Referred otalgia with a normal ear is an important presentation in head and neck oncology — oropharyngeal cancers may present with referred otalgia 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 typically affects diabetic, older and immunocompromised patients (e.g. HIV, post-chemotherapy) with Pseudomonas aeruginosa osteitis of the skull base. Hospital teams arrange aural toilet, culture, inflammatory markers, imaging and systemic antipseudomonal treatment where indicated (guided by microbiology, imaging, severity and local protocols); not every patient needs admission or IV antibiotics, and biopsy may be needed because malignancy can mimic necrotising otitis externa (ENT UK).

The distinction between primary and referred otalgia starts with otoscopy — this makes proper otoscopic technique critical, but a normal ear is a prompt to look elsewhere, not proof of referred pain. 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 a common cause of referred otalgia — 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 can cause lasting facial nerve palsy — start antiviral therapy promptly, ideally within 72 hours, after checking renal function and contraindications, and arrange same-day ENT or acute specialist discussion. Evidence for corticosteroids in Ramsay Hunt is less robust than for Bell's palsy; consider them only after assessing contraindications and in line with the local pathway. 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 is not needed for straightforward first-episode OE and should not delay treatment — reserve it for treatment failure, recurrence, immunocompromise, suspected fungal or necrotising disease. Persistent or unexplained adult middle-ear effusion warrants ENT assessment (NICE NG98); urgent referral is particularly important where unilateral, persistent after URTI, associated with hearing loss or present in a person of Chinese or South-East Asian family origin (nasopharyngeal pathology). 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 time-critical (NICE NG98): onset over 3 days or less within the previous 30 days → immediate ENT/ED assessment within 24 hours; later presentation or rapid progression over 4–90 days → urgent ENT/audiovestibular referral within 2 weeks. If SSNHL occurs with otalgia, ENT assess for 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% spray is an option for OE — an antiseptic with no antibiotic resistance risk. Topical aminoglycosides (gentamicin, neomycin) are potentially ototoxic — avoid them when the TM is perforated, a grommet is present, or TM integrity cannot be confirmed (e.g. swollen or debris-filled canal). Topical quinolones are non-ototoxic but should be reserved for appropriate indications in line with local antimicrobial guidance. NICE NG91 (children) separates paediatric AOM criteria from adult management; for adults use local antimicrobial guidance and clinical review rather than a rigid 72-hour rule.

The herpes zoster vaccine (Shingrix) protects against shingles and postherpetic neuralgia. Opportunistically check shingles vaccination status in eligible cohorts (UKHSA Green Book chapter 28a). Cotton buds traumatise the canal and can cause foreign bodies and TM perforation — the message "never put anything smaller than your elbow in your ear" is worth repeating at every OE consultation.

Local head-and-neck pathways (carried over from earlier NICE guidance; not an NG12 criterion) recommend urgent head-and-neck referral for unilateral unexplained head-and-neck pain lasting more than 4 weeks with otalgia and normal otoscopy — oropharyngeal cancers (including HPV-associated) may present with otalgia, and earlier referral is appropriate with additional risk factors or red flags. Apart from specified situations such as persistent hoarseness, primary-care investigations for suspected head-and-neck cancer can delay referral. Fungal OE (otomycosis) should be considered when OE fails to respond to topical antibiotic/acidic preparations — white, grey, green or black debris may suggest it, but appearance is not definitive. Arrange aural toilet and consider topical antifungal treatment (e.g. clotrimazole 1% solution) or ENT advice.