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Ear pain can be caused by disease in the external, middle, or inner ear, but the three are indistinguishable in terms of the pain experienced.

External ear pain may be:

Mechanical: trauma, foreign bodies such as hairs, insects or cotton buds.
Infective (otitis externa): Staphylococcus, Pseudomonas, Candida, herpes zoster, or viral Myringitis. (See Otitis externa)
Middle ear pain may be:

Mechanical: barotrauma (often iatrogenic), Eustachian tube obstruction leading to acute otitis media.
Inflammatory / infective: acute otitis media, mastoiditis.

The neuroanatomic basis of referred earaches rests within one of five general neural pathways. The general ear region has a sensory innervation provided by four cranial nerves and two spinal segments. Hence, pathology in other “non-ear” parts of the body innervated by these neural pathways may refer pain to the ear. These general pathways are:

Via Trigeminal nerve [cranial nerve V]. Rarely, trigeminal neuralgia can cause earaches. Oral cavity carcinoma can also cause referred ear pain via this pathway.
Via Facial nerve [cranial nerve VII]. This can come from the teeth, the temporomandibular joint (due to its close relation to the ear canal), or the parotid gland.
Via Glossopharyngeal nerve [cranial nerve IX]. This comes from the oropharynx, and can be due to pharyngitis, pharyngeal ulceration, tonsillitis, or to carcinoma of the oropharynx (base of tongue, soft palate, pharyngeal wall, tonsils).
Via Vagus nerve [cranial nerve X]. This can arise from the laryngopharynx in carcinoma of this area, or from the esophagus in GERD.
Via the second and third spinal segments, C2 and C3.
In an adult with chronic ear pain, yet a normal ear on exam, the diagnosis is carcinoma of the head and neck region until proven otherwise. Yet some patients will have a “psychogenic otalgia,” and no cause as to the pain in ears can be found (suggesting a psychosomatic origin). The patient in such cases should be kept under observation with periodic re-evaluation.

Dental disease may cause pain in the region of the ear. E.g. dental caries causing pulpitis and/or periapical periodontitis (which may be associated with a periapical abscess) in a tooth can be referred via the auriculotemporal nerve (a branch of the trigeminal nerve), the tympanic nerve (a branch of the glossopharyngeal nerve) or via the auricular nerve[disambiguation needed] (a branch of the vagus nerve). Temporomandibular joint dysfunction, impacted third molar teeth, and lesions of the floor of mouth or ventral surface of the tongue (underside of the tongue) are other possible causes of dental conditions which can cause ear pain.

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