What are the treatment guidelines for otalgia (ear pain)?

From the Guidelines

Treatment guidelines for otalgia prioritize pain management, with analgesic treatment recommended based on the severity of pain, as stated in the clinical practice guideline for acute otitis externa 1. For most cases of ear pain due to acute otitis media, start with analgesics like acetaminophen (10-15 mg/kg every 4-6 hours for children; 500-1000 mg every 6 hours for adults) or ibuprofen (10 mg/kg every 6-8 hours for children; 400-600 mg every 6-8 hours for adults) for pain relief. Key considerations in managing otalgia include:

• Assessing patients for pain and recommending analgesic treatment based on pain severity, as emphasized in the clinical practice guideline for acute otitis externa 1.
• Using topical preparations for initial therapy of diffuse, uncomplicated acute otitis externa (AOE), as recommended in the guideline 1.
• Informing patients on how to administer topical drops and enhancing delivery of topical drops when the ear canal is obstructed, as suggested in the guideline 1.
• Recommending a non-ototoxic topical preparation when the patient has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube, as advised in the guideline 1.
• Reassessing the patient if they fail to respond to the initial therapeutic option within 48-72 hours to confirm the diagnosis of diffuse AOE and to exclude other causes of illness, as recommended in the guideline 1. The clinician should assess patients with AOE for pain and recommend analgesic treatment based on the severity of pain, with a strong recommendation for pain management in the clinical practice guideline for acute otitis externa 1. In terms of specific treatments, the following may be considered:
• Antibiotic ear drops like ciprofloxacin/dexamethasone (4 drops twice daily for 7 days) for otitis externa (swimmer's ear), along with keeping the ear dry.
• Treating the underlying condition for referred pain from temporomandibular joint disorders or dental issues.
• Using decongestants like pseudoephedrine and gentle Valsalva maneuvers for ear pain from barotrauma. If symptoms persist beyond 48-72 hours despite treatment, worsen significantly, or are accompanied by high fever, hearing loss, or dizziness, further evaluation is necessary as these may indicate complications requiring more aggressive intervention.

From the FDA Drug Label

Directions FOR USE IN THE EAR ONLY adults and children over 12 years of age: • tilt head sideways • place 5 to 10 drops into ear • tip of applicator should not enter ear canal • keep drops in ear for several minutes by keeping head tilted or placing cotton in the ear • use twice daily for up to four days if needed, or as directed by a doctor The treatment guidelines for otalgia using carbamide peroxide (OTIC) are to:

• Use 5 to 10 drops in the ear, twice daily for up to four days if needed
• Keep the head tilted or place cotton in the ear to keep the drops in for several minutes
• Consult a doctor for children under 12 years 2

From the Research

Treatment Guidelines for Otalgia

• The treatment of otalgia depends on the underlying cause, which can be primary otologic or secondary nonotologic 3.
• Primary otalgia is often caused by acute otitis media or otitis externa, and treatment typically involves antibiotics and pain management 4.
• Secondary otalgia, on the other hand, is often referred from other areas such as the temporomandibular joint, dental pathology, or cervical spine pathology, and treatment should be directed at the underlying cause 3, 5.
• For acute otitis media, management should begin with adequate analgesia, and antibiotic therapy can be deferred in children over two years old with mild symptoms 4.
• High-dose amoxicillin is the antibiotic of choice for treating acute otitis media in patients who are not allergic to penicillin 4.
• For pain relief in children with acute otitis media, paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) can be used, with low-quality evidence suggesting that both are more effective than placebo in relieving short-term ear pain 6.
• There is insufficient evidence to suggest a difference between ibuprofen and paracetamol in relieving short-term ear pain in children with acute otitis media 6.

Assessment and Management of Referred Otalgia

• Referred otalgia requires a thorough assessment to determine the underlying cause, which can include dental and oral mucosal pathologies, temporomandibular joint disorders, cervical spine pathology, sinusitis, upper airway infection, and reflux, as well as head and neck malignancy 5.
• Understanding the common causes of referred otalgia can help reduce wait times for specialist assessment and allow for easier access to management options for patients in community clinics 5.
• A detailed history and physical examination with directed studies as indicated can help elucidate the cause of the pain 7.