What is the best treatment for a sinus infection accompanied by ear pain?

Treatment of Sinus Infection with Ear Pain

For a sinus infection with ear pain, initiate amoxicillin-clavulanate (high-dose: 4g/250mg daily for adults or 90mg/6.4mg per kg per day for children) combined with aggressive pain management using NSAIDs or acetaminophen, and add intranasal corticosteroids to reduce inflammation and promote drainage. 1, 2

Antibiotic Selection

The ear pain accompanying your sinus infection suggests either referred pain from sinus inflammation or concurrent middle ear involvement, both requiring appropriate antimicrobial coverage:

• First-line choice: Amoxicillin-clavulanate provides optimal coverage against the major sinusitis pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 1, 3
• Dosing: Adults should receive high-dose formulations (4g amoxicillin/250mg clavulanate daily or 875mg/125mg twice daily) to overcome resistant organisms 1, 4
• Alternative agents if β-lactam allergy: Respiratory fluoroquinolones (levofloxacin, moxifloxacin) or second/third-generation cephalosporins (cefuroxime-axetil, cefpodoxime-proxetil) 1
• Duration: 10-14 days, though some evidence supports 5-day courses for uncomplicated cases 3, 5

Pain Management is Critical

The ear pain component requires dedicated attention, as pain from sinus disease can be severe and is frequently undertreated:

• NSAIDs are superior to acetaminophen alone for acute inflammatory pain and should be administered at fixed intervals (not PRN) during the first 48-72 hours 1
• Combination therapy: Consider acetaminophen plus ibuprofen, or fixed-dose combinations with opioids (oxycodone/acetaminophen) for moderate-to-severe pain 1
• Early aggressive dosing is more effective than waiting for pain to escalate—pain is easier to prevent than treat 1
• Reassess at 48-72 hours: If pain persists or worsens despite appropriate therapy, re-evaluate for complications or alternative diagnoses 1

Adjunctive Therapies

These measures enhance drainage and reduce inflammation:

• Intranasal corticosteroids (mometasone, fluticasone) are the cornerstone of treatment, reducing mucosal inflammation and promoting sinus drainage 2, 6, 7
• Saline irrigation (preferably hypertonic) mechanically removes mucus and prevents crusting 2, 6
• Oral decongestants may provide symptomatic relief by widening ostia, though use cautiously in patients with hypertension or cardiac disease 6
• Short-course oral corticosteroids (prednisone 24-80mg daily for 3-7 days) can be added for severe symptoms or marked mucosal edema, showing 20% absolute improvement in symptom resolution at days 3-7 8, 9

When to Reassess or Escalate

Critical decision points to avoid missing complications:

• No improvement at 72 hours: Switch to broader-spectrum antibiotics (respiratory fluoroquinolone) or consider imaging 1
• Warning signs requiring urgent evaluation: High fever, severe unilateral facial pain, periorbital edema, visual changes, meningeal signs, or severe headache preventing sleep 1, 10
• Recurrent episodes (≥3-4 per year): Refer to ENT for evaluation of anatomic abnormalities, allergic rhinitis, or immunodeficiency 2, 6

Common Pitfalls to Avoid

• Don't use topical anesthetic ear drops (benzocaine/antipyrine)—they mask disease progression without treating the underlying infection and are not FDA-approved 1
• Don't assume viral etiology when ear pain is present—this suggests bacterial involvement or complications requiring antibiotics 1, 3
• Don't underdose pain medication—the proximity of inflamed tissue to sensitive periosteum causes severe pain that requires adequate analgesia 1
• Don't delay imaging if diagnosis is uncertain or symptoms are severe—frontal, ethmoidal, or sphenoidal sinusitis carries higher complication risk 1, 10