When are oral steroids, such as prednisone (corticosteroid), effective in managing otalgia (ear pain)?

Oral Steroids for Otalgia: When They Are Effective

Oral steroids have very limited effectiveness for otalgia and are only beneficial in two specific scenarios: (1) acute otitis media with tympanostomy tubes already in place, where they modestly reduce duration of ear discharge and pain, and (2) herpes zoster oticus (Ramsay Hunt syndrome), where they are combined with antivirals for severe otalgia with facial paralysis. 1, 2

Effective Uses of Oral Steroids in Otalgia

Acute Otitis Media with Tympanostomy Tubes

• Oral prednisolone (2 mg/kg/day for 3 days) combined with antibiotics reduces otorrhea duration from a median of 3 days to 1 day (p <0.001), with 91% of children having resolution within 2 days versus 30% with placebo 2
• This represents the strongest evidence for oral steroid use in ear pain, though the benefit is modest and short-term 2
• The mechanism involves reducing middle ear inflammation when drainage occurs through existing tubes 2

Herpes Zoster Oticus (Ramsay Hunt Syndrome)

• Systemic steroids combined with prompt antiviral therapy are indicated for severe otalgia accompanied by vesicles on the external ear canal, facial paralysis, and loss of taste 1
• This represents a viral infection requiring urgent treatment, not typical otalgia 1

Ineffective Uses: Where Oral Steroids Do NOT Work

Otitis Media with Effusion (OME)

• The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends AGAINST routine oral corticosteroids for OME due to preponderance of harm over benefit 3
• The highest quality recent trial (OSTRICH, 2018) with 389 children showed no significant improvement in hearing at 5 weeks (40% with steroids vs 33% with placebo, p=0.16) and no improvement in quality of life 4
• A 2023 Cochrane review confirmed oral steroids probably result in little or no difference in normal hearing after 12 months (RR 1.14,95% CI 0.97-1.33) and no difference in OME-related quality of life 5
• Adverse effects include behavioral changes, increased appetite, weight gain, adrenal suppression, and rarely avascular necrosis of the femoral head 3

Acute Otitis Media (Intact Tympanic Membrane)

• A 2013 systematic review found no significant benefit of systemic steroids for AOM when one intramuscular dose of ceftriaxone was combined with 5 days of oral prednisolone versus placebo 1
• Oral steroids do not reduce pain or improve outcomes in standard AOM 1

Acute Otitis Externa

• Topical steroids may help with pain relief in AOE, but oral steroids have no established role 1
• The 2014 AAO-HNS guideline identified the need for clinical trials to determine efficacy of topical steroids for AOE pain relief, but oral steroids are not recommended 1

Post-Viral Rhinosinusitis with Referred Otalgia

• Systemic corticosteroids show only a small effect on facial pain at days 4-7 (RR 1.17,95% CI 1.05-1.30) but no effect on recovery at 7-14 days 1
• The European Position Paper on Rhinosinusitis 2020 advises against systemic corticosteroids for post-viral rhinosinusitis given the self-limiting nature and minimal benefit 1

Critical Clinical Pitfalls to Avoid

Do Not Use Oral Steroids For:

• Routine OME management - watchful waiting for 3 months is first-line, with surgical options (tympanostomy tubes) if persistent with documented hearing loss 3, 5
• Repeated or prolonged courses - this increases adverse effect risk without additional benefit 3
• Referred otalgia from TMJ, dental pathology, or upper aerodigestive tract cancer - these require addressing the primary source, not steroids 1

When Parents Request Steroids to Avoid Surgery:

• A single short course (10-14 days) might be considered only with clear understanding that long-term resolution is unlikely 3
• The number needed to treat is 14 children to achieve improved hearing in one child, with no quality of life benefit 4
• Spontaneous resolution occurs in 33% of children with persistent OME even without treatment 4

Preferred Alternatives to Oral Steroids

For OME-Related Otalgia:

• Watchful waiting for 3 months from effusion onset 3
• Hearing testing if OME persists ≥3 months or if language delay suspected 3
• Tympanostomy tubes for persistent bilateral OME with documented hearing loss after 3 months 1, 3

For Acute Otitis Media with Tubes:

• Topical ciprofloxacin 0.3%/dexamethasone 0.1% drops are first-line, with median time to cessation of otorrhea of 4 days 6
• This combination is superior to antibiotics alone and avoids systemic steroid exposure 6

For Contact Dermatitis of Ear Canal:

• Topical steroids or calcineurin inhibitors (tacrolimus 0.1% ointment or pimecrolimus 1% cream) after removing the sensitizing agent 1
• Oral steroids are not indicated for allergic contact dermatitis causing otalgia 1