While the vast majority of patients with otalgia have an otologic cause, the clinician must recognize that otalgia may be referred. Sensory innervation of the ear includes cranial nerves V, VII, IX, and X, and therefore disorders of structures with similar innervation can cause otalgia. It is imperative that the physician not simply attribute otalgia to an ear infection unless the physical examination supports this diagnosis. Otalgia can result from dysfunction of the nose, sinuses, oral cavity, pharynx, larynx, dentition, temporo-mandibular joints, and salivary glands. These structures must be thoroughly assessed, especially if the examination of the ear appears normal. This is especially true in smokers, whose initial symptom of laryngopharyngeal carcinoma may be otalgia. Otolaryngologic referral for laryngoscopy may be indicated with suspected referred otalgia. (See eBox 19-1 and eBox 19-2 online at www.expertconsult.com for differential diagnosis of otalgia.)

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