Referred otalgia with a normal ear is one of the most important presentations in head and neck oncology — up to 50% of oropharyngeal cancers present with referred otalgia as the only symptom due to shared sensory innervation (Arnold's nerve — CN X auricular branch, Jacobson's nerve — CN IX tympanic branch, auriculotemporal nerve — CN V3). A normal otoscopic examination in a patient with unilateral otalgia mandates thorough oral cavity and oropharyngeal examination. Necrotising otitis externa has a mortality of 10–20% even with treatment — it typically affects diabetics and immunocompromised patients (e.g. HIV, post-chemotherapy) with Pseudomonas aeruginosa osteitis of the skull base.

The distinction between primary and referred otalgia is made entirely by otoscopy — this makes proper otoscopic technique critical. The ear receives sensory supply from five different cranial and spinal nerves (V, VII, IX, X, C2/C3) — each nerve innervates a different anatomical region, making the ear a common site for referred pain from distant pathology. TMJ dysfunction is the most common cause of referred otalgia overall — it is frequently missed because clinicians focus on the ear. The TMJ sits immediately anterior to the external auditory canal and tenderness is palpable pre-auricular on jaw opening.

Cholesteatoma is a critical diagnosis to make in primary care — it is a locally destructive epidermal cyst that erodes ossicles, the mastoid, facial nerve canal, and tegmen (leading to intracranial complications). The classic description of painless, smelly, unilateral discharge should always prompt otoscopy looking for the attic perforation (superior to the pars tensa). Ramsay Hunt syndrome causes permanent facial nerve palsy in 50% of cases if not treated within 72 hours — early antiviral therapy (aciclovir 800 mg 5× daily for 7 days + prednisolone 60 mg reducing over 10 days) significantly improves facial nerve recovery odds. AOM in adults is less common than in children and should prompt consideration of sinister causes if recurrent.

The oral cavity and oropharyngeal examination is the most frequently omitted examination in otalgia — and the most consequential omission, as oropharyngeal cancers (HPV-associated tonsillar and tongue base cancers) are increasing in incidence and frequently present with otalgia alone. Weber test lateralisation is clinically important: sound lateralises to the affected side in conductive hearing loss (OE, AOM, OME) and away from the affected side in sensorineural hearing loss. Mastoiditis is a clinical diagnosis requiring immediate action — waiting for imaging before treatment is inappropriate when there is post-auricular tenderness, swelling, and displaced pinna.

An ear swab before prescribing topical antibiotics for OE guides treatment but should not delay treatment in straightforward presentations — swab results are used if treatment fails at 1 week. Adults with OME (glue ear) should be investigated for a nasopharyngeal cause — unilateral OME in an adult is a red flag for nasopharyngeal carcinoma (Epstein-Barr virus associated, most common in young South/East Asian adults) and requires urgent ENT referral. AOM resolution should be confirmed with otoscopy at 4–6 weeks in adults — persistent OME after AOM warrants audiometry and ENT review.

Sudden sensorineural hearing loss (SSNHL) is an ENT emergency — it requires systemic corticosteroids within 72 hours for best cochlear recovery outcomes. If SSNHL occurs with otalgia, it must be urgently assessed by ENT to rule out Ramsay Hunt, labyrinthitis, acoustic neuroma, and perilymph fistula. Cholesteatoma diagnosis in primary care is highly impactful — identifying it early and referring to ENT for mastoidectomy prevents intracranial complications (meningitis, brain abscess, sigmoid sinus thrombosis) and facial nerve damage. Primary care doctors should view chronic unilateral offensive ear discharge as cholesteatoma until proven otherwise.

Acetic acid 2% (EarCalm) spray is first-line for OE per NICE guidance — it is an antiseptic with no antibiotic resistance risk, is low-cost, and is equally effective to topical antibiotics for mild-moderate OE. Topical aminoglycosides (gentamicin) are ototoxic and contraindicated when the TM is perforated — always check TM integrity before prescribing topical ear drops. The delayed prescribing strategy for AOM is supported by Cochrane evidence — 80% of patients recover without antibiotics, and waiting 72 hours while monitoring reduces antibiotic prescribing by 70% without increasing complication rates.

The herpes zoster vaccine (Shingrix) has 97% efficacy against shingles in adults 50–69 and 91% efficacy over age 70 — it also prevents postherpetic neuralgia (the most disabling complication) and Ramsay Hunt syndrome specifically. Opportunistic checking of shingles vaccination status in the 50–70 age group is an important primary prevention intervention. Cotton buds are responsible for approximately 34% of ear canal foreign body presentations and the majority of traumatic TM perforations in primary care — the message "never put anything smaller than your elbow in your ear" is worth repeating at every OE consultation.

The 3-week rule for persistent adult otalgia with normal otoscopy is non-negotiable — oropharyngeal and hypopharyngeal cancers are at an increasingly high incidence (particularly HPV-associated oropharyngeal cancer in 40–60 year old males) and otalgia is frequently the first symptom. Delayed diagnosis at this site results in significantly worse prognosis (5-year survival drops from 85% stage I to 35% stage IV). Fungal OE (otomycosis — Aspergillus species) should be suspected when OE fails to respond to topical antibiotic/acidic preparations — the clue is white or black debris in the canal, often described as "wet newspaper" texture. Treatment is clotrimazole 1% solution or econazole 1% cream.