What are the steps to manage otalgia (earache) in an outpatient setting?

From the Guidelines

The management of earache in an outpatient setting should begin with a thorough history and physical examination to determine the cause, and for acute otitis externa, topical preparations should be used as initial therapy, with pain management assessed and treated based on severity, as recommended by the strongest evidence 1. The approach to earache management involves distinguishing between different causes such as acute otitis media, otitis externa, and temporomandibular joint dysfunction.

• For acute otitis externa, the evidence suggests that clinicians should assess patients for pain and recommend analgesic treatment based on the severity of pain, with a strong recommendation for pain management 1.
• The use of topical antibiotic drops such as ciprofloxacin/dexamethasone or ofloxacin is recommended for otitis externa, with the clinician informing patients how to administer topical drops and enhancing delivery when the ear canal is obstructed 1.
• For pain relief, oral analgesics such as acetaminophen or ibuprofen can be used, with the recognition that pain is easier to prevent than treat, and thus early treatment at an appropriate starting dose is always indicated 1.
• The evidence also suggests that adding a topical steroid to topical antimicrobial drops may hasten pain relief in some cases, but other studies have shown no significant benefits, and therefore this should be considered on a case-by-case basis 1.
• Referral to an ENT specialist is necessary for persistent symptoms beyond 3 weeks, recurrent episodes, hearing loss, or signs of complications such as mastoiditis or facial nerve paralysis.
• The key to effective earache management is to target the underlying cause while providing symptomatic relief through appropriate analgesics and specific treatments based on the diagnosis, with a focus on pain management and topical therapy for otitis externa, as supported by the evidence 1.

From the FDA Drug Label

For a Middle Ear Infection: The person receiving ofloxacin otic solution, 0. 3% should lie on his/her side with the infected ear up. Patients (12 and older) should have 10 drops of ofloxacin otic solution, 0. 3% put into the infected ear. Pediatric patients under 12 should have 5 drops put into the infected ear.

For an Ear Canal Infection (“Swimmer’s Ear”): The person receiving ofloxacin otic should lie on his/her side with the infected ear up Patients (13 and older) should have 10 drops of ofloxacin otic put into the infected ear. Pediatric patients under 13 should have 5 drops put into the infected ear.

The steps for treating an earache in an outpatient setting are:

• Wash hands before administering the ear drops
• Clean the ear and warm the bottle by holding it in the hand for one or two minutes
• Add drops to the infected ear, with the number of drops depending on the patient's age and type of infection
• Press or pull the ear to facilitate penetration of the drops into the middle ear or ear canal
• Stay on side for at least 5 minutes after administering the drops
• Repeat the process for the other ear if both ears are infected
• Use the ear drops for the prescribed duration, even if symptoms improve, to prevent the infection from returning 2

From the Research

Earache in Outpatient Setting Steps

• The first step in managing earache in an outpatient setting is to determine the cause of the ear pain, which can be due to various conditions such as otitis externa or otitis media 3, 4.
• For otitis externa, treatment involves cleaning the canal thoroughly and instilling ototopical broad-spectrum antibiotics 3.
• Alternatively, non-antibiotic treatments such as antiseptics or steroids can be used, which have been shown to be effective in managing acute otitis externa 5.
• For otitis media, pain management is a key component of treatment, and both paracetamol and ibuprofen have been shown to be effective in relieving ear pain in children 6.
• Antibiotics such as amoxicillin/clavulanate or azithromycin may be prescribed for otitis media, with azithromycin being a safer and more tolerable option 7.
• It is essential to note that the choice of treatment depends on the specific condition, patient age, and other factors, and should be determined by a healthcare professional 4.

Treatment Options

• Ototopical broad-spectrum antibiotics for otitis externa 3
• Non-antibiotic treatments such as antiseptics or steroids for otitis externa 5
• Paracetamol or ibuprofen for pain management in otitis media 6
• Antibiotics such as amoxicillin/clavulanate or azithromycin for otitis media 7

Important Considerations

• Proper diagnosis and treatment by a healthcare professional are crucial in managing earache in an outpatient setting 4.
• Patient education on preventive measures, such as avoiding prolonged exposure to heat and moisture, can help reduce the risk of otitis externa 3.