How to manage ear pain in a pediatric patient with potential acute otitis media or otitis externa?

Management of Ear Pain in Pediatric Patients

Immediately administer weight-based analgesics (acetaminophen or ibuprofen) for pain control, then perform pneumatic otoscopy to differentiate between acute otitis media (AOM) and otitis externa before deciding on antibiotic therapy. 1, 2

Step 1: Immediate Pain Management (First Priority)

Pain control must be addressed immediately, regardless of whether antibiotics will be prescribed. 1

• Administer weight-based acetaminophen or ibuprofen to provide symptomatic relief within 24 hours 2
• Ibuprofen may be superior to acetaminophen alone because it addresses both pain and inflammation 2
• Continue analgesics as long as needed, not just for the first 24 hours 1
• Antibiotics do not provide symptomatic relief in the first 24 hours and even after 3-7 days, 30% of children younger than 2 years may have persistent pain 1

Common pitfall: Clinicians often view otalgia as a peripheral concern not requiring direct attention, but pain is the major symptom and should be the primary focus of initial management 1

Step 2: Diagnostic Examination with Pneumatic Otoscopy

Perform pneumatic otoscopy to determine if middle ear effusion and inflammation are present. 1, 2

Diagnostic Criteria for Acute Otitis Media (AOM):

AOM requires ALL three elements 1:

• Acute onset of signs and symptoms (rapid onset of otalgia, ear pulling in infants, irritability, otorrhea, or fever)
• Middle ear effusion indicated by bulging tympanic membrane, limited/absent tympanic membrane mobility, air-fluid level, or otorrhea
• Signs of middle ear inflammation indicated by distinct erythema of the tympanic membrane

Specific Diagnostic Findings:

Diagnose AOM if: 1, 2

• Moderate to severe bulging of the tympanic membrane (97% specificity for bacterial AOM) 3
• New onset otorrhea not caused by otitis externa
• Mild bulging of the tympanic membrane PLUS recent onset ear pain (<48 hours) or intense erythema

Differentiating Otitis Externa:

Diagnose otitis externa if: 4, 5

• Tenderness with movement of the pinna or tragus (classic finding)
• Generalized inflammation of the external ear canal with canal edema
• Pain with manipulation of the ear structures

Common pitfall: Clinical history alone is poorly predictive of AOM, especially in younger children, and otitis media with effusion (OME) is often mistakenly identified as AOM, leading to unnecessary antibiotic prescriptions 1, 2

Step 3: Antibiotic Decision Algorithm (Only If AOM Diagnosed)

Immediate Antibiotic Therapy Indicated:

Prescribe antibiotics immediately if: 1, 2

• Moderate to severe ear pain lasting ≥48 hours
• Temperature ≥39°C (102.2°F)
• Bilateral AOM in children <24 months
• Any AOM with otorrhea

Observation with Close Follow-up Permitted:

Consider observation (48-72 hours) with reliable follow-up if: 1, 2

• Unilateral AOM in children 6-23 months with non-severe symptoms (mild otalgia <48 hours, temperature <39°C)
• Any AOM in children ≥24 months with non-severe symptoms

Critical requirement: When observation is used, a mechanism must be in place to ensure follow-up and antibiotic initiation if symptoms worsen or fail to improve within 48-72 hours 1

Step 4: Antibiotic Selection (When Indicated for AOM)

First-Line Therapy:

Prescribe high-dose amoxicillin 80-90 mg/kg/day divided every 8-12 hours (maximum 500 mg/dose). 2, 6

Use Amoxicillin-Clavulanate Instead If:

2, 6

• Child received amoxicillin in the last 30 days
• Concurrent purulent conjunctivitis
• History of recurrent AOM unresponsive to amoxicillin

Penicillin Allergy:

Use cefdinir or azithromycin as first-line in patients with penicillin allergy, based on risk of cephalosporin cross-reactivity. 6

Step 5: Treatment for Otitis Externa (If Diagnosed)

Do NOT use systemic antibiotics for uncomplicated otitis externa. 2, 4

Topical Antibiotic Treatment:

Prescribe topical antibiotic ear drops as first-line therapy: 4, 5

• Acetic acid 2%, aminoglycosides, polymyxin B, or quinolones with or without corticosteroids
• No single preparation is clinically superior; choice based on cost, tympanic membrane integrity, and adherence 4
• Duration: 7-10 days 4

Systemic Antibiotics for Otitis Externa Only If:

4, 5

• Extension of infection outside the ear canal
• Diabetes mellitus
• Immunocompromised state
• Prior head/neck radiotherapy

Special Consideration: Tympanostomy Tubes

If the child has tympanostomy tubes with ear drainage, treat with topical antibiotic ear drops alone (ofloxacin or ciprofloxacin-dexamethasone). 2

Ofloxacin Dosing for Tympanostomy Tubes:

7

• Pediatric patients 1-12 years: 5 drops (0.25 mL) into affected ear twice daily for 10 days
• Warm solution by holding bottle in hand for 1-2 minutes
• Patient lies with affected ear upward, pump tragus 4 times after instillation, maintain position for 5 minutes

Reassessment Criteria

Schedule follow-up or provide clear return precautions if: 2

• No improvement in pain within 24-48 hours of analgesics
• Persistent symptoms after 48-72 hours of antibiotics
• Development of fever, worsening symptoms, or new signs of infection

Red Flag Symptoms Requiring Urgent Evaluation:

3

• Altered mental status, confusion, or decreased responsiveness (possible meningitis/intracranial abscess)
• Severe headache with vomiting
• Stiff neck (nuchal rigidity)
• Bulging fontanelle in infants
• Seizures or focal neurological deficits
• Swelling, redness, or tenderness behind the ear (possible mastoiditis)

Common pitfall: Never prescribe antibiotics for ear pain alone without evidence of infection on examination, as this contributes to antibiotic resistance and exposes the child to unnecessary adverse effects 2