared dorm room. You strongly suspect that Tracy’s ear pain is related to Temporomandibular Joint dysfunction (TMJ). You tell her to visit her dentist to make sure that she doesn’t have any dental reasons for her ear pain and recommend an over-the-counter bite guard. You also suggest that she stop chewing gum, try a soft diet, and consider stress reduction practices such as meditation. If these treatments don’t help, she should call you back and schedule a follow-up appointment.
Ear pain with a normal ear exam can be caused by a number of sources. These include TMJ, dental causes (including cavities and ulcers), cervical spine arthritis, pharyngitis, tonsillitis, neuropathic pain, and Eustachian tube dysfunction. Significantly less common reasons for ear pain and no obvious defect include tumors, Bells’ palsy, temporal arteritis, referred pain from cranial nerve IX or X, and cardiovascular events. With a TMJ diagnosis, you suspect Tracy’s ear pain should improve over the next few weeks. She should follow up with you if her pain persists or if she develops additional symptoms, such as a fever.
How do you manage your patients with ear pain and a normal ear exam? Comment below.
Earwood JS, Rogers TS, and NA Rathjen. Ear Pain: Diagnosing Common and Uncommon Causes. Am Fam Physician. 97(1):20-27.
Ely, John. Diagnosis of Ear Pain. Am Fam Physician. 77(5):621-628.
Dr. V. Silverstein
Published on 9/6/18