What is the best treatment approach for an adult patient with no significant medical history presenting with unilateral ear pain?

Treatment for Unilateral Ear Pain in Adults

The treatment of unilateral ear pain in adults depends critically on identifying the underlying cause through systematic evaluation, with acute otitis externa requiring topical antibiotics, acute otitis media requiring oral antibiotics (amoxicillin first-line), and referred pain requiring treatment of the primary source. 1

Immediate Diagnostic Assessment

The first priority is determining whether the pain originates from the ear itself (primary otalgia) or is referred from another source (secondary otalgia):

• Perform otoscopic examination to identify acute otitis externa (diffuse ear canal inflammation, debris, edema), acute otitis media (bulging or erythematous tympanic membrane), cerumen impaction, tympanic membrane perforation, or cholesteatoma 1, 2
• Assess for red flag features including focal neurologic deficits (weakness, dysarthria, ataxia, facial numbness), severe headache, diplopia, or concurrent vision changes that mandate immediate neuroimaging with MRI 3, 1
• Evaluate pain characteristics: sharp/shooting pain suggests neuralgia (glossopharyngeal, geniculate), dull/aching suggests TMJ or musculoskeletal causes, pulsatile suggests vascular etiology 3, 4
• Check for triggers: pain with swallowing suggests glossopharyngeal neuralgia, pain with jaw movement suggests TMJ dysfunction, pain with neck position suggests cervical radiculopathy 3

Treatment Based on Etiology

Acute Otitis Externa (Swimmer's Ear)

Prescribe topical antibiotic drops as first-line treatment for diffuse inflammation of the external ear canal:

• Topical fluoroquinolone drops (ciprofloxacin or ofloxacin) are preferred as they provide broad-spectrum coverage and are non-ototoxic if tympanic membrane perforation is present 1
• Ensure adequate pain control with scheduled acetaminophen or NSAIDs, as pain from otitis externa can be severe due to proximity of inflamed periosteum 1
• Consider opioids (oxycodone, hydrocodone) for severe pain, particularly in the first 24-48 hours 1
• Perform aural toilet to remove debris and allow medication penetration; this may require topical anesthesia or procedural sedation if canal is severely inflamed 1
• Avoid ototoxic preparations (aminoglycosides, alcohol-based drops) if tympanic membrane integrity is uncertain 1

Acute Otitis Media

Prescribe oral amoxicillin 500-875 mg twice daily as first-line antibiotic therapy for adults with acute otitis media (moderate-severe tympanic membrane bulging or new otorrhea):

• Amoxicillin is the preferred initial antibiotic unless the patient received it within the past 30 days, has concurrent purulent conjunctivitis, or has penicillin allergy 1
• Use amoxicillin-clavulanate if the patient received amoxicillin in the last 30 days or has recurrent AOM unresponsive to amoxicillin 1
• Provide analgesics (acetaminophen, ibuprofen, or combination with opioids) as antibiotic therapy does not provide symptomatic relief in the first 24 hours 1
• Reassess at 48-72 hours if symptoms worsen or fail to improve, and consider changing antibiotic therapy 1
• Topical benzocaine-antipyrine drops may be used for additional pain relief, instilling 5 drops every 1-2 hours until pain resolves, though FDA approval for safety and effectiveness is lacking 5, 1

Cerumen Impaction

Remove impacted cerumen if it is causing pain or obstructing visualization of the tympanic membrane:

• Instill ceruminolytic agents (carbamide peroxide, mineral oil, or benzocaine-antipyrine solution) three times daily for 2-3 days to soften cerumen before removal 5
• Perform manual removal via irrigation, curettage, or suction after cerumen softening 5
• Use benzocaine-antipyrine drops after removal to dry the ear canal and relieve residual discomfort 5

Referred Otalgia (Normal Ear Examination)

When otoscopic examination is normal, systematically evaluate for referred pain sources:

Temporomandibular Joint (TMJ) Dysfunction

• Prescribe NSAIDs and recommend soft diet, jaw rest, and avoidance of excessive jaw movements 3
• Refer to dentistry for occlusal splint fabrication and physical therapy 3
• Consider muscle relaxants for severe trismus or muscle spasm 3

Glossopharyngeal Neuralgia

• Initiate carbamazepine 100-200 mg twice daily or oxcarbazepine 300 mg twice daily as first-line pharmacotherapy, titrating to effect 3
• Refer to neurosurgery for microvascular decompression if refractory to medical management 3
• Obtain MRI brain with contrast to exclude structural lesions (posterior fossa tumor, vascular compression) 3

Cervical Radiculopathy

• Order cervical spine MRI if arm tingling follows dermatomal pattern or neck position triggers pain 3
• Prescribe NSAIDs and refer to physical therapy for cervical traction and strengthening 3
• Consider epidural steroid injections for persistent radicular symptoms 3
• Refer to neurosurgery if progressive neurologic deficits develop 3

Dental Disease

• Refer to dentistry urgently for evaluation of dental abscess, caries, or periodontal disease 2
• Prescribe antibiotics (amoxicillin or clindamycin) if dental infection is suspected pending dental evaluation 2

Critical Red Flags Requiring Urgent Evaluation

Order immediate MRI brain with contrast if any of the following are present:

• Focal neurologic symptoms (weakness, dysarthria, hemiataxia, facial numbness, diplopia) suggesting brainstem or posterior circulation stroke 3, 1
• Severe headache with vision changes in young overweight women, suggesting idiopathic intracranial hypertension 3, 4
• Pulsatile tinnitus accompanying ear pain, requiring CT angiography to exclude dural arteriovenous fistula, arterial dissection, or vascular malformation 4
• Unilateral hearing loss with ear pain, requiring audiometry and MRI internal auditory canals to exclude vestibular schwannoma or sudden sensorineural hearing loss 1, 6

Common Pitfalls to Avoid

• Do not prescribe topical aminoglycoside drops if tympanic membrane perforation or tympanostomy tube is present, as they are ototoxic 1
• Do not attribute ear pain to psychogenic causes without thorough evaluation for structural and referred sources 7
• Do not delay imaging in patients over 50 years, smokers, alcohol users, or diabetics, as they have higher risk of serious occult pathology (malignancy, temporal arteritis) 2
• Do not miss bilateral sudden hearing loss, which requires urgent evaluation for autoimmune disease, meningitis, ototoxicity, or systemic disorders 1
• Do not overlook concurrent middle ear disease in patients with otitis externa and tympanostomy tubes, as they may require systemic antibiotics in addition to topical therapy 1