Red Ear Syndrome (RES): Why your ear turns red, burns and yet tests are normal

Congested ear in Red Ear Syndrome.

Have you ever had one ear suddenly turn red, feel hot and burn — yet the ENT exam and scans are normal? That’s the hallmark of Red Ear Syndrome (RES). RES is rare, often confused with skin infection or allergy, and frequently missed — but knowing about it helps patients stop unnecessary antibiotics and get the right care.

What is Red Ear Syndrome?

Red Ear Syndrome (RES) is a disorder that causes short-lived or longer episodes of ear redness (erythema) accompanied by burning, stinging or aching pain. Episodes can be unilateral (one ear) or bilateral, last from minutes to hours, and often occur repeatedly. Physical ear examination and hearing tests are typically normal between attacks.

Typical symptoms

• Sudden reddening of one or both external ears

• Burning or hot sensation in the ear

• Sharp, stabbing, or aching ear pain during attacks

• Triggers: light touch, heat or cold, chewing, neck movement, stress, or sometimes no trigger

• Episodes last minutes to hours and then resolve

• No ear discharge, and hearing is usually normal.

Why patients are often told “your ear is normal”

Because RES is primarily neurovascular (nerve + blood flow) — not an infection or structural ear disease — otoscopy, audiology and routine imaging are commonly normal. That’s why patients often experience long delays before getting the correct diagnosis.

Who gets RES — primary vs secondary forms

Primary RES: often seen in younger patients and frequently associated with migraine or primary headache disorders.

Secondary RES: occurs in adults and can be linked to cervical spine disease (C2–C3 nerve roots), temporomandibular joint problems, trigeminal neuralgia variants, or other neuralgias.

Evaluation for associated conditions is important.

How we diagnose it

1. Careful history (pattern, triggers, duration) — this is the most important step.

2. Examination to exclude: otitis externa/media, skin disease (eczema / cellulitis), relapsing polychondritis, or allergic causes.

3. Audiogram / basic ENT tests are done to reassure the patient.

4. Targeted imaging (if needed) — cervical spine or TMJ imaging only when clinical signs point that way. No single test proves RES — diagnosis is clinical and by exclusion.

Treatment options

RES can be treatment-resistant in some patients, but many benefit from targeted approaches. Treatment should be individualized and often focuses on associated conditions (eg, migraine) and symptom control.

Common strategies we use:

• Trigger avoidance: heat, tight headgear, chewing patterns, stress management.

• Neuropathic pain medications: gabapentin, pregabalin, low-dose amitriptyline — can reduce attack frequency/intensity in many patients.

• NSAIDs / indomethacin: tried in some cases (variable benefit).

• Treat associated migraine: migraine prevention often reduces RES in patients with comorbid headache.

• Nerve blocks: greater auricular nerve or upper cervical blocks can provide temporary relief and help confirm a cervical nerve source. Some case series report benefit.

• Botulinum toxin (off-label): reported in case series for refractory cases with encouraging results in selected patients.

  
  

Important: avoid routine antibiotics/ear drops unless there is clear evidence of infection.