How to treat otitis media in an adult complaining of ear pain?

Treatment of Otitis Media in Adults with Ear Pain

Immediately prescribe analgesics (acetaminophen or ibuprofen at appropriate doses) for pain control, then determine if you are dealing with acute otitis media (middle ear infection) versus acute otitis externa (external ear canal infection), as this fundamentally changes your antibiotic approach. 1

Step 1: Distinguish Between Otitis Media and Otitis Externa

Perform pneumatic otoscopy to differentiate these conditions:

• Acute Otitis Media (AOM): Look for bulging tympanic membrane with decreased mobility, middle ear effusion, and signs of middle ear inflammation 2
• Acute Otitis Externa (AOE): Generalized inflammation of the external ear canal, pain with manipulation of the pinna or tragus, canal edema 2

This distinction is critical because systemic antibiotics should NOT be prescribed for uncomplicated acute otitis externa, where topical therapy is superior 2, 1

Step 2: Pain Management (Applies to Both Conditions)

Analgesics provide relief within 24 hours and should be started immediately, regardless of antibiotic use: 2, 1

• NSAIDs (ibuprofen) may be superior to acetaminophen alone as they address both pain and inflammation 1, 3
• Administer at fixed intervals rather than "as needed" during the acute phase 3
• Pain management is a strong recommendation even though antibiotics do not provide symptomatic relief in the first 24 hours 2

Step 3: Antibiotic Decision for Acute Otitis Media

When to Use Antibiotics:

Prescribe antibiotics immediately if: 2, 1

• Severe symptoms (moderate to severe otalgia >48 hours, temperature ≥39°C/102.2°F)
• Bilateral AOM
• AOM with otorrhea

Consider watchful waiting (48-72 hours) with reliable follow-up if: 2

• Mild symptoms (mild otalgia <48 hours, temperature <39°C)
• Unilateral disease
• Otherwise healthy adult
• Mechanism in place to ensure follow-up

First-Line Antibiotic Choice:

High-dose amoxicillin (80-90 mg/kg/day in divided doses) is the first-line agent for adults without penicillin allergy 2, 1, 4

Use amoxicillin-clavulanate instead if: 2, 4

• Treatment failure after 48-72 hours
• Recent antibiotic use (within 30 days)
• Concurrent purulent conjunctivitis

Alternative for penicillin allergy: 5

• Azithromycin (single 30 mg/kg dose or 500 mg daily for 3 days) shows clinical success rates of 85-88% 5

Evidence on Antibiotic Efficacy:

The evidence shows antibiotics reduce pain at 2-3 days (NNT=20) but increase adverse effects (NNH=14), primarily gastrointestinal 2, 1. Amoxicillin-clavulanate accelerates middle ear effusion resolution (18.9 vs 32.6 days, p=0.02) 2, 1.

Step 4: Treatment for Acute Otitis Externa

If AOE is diagnosed, do NOT use systemic antibiotics for uncomplicated cases: 2, 1

• Prescribe topical antibiotic drops (non-ototoxic if tympanic membrane perforation suspected) 2
• Topical therapy is the treatment of choice for acute tube otorrhea 2
• Systemic antibiotics are only indicated if: 2
  • Extension outside the ear canal
  • Diabetes mellitus
  • Immunocompromised state
  • Prior head/neck radiotherapy

Step 5: Assess for Modifying Factors

Identify conditions that alter management: 2, 1

• Non-intact tympanic membrane or tympanostomy tube present
• Diabetes mellitus
• Immunocompromised state
• Prior head/neck radiotherapy

These factors may require systemic antimicrobials covering Pseudomonas aeruginosa and Staphylococcus aureus 2

Step 6: Reassessment Criteria

Re-examine the patient if: 2, 1, 3

• No improvement in pain within 24-48 hours of analgesics
• Persistent symptoms after 48-72 hours of antibiotics
• Symptoms worsen at any time

For treatment failure, consider: 2

• Poor adherence to therapy
• Obstructed ear canal preventing drug delivery
• Resistant bacteria (obtain culture)
• Misdiagnosis (fungal infection, dermatologic disorder, foreign body)
• Contact sensitivity to ear drops (especially neomycin)

Common Pitfalls to Avoid

• Do not prescribe antibiotics for referred ear pain from pharyngitis when otoscopy is normal 1, 3
• Do not underdose or delay analgesics—pain management should be immediate and scheduled 1, 3
• Do not use systemic antibiotics for uncomplicated otitis externa—topical therapy is superior 2, 1
• Do not prescribe antibiotics for otitis media with effusion (OME) without acute symptoms, as they do not accelerate resolution 1