For a patient with an acute ear infection still painful after 2 courses of antibiotics, and also experiencing shoulder tendon pain, should I administer a dexamethasone (corticosteroid) injection or ketorolac (nonsteroidal anti-inflammatory drug, NSAID)?

Management of Acute Ear Infection with Persistent Pain and Shoulder Tendon Pain

For a patient with an acute ear infection still painful after two courses of antibiotics and concurrent shoulder tendon pain, a dexamethasone injection is recommended over ketorolac due to better safety profile and efficacy for both conditions.

Assessment of Ear Infection

• Persistent ear pain after two courses of antibiotics suggests treatment failure, which may require further evaluation including paracentesis with collection of bacteriological specimens 1
• Treatment failure is defined as worsening of condition, persistence of symptoms for more than 48 hours after initiating antibiotics, or recurrence of functional and systemic signs within 4 days of treatment discontinuation 1
• Consider referral to an ENT specialist, especially for patients under 2 years of age with persistent symptoms 1

Management Options for Persistent Ear Infection

• For ear infections, topical treatments may be more effective than systemic medications when the infection persists after antibiotic therapy 2
• Ciprofloxacin 0.3%/dexamethasone 0.1% otic suspension has demonstrated efficacy for treatment of persistent ear infections, with the dexamethasone component providing significant anti-inflammatory benefits 2
• Corticosteroids have shown benefit in reducing inflammation and pain in ear conditions, particularly when combined with appropriate antimicrobial therapy 2, 3

Management Options for Shoulder Tendon Pain

• For shoulder tendon pain, locally administered parenteral glucocorticoids (such as dexamethasone) are conditionally recommended over no treatment with local glucocorticoids 1
• Corticosteroid injections are commonly used for shoulder pain conditions including rotator cuff tendinosis, adhesive capsulitis, and impingement syndrome 4
• Subacromial or glenohumeral corticosteroid injections have shown short-term benefit for shoulder pain compared to placebo 5
• While NSAIDs are recommended for tendon disorders, they may not be as effective as local corticosteroid injections for certain shoulder conditions 1

Comparing Dexamethasone vs. Ketorolac

Dexamethasone Benefits:

• Effective for both inflammatory ear conditions and shoulder tendon pain 2, 3
• Can be administered locally for both conditions, minimizing systemic effects 1
• Demonstrated efficacy in reducing inflammation in both ear and shoulder conditions 2, 1

Ketorolac Limitations:

• Ketorolac (NSAID) is indicated only for short-term (up to 5 days) management of moderately severe acute pain 6
• Carries significant risks including gastrointestinal bleeding, cardiovascular events, and renal impairment 6
• Risk of serious GI bleeding increases with age and dose, particularly in patients over 65 years 6
• Contraindicated in many conditions including advanced renal impairment, high risk of bleeding, and during labor and delivery 6

Treatment Recommendation

1. For the ear infection:

   • Consider topical treatment with ciprofloxacin/dexamethasone otic suspension if tympanic membrane is not intact 2
   • If tympanic membrane is intact, consider referral for paracentesis with collection of bacteriological specimen 1

2. For the shoulder tendon pain:

   • Local dexamethasone injection is recommended for shoulder tendon pain that has not responded to conservative measures 1, 4
   • The injection should target the specific affected area (subacromial, glenohumeral, or peritendinous) based on clinical examination 4, 5

3. Avoid ketorolac injection due to:

   • Limited duration of use (maximum 5 days) 6
   • Significant risk profile including GI bleeding, cardiovascular events, and renal effects 6
   • Lack of specific evidence supporting superiority over corticosteroids for these conditions 7

Follow-up Recommendations

• Reassess ear symptoms within 48-72 hours to evaluate response to treatment 1
• For shoulder pain, follow up within 2-4 weeks to assess response to corticosteroid injection 4, 5
• Consider physical therapy for shoulder tendon pain as an adjunct to injection therapy 1
• If symptoms persist, consider further diagnostic evaluation including imaging studies for both conditions 1