What are the treatment options for ear pain that worsens at night?

Ear Pain Worse at Night: Treatment Approach

For ear pain that worsens at night, immediately prescribe analgesics (ibuprofen 400mg every 4-6 hours or acetaminophen) as first-line therapy, then determine whether the pain originates from the ear itself (primary otalgia) or is referred from another source (secondary otalgia) to guide definitive treatment. 1, 2

Immediate Pain Management

• Start analgesics immediately at diagnosis, as pain is easier to prevent than treat and provides relief within 24 hours while definitive therapy takes effect 1, 2
• For mild to moderate pain, prescribe ibuprofen 400mg every 4-6 hours (maximum 3200mg daily) or acetaminophen as monotherapy 1, 3
• For moderate to severe pain, prescribe fixed-combination products containing acetaminophen or ibuprofen with an opioid (oxycodone or hydrocodone) limited to 48-72 hours while awaiting improvement from definitive therapy 1
• Administer analgesics at fixed intervals rather than as-needed when frequent dosing is required 1

Diagnostic Evaluation

• Examine the ear canal and tympanic membrane—if abnormal findings are present, this indicates primary otalgia; if examination is completely normal, this indicates secondary (referred) otalgia until proven otherwise 1, 2
• For primary otalgia, assess for acute otitis externa (AOE) by checking for tragus tenderness, pinna traction pain, canal edema, erythema, debris, or purulent material 4, 1
• For acute otitis media (AOM), evaluate the tympanic membrane for bulging, decreased mobility, erythema, or middle ear effusion 2
• In patients with normal ear examination and risk factors (smoking, alcohol use, age >50 years, diabetes), consider malignancy or temporomandibular joint syndrome as the most common causes of referred ear pain 2, 5

Definitive Treatment for Primary Otalgia

• For uncomplicated acute otitis externa, prescribe topical antibiotics active against Pseudomonas aeruginosa and Staphylococcus aureus as first-line therapy—do NOT prescribe systemic antibiotics 4, 1, 2
• Use non-ototoxic topical preparations if tympanic membrane perforation or tympanostomy tubes are present or suspected 1, 2
• If the ear canal is obstructed with debris, perform aural toilet or place a wick to facilitate medication delivery 4
• Avoid benzocaine otic solution as it is not FDA-approved for safety, effectiveness, or quality, and may mask progression of underlying disease 1, 6

Reassessment Timeline

• Patients should show clinical improvement (reduced otalgia, itching, fullness) within 48-72 hours of initiating treatment 4, 1
• Reassess patients who fail to improve within 48-72 hours to confirm diagnosis, assess adherence to therapy, evaluate for canal obstruction, and consider treatment failure 4, 1
• Complete symptom resolution may take up to 2 weeks, but early improvement should be evident by 72 hours 4

Critical Pitfalls to Avoid

• Failing to provide adequate analgesia in the first 24-48 hours when definitive therapy has not yet taken effect 1, 2
• Prescribing systemic antibiotics for uncomplicated otitis externa when topical therapy is superior 1, 2
• Missing malignancy in high-risk patients (smokers, alcohol users, age >50, diabetics) who present with persistent otalgia and normal ear examination 2, 5
• Using topical anesthetics that may mask disease progression while providing only temporary symptom suppression 1, 6