Primary or secondary otalgia-uncovering the mystery.

We describe two cases illustrating the diagnostic challenges of referred otalgia when otoscopic findings are normal. The first patient presented with a 5-month history of severe right ear pain unresponsive to prior treatment. Despite a normal otoscopic examination and a previously normal CT scan, MRI revealed extensive skull base inflammation. Subsequent surgical sampling confirmed Aspergillus, and the patient improved with targeted antifungal therapy. The second patient presented with acute left otalgia, dysphagia and tongue deviation. Otoscopy and CT imaging were unremarkable, but MRI demonstrated neurovascular compression of the medulla and hypoglossal nerve by a tortuous vertebral artery. Her symptoms were managed medically with neuropathic pain therapy and swallowing rehabilitation. These cases underscore the importance of considering distant head-neck and skull base sources of pain when otoscopy is normal, understanding the ear's complex innervation and pursuing advanced imaging early to avoid delays in diagnosing serious underlying pathology.