What medications are used to treat an ear block?

Medications for Ear Block

For ear wax impaction causing ear blockage, apply cerumenolytic ear drops (such as sodium bicarbonate, oil-based drops, or carbamide peroxide) for 5 days followed by irrigation if needed; for acute otitis externa with ear blockage, use topical fluoroquinolone antibiotic drops (ofloxacin or ciprofloxacin-dexamethasone) without oral antibiotics; and for middle ear effusion with tympanostomy tubes causing drainage and blockage sensation, use topical antibiotic ear drops alone (ofloxacin or ciprofloxacin-dexamethasone). 1, 2

Determining the Cause of Ear Block

The first critical step is identifying whether the blockage is from:

• Ear wax (cerumen) impaction - the most common cause in primary care 3
• Acute otitis externa (swimmer's ear) - infection of the ear canal with pain, erythema, and tragal tenderness 1, 2
• Middle ear fluid with tympanostomy tubes - drainage through tubes causing blockage sensation 1
• Eustachian tube dysfunction - pressure sensation, particularly during air travel 4

Assessment should determine if the tympanic membrane is intact or perforated and whether tympanostomy tubes are present, as this guides treatment selection 2.

Treatment for Ear Wax Impaction

Cerumenolytic Drops

Apply ear drops for 5 days to soften and facilitate wax removal - this is more effective than no treatment (22% complete clearance vs 5% with no treatment; NNTB = 8) 3.

Effective options include:

• Sodium bicarbonate ear drops - significantly better than no treatment and effective with multiple applications 3, 5
• Oil-based drops (olive oil, almond oil) - comparable efficacy to water-based treatments 3
• Carbamide peroxide 6.5% (Murine) - water-based cerumenolytic 6
• Docusate sodium - effective with multiple applications 5

No single cerumenolytic has proven superior to others in high-quality trials 3, 7. Water or saline alone shows no evidence of being less effective than commercial cerumenolytics 3.

Application Technique

• Instill drops twice daily for up to 5 days 3
• "Pump" the tragus several times after placing drops to facilitate entry 1
• If wax persists after 5 days, mechanical removal (irrigation, suction, or manual extraction) may be needed 1, 3

Treatment for Acute Otitis Externa (Infected Ear Canal)

Topical Antibiotic Drops - First Line

Prescribe topical fluoroquinolone antibiotic ear drops ONLY, without oral antibiotics, for uncomplicated acute otitis externa 1, 2.

Recommended agents:

• Ofloxacin 0.3% - non-ototoxic fluoroquinolone, safe if tympanic membrane integrity uncertain 1, 2
• Ciprofloxacin-dexamethasone - combination antibiotic-steroid may hasten pain relief 1

Application Protocol

• Apply drops twice daily for 7-10 days 1
• Perform aural toilet (gentle suctioning or lavage) before initiating drops to remove debris 1, 2
• Use tragal pumping after instillation 1
• Avoid water entry during treatment 1

Pain Management

Administer oral analgesics at adequate doses on a fixed schedule rather than as-needed 1:

• Mild to moderate pain: Acetaminophen or NSAIDs (ibuprofen significantly reduces pain vs placebo) 1
• Moderate to severe pain: Combination products with oxycodone or hydrocodone 1
• NSAIDs during the acute phase significantly reduce pain compared to placebo 1

Avoid topical anesthetic drops (benzocaine) - not FDA-approved for safety/effectiveness, may mask disease progression, and contraindicated if tympanic membrane integrity uncertain 1.

Special Populations

Diabetic or immunocompromised patients require heightened vigilance - avoid ear canal irrigation which may precipitate necrotizing otitis externa; consider earlier specialist referral 2.

Treatment for Tympanostomy Tube Otorrhea

Acute Drainage Through Tubes

Use topical antibiotic ear drops alone (ofloxacin or ciprofloxacin-dexamethasone) without oral antibiotics for uncomplicated tube otorrhea 1.

• Apply drops twice daily for up to 10 days 1
• Pump the tragus after instillation to help drops enter the tube 1
• Remove dried drainage with cotton-tipped swab dipped in hydrogen peroxide or warm water 1
• Oral antibiotics are unnecessary unless the child is very ill or has concurrent illness requiring systemic antibiotics 1

Clinical cure rates with topical therapy: 77-96% vs 30-67% with oral antibiotics 1.

Postoperative Prevention

Do NOT routinely prescribe antibiotic ear drops following tube insertion 1.

• Intraoperative saline washout reduces postoperative otorrhea from 30% to 16% (NNTB = 7) 1
• Single application of antibiotic-steroid drops at surgery reduces otorrhea from 9% to 1% (NNTB = 13) 1
• Routine postoperative drops have cost, administration difficulties, and potential harm (fungal infections, local reactions) 1

Treatment for Eustachian Tube Dysfunction

During Air Travel

Perform autoinflation techniques at first signs of pressure 4:

• Yawning, swallowing, or chewing 4
• Valsalva maneuver (pinch nose and blow gently) 4

Avoid flying during upper respiratory tract infections - the most important preventive measure 4.

Consider oral decongestants or antihistamines before flight if unable to avoid flying with URI symptoms 4.

When to Refer or Escalate

Refer to otolaryngology if 1, 2:

• Ear drainage continues >7 days despite appropriate topical therapy 1
• Persistent or worsening symptoms despite treatment 2
• Recurrent episodes of drainage 1, 2
• Hearing loss or persistent pain 1, 2
• Diabetic or immunocompromised patients with severe symptoms 2

Common Pitfalls

• Do not prescribe oral antibiotics for acute otitis externa or uncomplicated tube otorrhea - topical therapy alone is superior 1
• Do not use aminoglycoside drops (gentamicin, neomycin) if tympanic membrane integrity uncertain - ototoxic; use fluoroquinolones instead 1, 2
• Do not use topical anesthetic drops if tubes present or TM integrity uncertain - not approved for middle ear use 1
• Do not expect immediate wax clearance - drops require 5 days of application for optimal effect 3
• Do not routinely prescribe antibiotic drops after tube placement - no evidence of benefit and potential for harm 1