Skip to main content

Health condition · Clinically reviewed

Ear pain, primary, referred and when to worry.

Most earache is short lived and settles with simple measures. Persistent, one-sided ear pain in an adult with a normal ear examination is a different story and deserves a careful look.

Jump to treatment
A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE, ENT UK and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice, including NICE NG12 head and neck cancer red flags for referred otalgia.

Key facts

Ear pain at a glance.

The essentials, in plain English. What otalgia is, where the pain can come from, and how UK clinicians decide what to do next.

  • What it is

    Otalgia is pain felt in or around the ear. It is either primary (from the ear itself) or referred (from structures sharing cranial or cervical nerve supply).

  • Primary otalgia

    Otitis externa, otitis media, cholesteatoma, mastoiditis, barotrauma, foreign body, perichondritis, herpes zoster (Ramsay Hunt), trauma and tumour.

  • Referred otalgia

    Dental and TMJ disease, oropharyngeal and laryngeal disease (including cancer), cervical spine problems, neuralgias and parotid disease.

  • Nerve pathways

    The ear receives sensory supply from the trigeminal, facial, glossopharyngeal, vagus and upper cervical nerves. Pain can arrive along any of them.

  • Red flag

    Unilateral persistent otalgia in an adult with a normal ear examination, especially with smoking, alcohol, dysphagia, hoarseness or a neck lump.

  • Treatment

    Target the underlying cause. Simple analgesia with paracetamol and ibuprofen covers most primary otalgia while the trigger settles.

Why this guide matters

Not every earache is an ear problem.

The three principles below shape everything else on this page and explain why persistent unilateral ear pain in an adult is treated as a head and neck problem until proven otherwise.

  • Primary vs referred otalgia

    Primary otalgia comes from the ear itself. Referred otalgia travels along the trigeminal, facial, glossopharyngeal, vagus or cervical nerves from teeth, TMJ, throat, larynx or spine.

  • A normal ear examination is a clue

    When the ear looks normal but the pain persists, the source is almost always outside the ear. This is where head and neck examination and imaging earn their keep.

  • Red flags change the pathway

    Smoking, alcohol, dysphagia, hoarseness, weight loss and a neck lump trigger NICE NG12 urgent referral, with flexible nasoendoscopy and biopsy where indicated.

How the diagnosis is made

From first symptom to a clear plan.

The steps a UK GP or ENT specialist normally follows, in order, so you know what to expect and why.

  1. 01

    Assessing

    History and pain pattern

    Onset, duration, character and side. Associated hearing loss, discharge, fever, dental symptoms, throat pain, cough, hoarseness, dysphagia or reflux.

  2. 02

    Assessing

    Otoscopy and tuning forks

    A careful look at canal and drum, tragal tenderness, Rinne and Weber tests. A normal ear examination in persistent unilateral pain is itself a warning sign.

  3. 03

    Assessing

    Head and neck examination

    Palpation of the mastoid, TMJ, cervical spine, parotid and neck nodes. Inspection of the oropharynx, tonsils, tongue base and cranial nerves.

  4. 04

    Confirming

    Targeted investigations

    Audiometry, ear swab for discharge, and blood tests where infection or arteritis is suspected. Not every episode needs a test.

  5. 05

    Confirming

    Dental and TMJ review

    OPG imaging and a dental opinion when referred pain from teeth, impacted molars or TMJ dysfunction is suspected.

  6. 06

    Referring

    Cross-sectional imaging

    CT temporal bone for mastoid or middle ear disease and MRI for suspected cranial nerve, skull base or referred pathology.

  7. 07

    Referring

    Two-week wait ENT referral

    Persistent unilateral otalgia with red flags triggers an urgent NICE NG12 head and neck cancer pathway, including flexible nasoendoscopy and biopsy.

Typical timeline: a first visit to a settled plan in days, with red flags fast-tracked within two weeks.

Symptoms

What ear pain looks like in practice.

The character, associated features and pattern of ear pain often point straight at the source. And the features that mean it is time to escalate.

  • Ear canal pain

    Tender tragus, itch and discharge point to otitis externa. Pain worsens on chewing or pulling the pinna.

  • Deep, throbbing ear pain

    Middle ear pressure with fever and hearing loss suggests acute otitis media, often after a viral cold.

  • Foul discharge and hearing loss

    Chronic malodorous discharge with a retraction pocket raises suspicion of cholesteatoma and needs ENT review.

  • Pain on flying or diving

    Barotrauma from pressure change can bruise or perforate the drum. Pain settles as pressure equalises.

  • Facial weakness and vesicles

    Ear pain with vesicles in the canal and facial nerve palsy is Ramsay Hunt syndrome. Antivirals and steroids are time-critical.

  • Jaw and temple pain

    Clicking, locking or morning tenderness at the jaw joint points to TMJ dysfunction as a referred cause.

  • Sore throat with earache

    Tonsillitis, quinsy and pharyngitis commonly refer pain to the ear via the glossopharyngeal nerve.

  • Red flag - persistent unilateral pain

    Ongoing one-sided ear pain in an adult with a normal ear examination, especially with hoarseness, dysphagia, weight loss, smoking or a neck lump.

Treatment

How ear pain is treated in the UK.

Treat the cause, control the pain, and escalate to imaging or a specialist when the pattern or examination demand it.

  • Treat the underlying cause

    Otitis externa, otitis media, TMJ, dental disease, tonsillitis and reflux each have their own pathway. Treating the source usually settles the pain.

  • Simple analgesia

    Paracetamol and ibuprofen at licensed doses control most primary otalgia. Warm compresses can help while medication takes effect.

  • Topical ear treatment

    Aural toilet, antibiotic or steroid drops for otitis externa. Microsuction clears debris and improves drop delivery in stubborn cases.

  • Systemic antibiotics

    Reserved for confirmed bacterial infection - acute otitis media with red flags, spreading otitis externa, mastoiditis or quinsy.

  • Antivirals and steroids

    High-dose aciclovir with prednisolone for Ramsay Hunt syndrome, ideally started within 72 hours of onset.

  • Neuralgia medication

    Carbamazepine or gabapentin for glossopharyngeal or trigeminal neuralgia, under specialist neurology guidance.

  • Surgical options

    Mastoidectomy for cholesteatoma, grommets for chronic middle ear disease, tonsillectomy for recurrent quinsy and drainage of abscesses.

  • Two-week wait referral

    Urgent ENT assessment with flexible nasoendoscopy, panendoscopy, biopsy and imaging when red flags for head and neck cancer are present.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or ENT surgeon knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE NG12. Suspected cancer: recognition and referral - head and neck.

  • NICE Clinical Knowledge Summaries. Otitis externa and otitis media.

  • ENT UK. Position papers on otalgia, cholesteatoma and Ramsay Hunt syndrome.

  • BMJ Best Practice. Assessment of ear pain in adults and children.

Red flags

When ear pain needs urgent attention.

Most earache settles quickly. These are the situations that will not, and where an urgent opinion is needed.

  • Persistent unilateral otalgia

    One-sided ear pain in an adult that persists despite a normal ear examination warrants urgent ENT assessment for referred head and neck cancer.

  • Hoarseness or dysphagia

    Ear pain with a change in voice, difficulty swallowing or a sensation of something stuck triggers an NG12 two-week wait referral.

  • Neck lump

    A new or growing neck lump alongside otalgia is a red flag for laryngeal, oropharyngeal or thyroid pathology.

  • Facial weakness with vesicles

    Ramsay Hunt syndrome needs same-day antivirals and steroids to protect facial nerve recovery.

  • Mastoid swelling or tenderness

    A hot, red, pushed-forward pinna with mastoid tenderness suggests mastoiditis. Same-day ENT assessment is required.

  • Severe pain in a diabetic or immunocompromised patient

    Consider malignant (necrotising) otitis externa. Urgent ENT assessment, imaging and intravenous antibiotics are needed.

  • Post-traumatic ear pain

    After a blow, blast or barotrauma with hearing loss, vertigo or bloody discharge, exclude drum perforation and inner ear injury.

  • Temporal artery tenderness in the elderly

    New unilateral head or ear pain with jaw claudication and raised inflammatory markers can be giant cell arteritis. Start steroids and refer urgently.

  • Neuralgic ear pain

    Brief, electric-shock like otalgia triggered by swallowing or talking suggests glossopharyngeal neuralgia and needs neurology input.

Living with it

A common symptom, with a clear playbook.

Four things that make the biggest difference day to day. Keep the ear dry when it is inflamed, manage pressure changes carefully, get reviewed if pain lingers, and get seen the same day for warning signs.

A quiet reminder

Persistent one-sided ear pain deserves a proper look.

A normal ear examination does not rule out serious disease. When the pattern does not fit, imaging and specialist review are the safe next step.

  1. 01 Protect

    Keep ears dry when infected

    Avoid swimming, showers without a plug and cotton buds during otitis externa. Water and trauma prolong symptoms.

  2. 02 Equalise

    Manage flights and diving

    Yawning, swallowing and the Valsalva manoeuvre help equalise pressure. Do not fly or dive with an active middle ear infection.

  3. 03 Review

    See a clinician if it lingers

    Ear pain that persists beyond a week, is one-sided or comes with hearing loss, discharge or a neck lump needs review.

  4. 04 Escalate

    Get seen the same day if severe

    Fever, facial weakness, severe pain in a diabetic patient, mastoid swelling or new hearing loss are not conditions to wait out.

Frequently asked

Everything we get asked about ear pain.

Quick answers on primary and referred causes, red flags, Ramsay Hunt and neuralgic ear pain.

  • What causes ear pain?

    Ear pain, or otalgia, is either primary (from the ear itself, such as otitis externa, otitis media, cholesteatoma or barotrauma) or referred (from structures sharing nerve supply, such as teeth, TMJ, tonsils, throat, larynx, cervical spine or the parotid gland).

  • When should I worry about ear pain?

    Persistent one-sided ear pain in an adult with a normal ear examination is a red flag, especially with hoarseness, difficulty swallowing, weight loss, a neck lump, smoking or heavy alcohol use. NICE NG12 recommends an urgent two-week wait head and neck cancer referral in these cases.

  • How is the cause of ear pain diagnosed?

    A clinician takes a full history, examines the ear with otoscopy, tests hearing, and examines the head and neck including teeth, TMJ, throat, cervical spine and neck nodes. Audiometry, imaging (CT temporal bone or MRI) and specialist endoscopy are added where indicated.

  • Can ear pain come from my teeth or jaw?

    Yes. Dental caries, impacted molars, dry socket and TMJ dysfunction commonly refer pain to the ear via the trigeminal nerve. Treating the dental or joint cause resolves the earache.

  • What is Ramsay Hunt syndrome?

    Reactivation of the varicella zoster virus in the geniculate ganglion causes severe ear pain, vesicles in the ear canal and facial nerve weakness. High-dose aciclovir with prednisolone within 72 hours gives the best chance of full facial recovery.

  • How is neuralgic ear pain treated?

    Glossopharyngeal and trigeminal neuralgia respond to carbamazepine or gabapentin, with specialist neurology input. For refractory cases, microvascular decompression or gamma knife radiosurgery are considered.

Related content

Keep reading.

Pulse Healthcare concierge

Send us your enquiry

A concierge service for UK private healthcare. We match you with the best vetted clinics and consultants in our network - they then contact you directly.

So we can match you to the right clinician close to you.

We reply to every enquiry within 24 hours (Mon–Fri). Confidential - your details are never shared outside our vetted consultant network.