What are the next steps for a patient with otitis media and otitis externa who was treated with Augmentin (amoxicillin-clavulanate) and corticosteroid drops 5 days ago, but now has new pain in the other ear?

Management of New Contralateral Ear Pain After Initial Treatment

Examine the newly painful ear immediately to determine if this represents new acute otitis externa, new acute otitis media, or referred pain from another source. 1

Immediate Assessment of the Contralateral Ear

Perform otoscopy on the newly painful ear to distinguish primary from secondary otalgia, as this fundamentally determines your next steps. 1, 2

• Assess for acute otitis externa (AOE): Look for canal edema, erythema, debris, or purulent material; perform tragus tenderness and pinna traction test, which are pathognomonic for AOE. 3, 1

• Assess for acute otitis media (AOM): Evaluate the tympanic membrane for bulging, decreased mobility on pneumatic otoscopy, erythema, or middle ear effusion. 1

• If otoscopy is normal, suspect secondary (referred) otalgia from temporomandibular joint syndrome, dental disease, or pharyngitis. 1, 2

If New Acute Otitis Externa is Diagnosed

Prescribe topical antibiotics active against Pseudomonas aeruginosa and Staphylococcus aureus as first-line therapy for the newly affected ear. 3, 1

• Use non-ototoxic topical preparations if there is any concern for tympanic membrane perforation or tympanostomy tubes. 3

• Provide analgesics (acetaminophen or ibuprofen) at fixed intervals rather than "as needed" for optimal pain control. 1, 4

• Assess the originally treated ear to determine if it has adequately responded to therapy, as the American Academy of Otolaryngology-Head and Neck Surgery recommends reassessment at 48-72 hours if improvement has not occurred. 3

If New Acute Otitis Media is Diagnosed

Continue the current 7-day course of Augmentin, as it provides appropriate coverage for AOM pathogens including penicillin-susceptible and intermediate Streptococcus pneumoniae, and beta-lactamase producing Haemophilus influenzae and Moraxella catarrhalis. 5

• Augmentin is effective for bilateral or sequential AOM and does not require dose adjustment for involvement of the contralateral ear. 5, 6

• Ensure the patient completes the full 7-day course as prescribed, since skipping doses or incomplete therapy decreases effectiveness and increases bacterial resistance. 7

Reassess the Originally Treated Ear

The originally treated ear should show clinical improvement by day 5 of therapy; lack of improvement warrants reassessment for treatment failure. 3

Common Causes of Treatment Failure to Consider:

• Poor adherence to therapy: Patients tend to under-administer drops as symptoms improve; verify proper drop administration technique. 3

• Canal obstruction: Debris or edema may prevent topical medication from reaching the affected area; consider aural toilet or wick placement. 3

• Fungal co-infection: Fungi may cause persistent infection after topical antibacterial therapy alters canal flora; consider culture if symptoms persist. 3

• Contact dermatitis: Prolonged use of corticosteroid drops can cause allergic contact dermatitis in 13-30% of patients, particularly with neomycin-containing preparations; presents with persistent erythema, pruritus, and edema. 3

• Misdiagnosis: Re-examine for foreign body, perforated tympanic membrane, middle ear disease, or dermatologic conditions (psoriasis, seborrheic dermatitis). 3

Critical Pitfall to Avoid

Do not assume the new ear pain represents treatment failure of the original infection or spread of infection. This is most likely a new, independent infection in the contralateral ear that requires its own diagnostic assessment and treatment plan. 1, 2

• Bilateral or sequential ear infections are common in children and do not necessarily indicate inadequate initial therapy. 5

When to Consider Systemic Antibiotics for AOE

If the originally treated ear shows treatment failure with topical therapy alone, add systemic antibiotics covering P. aeruginosa and S. aureus. 3

• The current Augmentin course does not provide adequate coverage for AOE pathogens (Pseudomonas), so if systemic therapy is needed for AOE, consider fluoroquinolones in appropriate age groups. 3

Follow-Up Timing

Reassess both ears in 48-72 hours to confirm clinical improvement; complete resolution may take up to 2 weeks, but improvement should be evident within 72 hours. 3, 1