What is the appropriate management for a patient presenting with severe left ear pain, tenderness to touch, and radiating pain to the left jaw and neck that has worsened over the past four days?

Management of Severe Left Ear Pain with Radiation to Jaw and Neck

This patient most likely has acute otitis externa (AOE), and you should immediately prescribe topical antibiotic drops (covering Pseudomonas aeruginosa and Staphylococcus aureus) along with oral analgesics, while carefully examining for signs of extension beyond the ear canal that would require systemic antibiotics. 1, 2

Immediate Diagnostic Assessment

Perform tragus tenderness and pinna traction test — pain with these maneuvers is pathognomonic for AOE and distinguishes it from other causes of ear pain. 1, 2 The fact that the "outside of the ear is painful to touch" strongly suggests AOE rather than middle ear disease or referred pain. 1, 2

Key Physical Examination Findings to Document:

• Canal inspection: Look for edema, erythema, debris, or purulent material in the external auditory canal. 1, 2
• Tympanic membrane evaluation: A normal-appearing tympanic membrane with good mobility on pneumatic otoscopy confirms AOE rather than acute otitis media. 1, 2
• Assess for extension: The radiation of pain to the jaw and neck raises concern for extension beyond the ear canal, which would change management. 1, 2

Critical Modifying Factors to Assess:

Screen for diabetes or immunocompromised state — these conditions dramatically increase risk for necrotizing otitis externa and mandate systemic antibiotics. 1, 2, 3

Ask about prior head/neck radiotherapy — this alters tissue healing and infection risk. 1, 2

Determine tympanic membrane integrity — if there's a perforation or tympanostomy tube, you must use non-ototoxic topical preparations. 1, 2

Pain Management (Start Immediately)

Prescribe NSAIDs (ibuprofen) or acetaminophen at fixed intervals, not as-needed — pain is easier to prevent than treat. 2, 4, 3 NSAIDs are superior to acetaminophen alone because they address both pain and inflammation. 2, 4, 3

For moderate to severe pain (which this patient clearly has given the description "super painful"), consider a 48-72 hour supply of combination acetaminophen/ibuprofen with an opioid (oxycodone or hydrocodone) while awaiting improvement from definitive therapy. 2

Do NOT use benzocaine otic solution — it is not FDA-approved for safety or effectiveness and may mask progression of underlying disease. 2

Antibiotic Therapy Decision Algorithm

For Uncomplicated AOE (No Extension):

Prescribe topical antibiotic drops ONLY — systemic antibiotics should NOT be used for diffuse, uncomplicated AOE. 1, 2, 3

For AOE with Extension or High-Risk Features:

Add systemic antibiotics if:

• Extension outside the ear canal (cellulitis of pinna, periauricular tissues, or neck) 1, 2, 3
• Diabetes mellitus 1, 2, 3
• Immunocompromised state 1, 2, 3
• Prior radiotherapy 1, 2

The radiation of pain to the jaw and neck in this patient warrants careful examination for cellulitis or soft tissue extension — if present, systemic antibiotics are mandatory. 1, 2

Enhancing Topical Drug Delivery

If the ear canal is obstructed by edema or debris:

• Perform aural toilet (gentle debridement) 1
• Place a wick to facilitate drug delivery 1
• Instruct the patient on proper drop administration technique 1

Reassessment Criteria

Re-examine the patient in 48-72 hours — the patient should show clinical improvement by this time, though complete resolution may take up to 2 weeks. 1, 2, 3

If No Improvement at 48-72 Hours, Consider:

• Poor adherence to therapy 2, 3
• Canal obstruction preventing drug delivery 2, 3
• Fungal co-infection 2, 3
• Contact dermatitis (especially to neomycin-containing drops) 2, 3
• Misdiagnosis — consider temporomandibular joint disorder, referred pain from dental/pharyngeal sources, or trigeminal neuralgia 1, 2

Common Pitfalls to Avoid

Do not prescribe systemic antibiotics for uncomplicated AOE — this is a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery based on lack of benefit and increased adverse effects. 1, 3

Do not delay or underdose analgesics — pain management should begin immediately at diagnosis, not after topical antibiotics have had time to work. 2, 4, 3

Do not miss necrotizing otitis externa — in diabetic or immunocompromised patients with severe pain radiating to the jaw/neck, this life-threatening condition requires urgent imaging, systemic antibiotics, and possible hospitalization. 1, 2