What are alternative treatments for ear ache when Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are not effective?

Alternative Treatments for Ear Ache When NSAIDs Are Not Effective

When NSAIDs are not effective for ear ache, acetaminophen alone or combined with opioids is recommended as the next step in pain management, with topical treatments and procedural interventions available for refractory cases. 1

Pain Assessment and Management Approach

• Pain from ear infections can be intense and severe due to the highly sensitive periosteum of the underlying bone being in close proximity to the ear canal skin 1
• Ongoing assessment of pain severity is essential for proper management, using appropriate pain scales particularly for children and non-English speaking patients 1
• Early treatment at appropriate doses is always indicated as pain is easier to prevent than treat 1

First-Line Alternatives When NSAIDs Fail

Acetaminophen

• Acetaminophen 650 mg every 4-6 hours (daily maximum of 4g/d) is recommended when NSAIDs are ineffective 1
• Acetaminophen is as effective as NSAIDs for mild-to-moderate pain according to the American College of Rheumatology 2
• Should be used with caution to prevent excess acetaminophen dosing, especially when combined with other medications 1

Opioid Combinations

• For moderate to severe ear pain, acetaminophen can be combined with an opioid (e.g., oxycodone, hydrocodone) 1
• Fixed-dose combinations may provide better relief when NSAIDs alone are insufficient 1
• Opioids such as fentanyl citrate, morphine sulfate, and hydromorphone are indicated for procedure-related pain and moderate to severe around-the-clock pain 1

Topical Treatment Options

Topical Anesthetics

• Benzocaine otic solution (with or without antipyrine) can provide temporary topical anesthesia of the ear canal 1
• Important caution: Should not be used if tympanostomy tube is present or if there is uncertainty regarding the integrity of the tympanic membrane 1
• If prescribed, patient should be reexamined within 48 hours to ensure appropriate response to primary therapy 1

Topical Steroids

• Adding a topical steroid to topical antimicrobial drops may hasten pain relief in some cases 1
• Evidence is mixed, with some studies showing benefits while others show no significant advantage 1

Naturopathic Options

• Naturopathic herbal extract ear drops containing allium sativum, verbascum thapsus, calendula flores, hypericum perfoliatum, lavender, and vitamin E in olive oil have shown efficacy in managing ear pain associated with acute otitis media 3
• These herbal extracts have demonstrated bacteriostatic and bactericidal activity against common pathogens, immunostimulation ability, and anti-inflammatory effects 3

Interventional Approaches for Refractory Cases

• Acute analgesia and procedural sedation may be required to accomplish adequate aural toilet in patients with severe inflammation and tenderness of the canal 1
• Analgesic cream can be applied to the ear canal in adults and cooperative children to relieve pain and anesthetize the external auditory meatus if the tympanic membrane is intact 1
• For severe cases, referral for interventional procedures may be necessary 1

Important Considerations and Precautions

• When frequent dosing is required, administering analgesics at fixed intervals rather than on a pro re nata (prn) basis may be more effective 1
• Limit opioid prescriptions to a small number of doses for the initial 48-72 hour treatment period to mitigate risks of opioid misuse or diversion 1
• Patients should be instructed to call healthcare providers if pain is not relieved with medication or if there is a change in pain characteristics 1
• Nonpharmacologic therapies such as heat or cold, relaxation, and distraction have unproven value but may be tried as adjuncts 1
• If ear pain persists beyond 48-72 hours despite appropriate treatment, reevaluation is necessary to rule out complications or alternative diagnoses 1