Ear pain (earache): causes, red flags and when to see a doctor

Ear pain falls into two groups. Primary otalgia comes from the ear canal, eardrum or middle ear. Referred otalgia is felt in the ear but arises from elsewhere, typically the teeth, jaw joint, tonsils or throat, because these areas share sensory nerve supply with the ear. If the ear looks normal on examination, a doctor will therefore look in the mouth and throat and ask about chewing and jaw clicking.

The NHS earache page lists the patterns: ear pain with toothache suggests teething in children or a dental abscess; ear pain with a change in hearing suggests glue ear, a build-up of earwax, an object stuck in the ear or a perforated eardrum, particularly after a loud noise or accident; ear pain with pain on swallowing suggests a sore throat, tonsillitis or quinsy; and ear pain with fever suggests an ear infection, flu or a cold.

According to the NHS, the symptoms of an ear infection usually start quickly: pain inside the ear, a high temperature, difficulty hearing, discharge running out of the ear, a feeling of pressure or fullness, and itching and irritation or scaly skin in and around the ear.

• Earwax build-up or a blocked ear, with muffled hearing and a feeling of fullness.

• Perforated eardrum after loud noise, injury or infection, which may bring a sudden drop in pain once it ruptures, plus discharge.

• Glue ear, where fluid sits behind the eardrum, more often in children and linked to colds.

• Dental problems: teething in a young child or a dental abscess in anyone.

• Throat problems: tonsillitis, quinsy (a complication of tonsillitis) and sore throat, with pain on swallowing.

• Jaw joint problems, which cause pain in front of the ear that worsens on chewing.

• Shingles around the ear may cause pain before a blistering rash appears, which is why a new painful rash needs prompt attention.

The NHS asks for an urgent GP appointment or NHS 111 contact when earache comes with any of these.

• Earache lasting more than 2 to 3 days.

• Becoming generally unwell, or having a very high temperature or feeling hot, cold or shivery.

• Swelling around the ear.

• Fluid coming from the ear.

• Hearing loss or a change in hearing.

• Something stuck in the ear; do not try to remove it yourself.

• A child under 2 with earache in both ears, or under 12 months old with an ear infection.

• Feeling sick or being sick, feeling dizzy, or a severe sore throat.

• Having diabetes, a heart, lung, kidney or neurological condition or a weakened immune system, for example during chemotherapy.

• Call 111 for advice about a child under 5.

The history covers which ear, how long, whether the pain is constant or comes in waves, any discharge, hearing change, ringing, dizziness, recent colds, swimming, cotton bud use, earplugs or hearing aids, dental problems and sore throat. The GP or pharmacist may use an otoscope, an instrument with a small light and magnifying glass, to look in the ear, and some otoscopes blow a puff of air to check for blockages that may signal infection, as the NHS describes.

If the ear looks normal, the doctor will examine the mouth, teeth, tonsils, neck and jaw joint. Hearing tests or a referral to ENT are used for persistent hearing change, discharge that will not clear, recurrent infections or any suspicion of a more serious problem.

The NHS suggests painkillers such as paracetamol or ibuprofen (children under 16 should not take aspirin) and a warm flannel on the ear. Discharge can be wiped away with cotton wool. Do not put anything inside the ear, including cotton buds or fingers, do not try to remove earwax, keep water and shampoo out of the ear, avoid swimming while infected and do not use decongestants or antihistamines, as there is no evidence that they help ear infections.

A pharmacist can advise on treatment and can supply treatment for a middle ear infection in children aged 1 to 17 without a GP visit, according to the NHS. A GP or pharmacist may offer antibiotic tablets or eardrops, antifungal or steroid eardrops or painkilling eardrops depending on the cause, and a spot or boil in the ear may be drained. Eardrops do not work if they are not used correctly, so ask for a demonstration.

Start with a pharmacist or GP. A dentist is the right first step if the pain seems to come from a tooth, and an ENT specialist handles recurrent infections, persistent hearing loss or discharge. Some people choose a private ENT appointment for faster microsuction of wax or hearing tests, which does not replace urgent care for the red flags above.