What is the role of topical lidocaine (local anesthetic) in treating ear ache in children?

Topical Lidocaine for Ear Ache in Children

Topical lidocaine ear drops should NOT be routinely used for ear pain in children with acute otitis media (AOM), as major guidelines explicitly state there is no specific indication for topical anesthetic drops in treating ear infections, and they may mask progression of underlying disease while pain is being suppressed. 1

Primary Pain Management Approach

Oral analgesics are the cornerstone of AOM pain management in children:

• Acetaminophen or ibuprofen should be the first-line treatment for ear pain in children with AOM 1
• Both medications are significantly more effective than placebo in relieving pain at 48 hours (NNTB of 6-7) 2
• NSAIDs administered during the acute phase significantly reduce pain compared with placebo 1
• Administer analgesics at fixed intervals rather than "as needed" when frequent dosing is required for adequate pain relief 1

Evidence Against Topical Anesthetics for AOM

The American Academy of Otolaryngology-Head and Neck Surgery provides clear guidance against routine use:

• Benzocaine otic solution (with or without antipyrine) is NOT approved by the FDA for safety, effectiveness, or quality 1
• There is no specific indication for using topical anesthetic drops in treating AOM 1
• Topical anesthetics may mask progression of underlying disease while pain is being suppressed, creating a false sense of improvement 1
• Topical anesthetic drops should NOT be used if a tympanostomy tube is present or if there is uncertainty regarding tympanic membrane integrity, as these drops are not approved for use in the middle ear 1

Limited Evidence for Topical Lidocaine

Despite guideline recommendations against routine use, recent research suggests potential benefit:

• One 2022 RCT (184 children) found that topical 1% lidocaine ear drops combined with oral paracetamol or ibuprofen provided significantly greater pain reduction at 10 minutes compared to oral analgesics alone (25-50% pain reduction) 3
• However, a 2012 systematic review concluded that further studies with more rigorous methodology are needed to demonstrate the utility of ototopical agents 4
• A 2017 guideline review found only 2 low-quality trials suggesting topical analgesics may be more effective than placebo at reducing ear pain 10-30 minutes after administration 1

When Topical Anesthetics Might Be Considered

If a topical anesthetic drop is prescribed despite guideline recommendations:

• The patient MUST be reexamined within 48 hours to ensure that AOM has responded appropriately to primary therapy 1
• Verify tympanic membrane integrity before application - never use if uncertain or if tubes are present 1
• Consider this only as an adjunct to oral analgesics, not as monotherapy 3
• Recognize this is off-guideline use with limited high-quality evidence 1

Appropriate Use of Topical Lidocaine in Other Pediatric Contexts

Topical lidocaine IS appropriate for procedural pain in children:

• Topical liposomal 4% lidocaine cream (LMX4) provides anesthesia in approximately 30 minutes for IV placement, venipuncture, lumbar puncture 1
• EMLA (lidocaine-prilocaine mixture) reaches full effectiveness in 60 minutes 1
• Topical lidocaine should be placed at least 2 sites over veins for IV access 1
• Contraindications include emergent need for IV access, allergy to amide anesthetics, and non-intact skin 1

Escalation for Severe Pain

When oral analgesics are insufficient:

• Opioids (oxycodone, hydrocodone, or ibuprofen with oxycodone) are indicated for moderate to severe pain 1
• Prescribe a limited number of doses for the initial 48-72 hour treatment period to mitigate risks of opioid misuse 1
• Parenteral analgesia may rarely be necessary to achieve adequate pain relief in a timely fashion 1

Critical Pitfalls to Avoid

• Do not rely on topical anesthetics as primary treatment - they are not guideline-recommended and may delay recognition of treatment failure 1
• Never use topical anesthetics without confirming intact tympanic membrane 1
• Do not underestimate pain severity - use validated pain assessment tools (FLACC scale, faces scale) particularly for young children 1
• Recognize that pain is easier to prevent than treat - start with appropriate analgesic doses early 1