What are the treatment options for ear pain?

Treatment Options for Ear Pain

For ear pain management, acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) should be used as first-line treatment, with combination therapy including opioids reserved for severe pain. 1

Diagnosis and Approach

Ear pain (otalgia) can originate from various conditions, requiring proper identification of the underlying cause:

• Primary otalgia: Pain originates directly from the ear

  • Acute otitis media (AOM)
  • Otitis externa (swimmer's ear)
  • Furunculosis (infected hair follicle)
  • Cerumen impaction

• Secondary otalgia: Pain referred from non-ear sources

  • Temporomandibular joint (TMJ) syndrome
  • Dental pathology
  • Tonsillitis
  • Head and neck malignancies

Treatment Algorithm for Ear Pain

Step 1: Analgesic Therapy

• Mild to moderate pain:

  • Acetaminophen or NSAIDs (e.g., ibuprofen) 1
  • Consider fixed interval dosing rather than as-needed for better pain control 1

• Moderate to severe pain:

  • NSAIDs plus opioid combinations (e.g., ibuprofen with oxycodone) 1
  • Early treatment at appropriate starting dose is crucial 1

Step 2: Condition-Specific Treatments

For Acute Otitis Externa:

• Topical antimicrobial/corticosteroid combination therapy 1, 2
• Ciprofloxacin 0.3%/dexamethasone 0.1% otic suspension provides superior pain relief 2
• Keep ear dry during treatment 2
• Avoid inserting anything into ear canal 2

For Acute Otitis Media:

• Analgesics for pain relief regardless of antibiotic use 1
• Consider observation with close follow-up for non-severe cases in children 6-23 months 1
• Topical analgesics may provide additional brief benefit 2

For Furunculosis:

• Local heat application
• Possible incision and drainage
• Systemic antibiotics covering Staphylococcus aureus 1

For Contact Dermatitis:

• Remove sensitizing agent (e.g., nickel earrings) 2
• Apply topical corticosteroids or calcineurin inhibitors 1, 2

For Cerumen Impaction:

• Hydrogen peroxide otic solution
  • Adults and children >12 years: 5-10 drops twice daily for up to 4 days 3
  • Children <12 years: consult a doctor 3

Evidence on Treatment Effectiveness

Low-quality evidence indicates both acetaminophen and ibuprofen are more effective than placebo for ear pain relief in children with AOM 4. At 48 hours:

• Paracetamol vs. placebo: 10% vs. 25% still with pain (NNT=7)
• Ibuprofen vs. placebo: 7% vs. 25% still with pain (NNT=6)

There is insufficient evidence to determine whether ibuprofen is superior to acetaminophen for ear pain relief 4.

Important Considerations and Cautions

• Pain is easier to prevent than treat; early intervention is crucial 1
• Topical anesthetic drops should not be used if tympanic membrane integrity is uncertain or if tympanostomy tubes are present 1
• Avoid using topical anesthetic drops for more than 48 hours without re-examination 1
• Neomycin-containing drops can cause contact sensitivity in 5-15% of patients with chronic external otitis 1
• Limit antibiotic eardrops to no more than 10 days to prevent yeast infections 2
• For hydrogen peroxide otic solution, stop use and consult a doctor if symptoms persist beyond 4 days 3

Alternative Treatments

Some evidence suggests naturopathic herbal extract ear drops may provide benefit for ear pain associated with AOM in children, particularly when combined with topical anesthetics 5. However, these should be considered as complementary approaches rather than primary treatment.

When to Refer

Medical evaluation is recommended if:

• Symptoms persist beyond 7 days despite treatment 2
• Pain is severe or worsening despite appropriate therapy
• There are signs of complications (facial paralysis, vertigo, severe headache)
• Recurrent episodes occur despite preventive measures