Earache can be caused by a variety of otologic problems, but external otitis and acute otitis media are the most common Differentiation of the two should be apparent by pneumatic otoscopy Pain out of proportion to the physical findings may be due to herpes zoster oticus, especially when vesicles appear in the ear canal or concha Persistent pain and discharge from the ear suggest osteomyelitis of the skull base or cancer, and patients with these complaints should be referred for specialty evaluation Nonotologic causes of otalgia are numerous The sensory innervation of the ear is derived from the trigeminal, facial, glossopharyngeal, vagal, and upper cervical nerves Because of this rich innervation, referred otalgia is quite frequent Temporomandibular joint dysfunction is a common cause of referred ear pain Pain is exacerbated by chewing or psychogenic grinding of the teeth (bruxism) and may be associated with dental malocclusion Repeated episodes of severe lancinating otalgia may occur in glossopharyngeal neuralgia Infections and neoplasia that involve the oropharynx, hypopharynx, and larynx frequently cause otalgia Persistent earache demands specialty referral to exclude cancer of the upper aerodigestive tract