Otalgia Treatment & Management

  • Author: John C Li, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
Updated: Sep 18, 2015

Medical Care

Identification of a causative etiology is often necessary to successfully treat referred otalgia. Once determined, most causes of referred otalgia can be readily treated. Use antibiotics in treating various types of infections (eg, tonsillitis, pharyngitis, sinusitis). Use antivirals if the causative agent is suspected to be viral such as in cases associated with herpes zoster or shingles. Antifungals are indicated if the source is caused by a fungus (eg, oral thrush/candidiasis). Antiulcer/antacid medications can be used for esophagitis and gastroesophageal reflux disease. Use NSAIDs when myalgias and neuralgias are suspected. Re-examine the patient after a 2-week trial of NSAIDs. Strong narcotic analgesics are not indicated and should not be used to treat referred otalgia. Narcotics may mask symptoms, making the correct diagnosis difficult to reach.

Perform a detailed search for the underlying diagnosis before initiating treatment. Starting analgesics before reaching a diagnosis increases the difficulty of determining the cause and may possibly obscure a life-threatening condition such as an occult cancer.

Any of the previously mentioned treatments can be implemented when the exact cause of referred otalgia is suspected. If the problem persists after a 2- to 3-week trial, a more advanced algorithm is indicated.

History should include the following:

  • Otologic history - Tinnitus, hearing, vertigo
  • Sinuses
  • Pulmonary history
  • Cardiac history
  • Dental history - Mastication
  • GI history - Dysphagia, esophagitis, reflux
  • Neurologic history - Neuralgias
  • Musculoskeletal history - Arthritis
  • Cervicofacial history
  • Myalgias
  • Trauma - Cervical spine (C-spine)
  • Infections - Tonsillitis, pharyngitis

Physical examination should include the following:

  • Nasopharyngoscopy
  • Laryngoscopy

Preliminary testing (appropriate to symptoms) should include the following:

  • Audio
  • Barium swallow
  • ECG C-spine radiography
  • Chest radiography
  • Panorex imaging

Treat the underlying problem appropriately with trial medications (eg, antibiotics, NSAIDs) and 2-week follow-up or with appropriate consultation (eg, dentist, gastroenterologist, neurologist, rheumatologist, neurosurgeon).

If the findings on history, physical examination, and testing are inconclusive, consider local anesthesia to block the source of pain as follows:

  • Nasal cavity pathology: Spray may localize the problem to the sinus or sphenopalatine oral cavity; consider specific nerve blocks.
  • Larynx: Use gargle or transtracheal 4% lidocaine.
  • Ear canal: Use topical agent for sensitive ear canal; consider injection for chorda tympani.
  • Muscular trigger points: Lidocaine injection can be useful in diagnosis.

If history and physical examination findings are inconclusive, perform other diagnostic procedures if suspicion still exists for the following conditions:

  • Upper respiratory tract tumor - Panendoscopy, chest radiography, CT scanning, or MRI as needed
  • Sinus disease - Sinus CT scanning
  • Intracranial/intratemporal disease - Audiometric battery and CT scanning or MRI as needed
  • Autoimmune disease - ESR, thyroid function studies (thyroiditis, temporal arteritis)
  • Endolymphatic hydrops - ESR, thyroid function test (TFT), fluorescent treponemal antibody absorption (FTA-Abs) test, fasting glucose, lipid profile
  • Eustachian tube dysfunction - Autoinsufflation (consider myringotomy)
  • Psychiatric disorder - Consider psychiatric consultation.

If no diagnosis is reached, consider watchful surveillance for 1-3 months and then re-evaluate.



In patients with odontogenic problems, either a dentist or an oral surgeon may be very helpful. Neurologists and pain management specialists (anesthesiologists) may treat neuralgias. Other consultations may be necessary, including a gastroenterologist for persons needing a further evaluation that requires a barium swallow or upper endoscopy or a rheumatology consultation for the evaluation of arthritis and other joint disorders.



Diet may be relevant if the patient has dental problems. A soft mechanical diet may be necessary to avoid exacerbation of the problem.



Because of the diversity of the causes of referred otalgia, listing activity restrictions on a general basis is impossible. Activity considerations are case specific. For example, patients with temporomandibular joint dysfunction should consider activities that involve jaw clenching.

Contributor Information and Disclosures

John C Li, MD Private Practice in Otology and Neurotology; Medical Director, Balance Center

John C Li, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Neurotology Society, American College of Surgeons, American Medical Association, American Tinnitus Association, Florida Medical Association, North American Skull Base Society

Disclosure: Received consulting fee from Synthes Power Tools for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development

Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Auditory Society, The Triological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, American Neurotology Society, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Otological Society

Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Michael E Hoffer, MD Director, Spatial Orientation Center, Department of Otolaryngology, Naval Medical Center of San Diego

Michael E Hoffer, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Received royalty from American biloogical group for other.


Jared Brunk, PA-C Physician Assistant Certified, Office of John Li, MD

Disclosure: Nothing to disclose.

Thomas Ulrich, PA-C Physician Assistant Certified, Office of John Li, MD

Disclosure: Nothing to disclose.

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This picture demonstrates the diversity of pathologies that can be the source of referred otalgia.
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