How can ear pain and pressure be managed?

Management of Ear Pain and Pressure

Immediate analgesic therapy with acetaminophen or NSAIDs at fixed intervals is the cornerstone of ear pain management, regardless of whether antibiotics are prescribed, and should begin at the time of diagnosis. 1, 2

Immediate Pain Management

Administer analgesics at fixed intervals rather than as-needed (PRN) to prevent pain rather than chase it. 2 Pain is easier to prevent than treat, and analgesics provide relief within 24 hours while antibiotics do not provide symptomatic relief in the first 24 hours. 1

First-Line Analgesic Options

• NSAIDs (ibuprofen) are superior to acetaminophen alone because they address both pain and inflammation, which is the primary pathophysiology in most ear conditions. 2, 3
• Acetaminophen remains an acceptable alternative for mild to moderate pain. 2, 4
• 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. 2

Evidence Supporting Analgesic Use

• Both paracetamol and ibuprofen are more effective than placebo in relieving pain at 48 hours (NNTB 6-7). 4
• Even after 3 to 7 days of antibiotic therapy, 30% of children younger than 2 years have persistent pain or fever, underscoring the importance of analgesic therapy. 1

Diagnostic Approach: Identify the Source

You cannot manage ear pain appropriately without visualizing the tympanic membrane. 2 If cerumen obstructs your view, remove it immediately using cerumenolytic agents, irrigation, or manual instrumentation. 1, 2

Key Diagnostic Distinctions

Acute Otitis Media (AOM):

• Bulging tympanic membrane is the most consistent sign (96% bacterial isolation rate). 2
• Cloudy or opaque tympanic membrane indicates middle ear effusion (95.7% positive predictive value). 2
• Pain without tragal tenderness. 2

Acute Otitis Externa (AOE):

• Tragal tenderness or pain with pinna traction is pathognomonic for AOE. 1, 2
• Canal edema, erythema, and debris on otoscopy. 1, 2
• Pain is the primary symptom. 1

Otic Barotrauma:

• History of recent air travel or pressure changes. 3
• Pain and pressure sensation without infection. 3

Condition-Specific Management

For Acute Otitis Media (AOM)

Analgesics are mandatory; antibiotics are conditional. 1, 2

Antibiotic Decision Algorithm:

• Severe AOM (temperature ≥39°C OR moderate-to-severe otalgia >48 hours): Prescribe antibiotics immediately. 1, 2
• Non-severe unilateral AOM in children 6-23 months: Either prescribe antibiotics OR offer observation with close follow-up based on shared decision-making. 1
• Observation option (48-72 hours): Appropriate for mild symptoms, age ≥2 years, and reliable follow-up. 1, 5

Antibiotic Selection (when indicated):

• High-dose amoxicillin (80-90 mg/kg/day) is first-line. 5
• Amoxicillin-clavulanate for treatment failure, recent antibiotic use, or concurrent purulent conjunctivitis. 5

For Acute Otitis Externa (AOE)

Topical antibiotics covering Pseudomonas aeruginosa and Staphylococcus aureus are first-line therapy. 1, 2

Critical: Do NOT prescribe systemic antibiotics for uncomplicated AOE. 1, 2, 5 This represents inappropriate antibiotic use and increases resistance without improving outcomes. 2

Topical therapy considerations:

• Use non-ototoxic preparations if tympanic membrane perforation or tympanostomy tubes are present or suspected. 1, 2
• Combination antibiotic/steroid drops (e.g., ciprofloxacin/dexamethasone) are appropriate. 2
• Consider ear canal wick placement if canal is severely edematous. 1

For Otic Barotrauma

NSAIDs are superior to acetaminophen because they address both pain and inflammation. 3

Non-pharmacologic maneuvers:

• Valsalva maneuver, chewing, yawning, and earlobe extension should be attempted repeatedly during the first 24-48 hours. 3
• These techniques open the Eustachian tube and help equalize middle ear pressure. 3

Do NOT prescribe systemic antibiotics unless there is evidence of acute otitis media with purulent otorrhea or systemic infection—barotrauma is a mechanical injury, not an infection. 3

What NOT to Do: Critical Pitfalls

Never use benzocaine otic solutions. They are not FDA-approved for safety, effectiveness, or quality, and may mask progression of underlying disease. 2, 3, 6

Never prescribe systemic antibiotics for:

• Uncomplicated acute otitis externa. 1, 2, 5
• Otitis media with effusion (OME)—antibiotics do not accelerate resolution. 5
• Referred ear pain from pharyngitis when otoscopy is normal. 5
• Otic barotrauma without evidence of infection. 3

Never treat ear pain without visualizing the tympanic membrane. This leads to misdiagnosis and inappropriate therapy. 2

Never underdose or delay analgesics. Pain management should be immediate and scheduled, not as-needed. 2, 5

Reassessment Criteria

Re-examine the patient if:

• No improvement in pain within 24-48 hours of analgesics. 2, 3, 5
• Persistent symptoms after 48-72 hours of antibiotics. 2, 5
• Pain persists beyond 48-72 hours in barotrauma. 3
• Effusion persists beyond 3 months (consider tympanostomy tubes). 5

For AOE specifically: The originally treated ear should show clinical improvement by day 5 of therapy; lack of improvement warrants reassessment for treatment failure, poor adherence, canal obstruction, fungal co-infection, contact dermatitis, or misdiagnosis. 2

Special Populations and Modifying Factors

High-risk patients requiring modified approach:

• Diabetes mellitus or immunocompromised state: Higher risk for necrotizing otitis externa; avoid aural irrigation with tap water and consider reacidifying the ear canal with vinegar or acetic acid drops after treatment. 1, 2
• Non-intact tympanic membrane or tympanostomy tubes: Require non-ototoxic topical therapy; avoid alcohol-containing solutions. 1, 2
• Prior head/neck radiotherapy: Altered tissue healing and infection risk. 2

Cerumen removal precautions:

• Do not irrigate if tympanic membrane perforation, ear surgery history, or anatomic canal abnormalities are present. 1
• Obtain detailed history before irrigation since the eardrum may not be visualized due to cerumen. 1