What is the approach to managing ear pain in adults and children?

Approach to Ear Pain in Adults and Children

Immediate First Step: Visualize the Tympanic Membrane

Remove obstructing cerumen immediately using cerumenolytic agents, irrigation, or manual instrumentation to visualize the tympanic membrane—treating ear pain without visualization leads to misdiagnosis and inappropriate therapy. 1

• Cerumen impaction itself can cause ear pain, but you cannot exclude serious pathology without direct visualization of the tympanic membrane 1
• Apply cerumenolytic agents for 15 minutes to 5 days, then irrigate or manually remove 1

Pain Management: Start Immediately

Administer acetaminophen or NSAIDs immediately at fixed intervals (not "as needed") regardless of the underlying diagnosis—pain is easier to prevent than treat. 2, 3

• NSAIDs (ibuprofen) provide superior pain relief compared to acetaminophen alone because they address both pain and inflammation 2, 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 3, 1
• Avoid benzocaine otic solution—it is NOT FDA-approved and may mask progression of underlying disease 1

Diagnostic Algorithm: Primary vs. Secondary Otalgia

Test for Primary Otalgia (Ear Pathology)

Press on the tragus or pull the pinna—pain with this maneuver is pathognomonic for acute otitis externa. 3, 1

If Tragus Tenderness Present: Acute Otitis Externa (AOE)

• Diagnosis requires canal edema, erythema, debris, or purulent material PLUS tragus tenderness 3
• Prescribe topical antibiotics covering Pseudomonas aeruginosa and Staphylococcus aureus as first-line therapy—do NOT prescribe systemic antibiotics for uncomplicated AOE. 2, 3
• Use topical antibiotic/steroid combination drops (e.g., ciprofloxacin/dexamethasone) for enhanced efficacy 3
• Use non-ototoxic preparations if tympanic membrane perforation or tympanostomy tubes are present 1
• Avoid neomycin-containing preparations in treatment failure—neomycin is the most common allergen causing chronic external otitis 1

If Tragus Test Negative: Examine Tympanic Membrane

Document tympanic membrane color, position (bulging vs. retracted), opacity, and mobility with pneumatic otoscopy. 1

Acute Otitis Media (AOM) Diagnosis

The American Academy of Pediatrics defines AOM by three major criteria: 4

1. Constitutional signs and symptoms (acute onset of ear pain, fever) 4
2. Tympanic membrane bulging (96% bacterial isolation rate when present—most consistent sign) 4, 1
3. Middle ear effusion (cloudy/opaque tympanic membrane has 95.7% positive predictive value) 4, 1

Alternative diagnostic criteria: mild bulging of tympanic membrane with recent onset (<48 hours) of ear pain or intense erythema 4

AOM Management: Severity-Based Antibiotic Decision

For severe AOM (temperature ≥39°C/102.2°F, moderate-to-severe otalgia >48 hours, bilateral AOM, or AOM with otorrhea): prescribe antibiotics immediately. 2

• High-dose amoxicillin (80-90 mg/kg/day in divided doses every 8-12 hours) is first-line for patients without penicillin allergy 2, 5
• Maximum adult dose: 500 mg per dose 5
• Amoxicillin covers Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2, 5

For mild AOM (mild otalgia <48 hours, temperature <39°C, unilateral disease in otherwise healthy patients): watchful waiting for 48-72 hours with reliable follow-up may be considered. 2

• Continue analgesics at fixed intervals during watchful waiting 2
• Antibiotics reduce pain at 2-3 days (NNT=20) but increase adverse effects (NNH=14), primarily gastrointestinal 2

If Tympanic Membrane Normal: Secondary Otalgia (Referred Pain)

A normal otoscopic exam with ear pain indicates referred pain from outside the ear until proven otherwise. 3, 1

Common causes of secondary otalgia: 6, 7

• Temporomandibular joint syndrome (most common in adults)—pain with chewing 6, 7
• Dental disease—inspect for caries, abscesses, periodontal disease 6, 7
• Pharyngitis—examine oropharynx for erythema, exudate, tonsillar enlargement 6, 7
• Cervical spine arthritis—assess neck range of motion 7

Management: Treat with acetaminophen or NSAIDs as primary intervention for pharyngitis with referred ear pain 3

Reassessment Criteria

Re-examine the patient if there is no improvement in pain within 24-48 hours of analgesics, persistent symptoms after 48-72 hours of antibiotics, or symptoms worsen at any time. 2, 3

Common causes of treatment failure: 2, 1

• Poor adherence to therapy
• Obstructed ear canal preventing drug delivery
• Resistant bacteria (obtain culture)
• Misdiagnosis (fungal infection, dermatologic disorder, foreign body)
• Contact sensitivity to ear drops (especially neomycin)

Red Flags Requiring Advanced Evaluation

Patients who smoke, drink alcohol, have diabetes, are older than 50 years, or are immunocompromised are at higher risk for serious occult causes (necrotizing otitis externa, temporal arteritis, malignant neoplasms) and warrant CT imaging, MRI, or otolaryngology consultation. 6, 7, 1

• Assess for postauricular erythema, swelling, and tenderness over the mastoid bone (mastoiditis) 1
• Prior head/neck radiotherapy alters tissue healing and infection risk 1
• Obtain CT temporal bone without contrast if preauricular swelling persists or worsens to evaluate for mastoiditis or complications 1

Critical Pitfalls to Avoid

• Do NOT prescribe systemic antibiotics for uncomplicated acute otitis externa—this represents inappropriate antibiotic use without improving outcomes 2, 3
• Do NOT prescribe antibiotics solely because of ear pain in pharyngitis 3
• Do NOT treat ear pain without visualizing the tympanic membrane—remove cerumen first 1
• Do NOT use imaging (CT, MRI) for diagnosis of uncomplicated AOM—diagnosis is clinical 4

Age-Specific Considerations

Children

• AOM should be suspected in children with ear pain or more subtle ear symptoms (ear rubbing, excessive crying, disturbed sleep, language delay) with or without fever 4
• Ear pain is present in only 50-60% of children with AOM 4
• In preverbal children, ear pain may manifest as ear manipulation (tugging, rubbing, holding), excessive crying, or changes in sleep and behavior patterns 4
• Pneumatic otoscopy is the primary diagnostic method—distinctly impaired tympanic membrane mobility is highly predictive of middle ear effusion 4

Adults

• Secondary otalgia is more common in adults than children 6, 7
• Initial presentation and symptoms differ slightly from children, but assessment and management are overall similar 4
• Temporomandibular joint syndrome and dental infections are the most common causes of secondary otalgia in adults 6, 7