What is the appropriate workup for otalgia (ear pain) in the Emergency Department (ED)?

From the Guidelines

The workup for otalgia in the Emergency Department should begin with a thorough history and physical examination, focusing on distinguishing diffuse acute otitis externa (AOE) from other causes of otalgia, otorrhea, and inflammation of the external ear canal, as recommended by the clinical practice guideline 1. The history should include determining if the pain is acute or chronic, unilateral or bilateral, and if there are associated symptoms like fever, discharge, hearing loss, or vertigo. Key points to consider in the physical examination include:

• Examining the external ear for trauma, cellulitis, or foreign bodies
• Using an otoscope to visualize the tympanic membrane for signs of acute otitis media (bulging, erythema), otitis externa (canal erythema, edema), or perforation
• Assessing for tenderness of the tragus or pinna, which is often intense and disproportionate to the appearance of the ear canal
• Checking for regional lymphadenitis or cellulitis of the pinna and adjacent skin Additional assessments should include cranial nerve examination, mastoid tenderness, and lymphadenopathy. Laboratory tests are generally unnecessary unless systemic infection is suspected, as stated in the guideline 1. Imaging is indicated only for complications or when malignancy is suspected, with CT being preferred for bony structures and MRI for soft tissues. Treatment depends on the diagnosis, with acute otitis media typically requiring analgesics and sometimes antibiotics, and otitis externa often needing topical antibiotics such as ciprofloxacin/dexamethasone drops, as recommended by the guideline 1. Patients should be advised to follow up with primary care or ENT if symptoms persist beyond 48-72 hours despite treatment, or immediately if they develop severe headache, facial paralysis, or mental status changes, as these may indicate complications requiring urgent intervention 1. It is also crucial to assess patients with AOE for pain and recommend analgesic treatment based on the severity of pain, as stated in the guideline 1. The clinician should inform patients how to administer topical drops and should enhance delivery of topical drops when the ear canal is obstructed by performing aural toilet, placing a wick, or both, as recommended in the guideline 1.

From the Research

Appropriate Workup for Otalgia in the Emergency Department

• The workup for otalgia (ear pain) in the Emergency Department (ED) may involve various methods of analgesia, including non-opioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen 2.
• Regional blocks of pain as part of a multimodal analgesic strategy can be helpful in relieving acute moderate to severe pain 2.
• Ear acupuncture may be considered as an adjunct to standard care for pain relief in the ED, with studies showing significant reduction in pain scores and improved patient satisfaction 3.
• Oral ibuprofen at doses of 400,600, and 800 mg has similar analgesic efficacy for short-term pain relief in adult patients presenting to the ED with acute pain 4.

Pain Management Protocols

• Adherence to implemented pain management protocols is crucial to optimize pain management in the ED, with studies showing that benefits of pain management protocols are proven but adherence needs to be monitored regularly 5.
• Multimodal and non-opioid analgesic treatment strategies are recommended for acute pain management in the ED, with the goal of reducing the use of opioids and associated adverse effects 6.

Considerations for Otalgia Management

• The choice of analgesic agent and treatment strategy should be based on the patient's condition, medical history, and preferences, as well as the severity of the pain 2, 6.
• Regular monitoring of pain scores and adjustment of treatment strategies as needed is essential to ensure effective pain management in the ED 5.