What is the recommended management for earache in an adult?

Management of Earache in an Adult

For adults with earache, immediately start acetaminophen or NSAIDs (with NSAIDs being superior for inflammatory conditions), then perform otoscopy to distinguish primary otalgia (ear pathology) from secondary otalgia (referred pain), as this determines whether topical antibiotics are needed. 1

Initial Pain Management

• Begin analgesics immediately at appropriate doses, as pain is easier to prevent than treat. 1
• NSAIDs (ibuprofen, naproxen) or acetaminophen are first-line for mild to moderate ear pain. 1
• NSAIDs demonstrate superior efficacy compared to acetaminophen alone because they address both pain and inflammation. 2
• For moderate to severe pain, prescribe fixed-combination products containing acetaminophen or ibuprofen with an opioid (oxycodone or hydrocodone), limited to a 48-72 hour supply. 1
• Administer analgesics at fixed intervals rather than as-needed when frequent dosing is required. 1

Diagnostic Approach

• Perform otoscopy immediately—a normal exam with ear pain indicates secondary (referred) otalgia until proven otherwise. 1
• Test for tragus tenderness and pinna traction, which are pathognomonic for acute otitis externa (AOE). 3, 1
• Inspect the canal for edema, erythema, debris, or purulent material suggesting AOE. 1
• Evaluate the tympanic membrane for color, position, translucency, perforation, and mobility to assess for middle ear pathology. 1
• Pain with chewing suggests temporomandibular joint syndrome or AOE. 1

Treatment Based on Diagnosis

For Acute Otitis Externa (Primary Otalgia)

• Prescribe topical antibiotics active against Pseudomonas aeruginosa and Staphylococcus aureus as first-line therapy—NOT systemic antibiotics. 1, 2
• Ofloxacin otic solution: 10 drops (0.5 mL) instilled into the affected ear once daily for seven days in patients 13 years and older. 4
• Warm the solution by holding the bottle in hand for 1-2 minutes before instillation. 4
• Patient should lie with affected ear upward for 5 minutes after instillation to facilitate penetration. 4
• Do NOT prescribe systemic antibiotics for uncomplicated AOE, as topical therapy is superior. 2
• Use non-ototoxic topical preparations if tympanic membrane perforation or tympanostomy tubes are present. 1

For Secondary Otalgia (Normal Otoscopy)

• The most common causes in adults are temporomandibular joint syndrome and dental infections. 5
• Examine the oral cavity, dentition, temporomandibular joint, oropharynx, and neck for pathology. 5
• Consider referred pain from cranial nerves V, IX, X, or cervical nerves C2-C3. 6
• When risk factors for malignancy are present (smoking, alcohol use, diabetes, age ≥50 years), obtain CT/MRI or otolaryngology consultation. 5

Medications to Avoid

• Benzocaine otic solution should be avoided as it is NOT FDA-approved for safety, effectiveness, or quality, and may mask progression of underlying disease. 1
• There is no specific indication for topical anesthetic drops in treating AOE. 1

Reassessment Criteria

• Patients should return within 48-72 hours if pain relief is inadequate or symptoms fail to improve. 1
• Clinical improvement should be evident by day 5 of topical antibiotic therapy for AOE; lack of improvement warrants reassessment for treatment failure. 1
• Poor adherence, canal obstruction, fungal co-infection, contact dermatitis, and misdiagnosis are common causes of treatment failure. 1
• Complete resolution may take up to 2 weeks, but improvement should be evident within 72 hours. 1

Special Populations

• Diabetes or immunocompromised state increases risk for necrotizing otitis externa, requiring more aggressive management. 1, 2
• Prior head/neck radiotherapy alters tissue healing and infection risk. 1
• Non-intact tympanic membrane requires non-ototoxic topical therapy. 1