eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > External Ear Diseases
Otalgia: Treatment & Medication
Updated: Aug 26, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Identification of a causative etiology is often necessary to successfully treat referred otalgia. Once determined, most causes of referred otalgia can be readily treated. Use antibiotics in treating various types of infections (eg, tonsillitis, pharyngitis, sinusitis). Use antivirals if the causative agent is suspected to be viral such as in cases associated with herpes zoster or shingles. Antifungals are indicated if the source is caused by a fungus (eg, oral thrush/candidiasis). Antiulcer/antacid medications can be used for esophagitis and gastroesophageal reflux disease. Use NSAIDs when myalgias and neuralgias are suspected. Re-examine the patient after a 2-week trial of NSAIDs. Strong narcotic analgesics are not indicated and should not be used to treat referred otalgia. Narcotics may mask symptoms, making the correct diagnosis difficult to reach.
Perform a detailed search for the underlying diagnosis before initiating treatment. Starting analgesics before reaching a diagnosis increases the difficulty of determining the cause and may possibly obscure a life-threatening condition such as an occult cancer.
Any of the previously mentioned treatments can be implemented when the exact cause of referred otalgia is suspected. If the problem persists after a 2- to 3-week trial, a more advanced algorithm is indicated, as follows:
- History
- Otologic history - Tinnitus, hearing, vertigo
- Sinuses
- Pulmonary history
- Cardiac history
- Dental history - Mastication
- GI history - Dysphagia, esophagitis, reflux
- Neurologic history - Neuralgias
- Musculoskeletal history - Arthritis
- Cervicofacial history
- Myalgias
- Trauma - Cervical spine (C-spine)
- Infections - Tonsillitis, pharyngitis
- Physical examination
- Nasopharyngoscopy
- Laryngoscopy
- Preliminary testing (appropriate to symptoms)
- Audio
- Barium swallow
- ECG C-spine radiography
- Chest radiography
- Panorex imaging
- Treat the underlying problem appropriately with trial medications (eg, antibiotics, NSAIDs) and 2-week follow-up or with appropriate consultation (eg, dentist, gastroenterologist, neurologist, rheumatologist, neurosurgeon).
- If the findings on history, physical examination, and testing are inconclusive, consider local anesthesia to block the source of pain as follows:
- Nasal cavity pathology: Spray may localize the problem to the sinus or sphenopalatine oral cavity; consider specific nerve blocks.
- Larynx: Use gargle or transtracheal 4% lidocaine.
- Ear canal: Use topical agent for sensitive ear canal; consider injection for chorda tympani.
- Muscular trigger points: Lidocaine injection can be useful in diagnosis.
- If history and physical examination findings are inconclusive, perform other diagnostic procedures if suspicion still exists for the following conditions:
- Upper respiratory tract tumor - Panendoscopy, chest radiography, CT scanning, or MRI as needed
- Sinus disease - Sinus CT scanning
- Intracranial/intratemporal disease - Audiometric battery and CT scanning or MRI as needed
- Autoimmune disease - ESR, thyroid function studies (thyroiditis, temporal arteritis)
- Endolymphatic hydrops - ESR, thyroid function test (TFT), fluorescent treponemal antibody absorption (FTA-Abs) test, fasting glucose, lipid profile
- Eustachian tube dysfunction - Autoinsufflation (consider myringotomy)
- Psychiatric disorder - Consider psychiatric consultation.
- If no diagnosis is reached, consider watchful surveillance for 1-3 months and then re-evaluate.
Consultations
In patients with odontogenic problems, either a dentist or an oral surgeon may be very helpful. Neurologists and pain management specialists (anesthesiologists) may treat neuralgias. Other consultations may be necessary, including a gastroenterologist for persons needing a further evaluation that requires a barium swallow or upper endoscopy or a rheumatology consultation for the evaluation of arthritis and other joint disorders.
Diet
Diet may be relevant if the patient has dental problems. A soft mechanical diet may be necessary to avoid exacerbation of the problem.
Activity
Because of the diversity of the causes of referred otalgia, listing activity restrictions on a general basis is impossible. Activity considerations are case specific. For example, patients with temporomandibular joint dysfunction should consider activities that involve jaw clenching.
Medication
Use antibiotics in treating various types of infections (eg, tonsillitis, pharyngitis, sinusitis). Use antivirals if the causative agent is suspected to be viral such as in cases associated with herpes zoster or shingles. Antifungals are indicated if the source is caused by a fungus (eg, oral thrush/candidiasis). Antiulcer/antacid medications can be used for esophagitis or gastroesophageal reflux disease. Use NSAIDs when myalgias and neuralgias are suspected. Reexamine the patient after a 2-week trial of NSAIDs.
Perform a detailed search for the underlying diagnosis before initiating treatment. Starting analgesics before reaching a diagnosis increases the difficulty of determining the cause and may possibly obscure a life-threatening condition such as an occult cancer.
Any of the previously mentioned treatments can be implemented when the exact cause of referred otalgia is suspected. If the problem persists after a 2- to 3-week trial, a more advanced algorithm is indicated.
Antibiotics
Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting. Resort to empiric antimicrobial therapy only after an exhaustive search for a source of pain has failed.
Amoxicillin and clavulanate (Augmentin)
Treats bacteria resistant to beta-lactam antibiotics.
Adult
875 mg PO bid
Pediatric
Not established
Coadministration with warfarin or heparin increases risk of bleeding
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Administer for a minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever); following treatment, perform cultures to confirm eradication of streptococci
Amoxicillin (Amoxil, Trimox)
Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.
Adult
500 mg PO tid
Pediatric
Not established
Reduces efficacy of PO contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
Clarithromycin (Biaxin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing cessation of RNA-dependent protein synthesis.
Adult
500 mg PO bid
Pediatric
Not established
Toxicity increases with coadministration of fluconazole, astemizole, and pimozide; clarithromycin effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; cardiac arrhythmias may occur with coadministration of cisapride; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Documented hypersensitivity; coadministration of pimozide or cisapride
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; administer half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies
Ciprofloxacin (Cipro)
Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis, and consequently, growth.
Adult
500 mg PO bid
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Antivirals
Nucleoside analogs are initially phosphorylated by viral thymidine kinase to eventually form a nucleoside triphosphate.
Acyclovir (Zovirax)
Has demonstrated inhibitory activity against both HSV-1 and HSV-2. Selectively incorporated into infected cells.
Adult
800 mg PO 5 times/d for 7-10 d
Pediatric
Not established
Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or when using nephrotoxic drugs
Famciclovir (Famvir)
Prodrug that when biotransformed into active metabolite, penciclovir, may inhibit viral DNA synthesis/replication.
Adult
500 mg PO tid for 7 d
Pediatric
Not established
Coadministration of probenecid or cimetidine may increase toxicity; coadministration increases bioavailability of digoxin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or coadministration of nephrotoxic drugs
Valacyclovir (Valtrex)
Prodrug rapidly converted to the active drug acyclovir. More expensive but has a more convenient dosing regimen than acyclovir.
Adult
1000 mg PO tid for 7 d
Pediatric
Not established
Probenecid, zidovudine, or cimetidine coadministration prolongs half-life and increases CNS toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome
Antifungals
Mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.
Fluconazole (Diflucan)
Synthetic PO antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation.
Adult
6 mg/kg PO/IV on day 1, then 3 mg/kg PO/IV qod
Pediatric
Not established
Levels may increase with hydrochlorothiazide; levels may decrease with chronic coadministration of rifampin; coadministration of fluconazole may decrease phenytoin concentrations; may increase concentrations of theophylline, tolbutamide, glyburide, and glipizide; effects of anticoagulants may increase with fluconazole coadministration; increases in cyclosporine concentrations may occur when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor closely if rashes develop and discontinue drug if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) with underlying medical conditions such as AIDS or a malignancy and while taking multiple concomitant medications; not recommended for breastfeeding women
Nystatin (Mycostatin)
Fungicidal and fungistatic antibiotic obtained from Streptomyces noursei. Effective against various yeasts and yeastlike fungi. Changes permeability of fungal cell membrane after binding to cell membrane sterols, causing cellular contents to leak.
Adult
4-6 mL PO swish and swallow qid
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat systemic mycoses
Antacids
These agents can be used for esophagitis or gastroesophageal reflux disease.
Famotidine (Pepcid)
Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and reduced hydrogen concentrations.
Adult
20-40 mg PO qhs
Pediatric
Not established
May decrease effects of ketoconazole and itraconazole
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
If changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Ranitidine (Zantac)
Inhibits histamine stimulation of the H2 receptor in gastric parietal cells, which reduces gastric acid secretion, gastric volume, and hydrogen concentrations.
Adult
150 mg PO bid or 300 mg qhs
Pediatric
Not established
May decrease effects of ketoconazole and itraconazole; may alter serum levels of ferrous sulfate, diazepam, nondepolarizing muscle relaxants, and oxaprozin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal or liver impairment; if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Lansoprazole (Prevacid)
Inhibits gastric acid secretion.
Adult
15-30 mg PO qd
Pediatric
Not established
May decrease effects of ketoconazole and itraconazole; may increase theophylline clearance
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Consider adjusting dose in liver impairment
Omeprazole (Prilosec)
Inhibit gastric acid secretion by inhibiting H+/K+ ATPase enzyme system at secretory surface of gastric parietal cells.
Adult
20-60 mg PO qd
Pediatric
Not established
May decrease absorption of iron, itraconazole, and ketoconazole; may increase toxicity of warfarin, digoxin, and phenytoin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Bioavailability may increase in elderly patients
Esomeprazole magnesium (Nexium)
S-isomer of omeprazole. Inhibits gastric acid secretion by inhibiting H+/K+ -ATPase enzyme system at secretory surface of gastric parietal cells.
Used in severe cases of and patients not responding to H2 antagonist therapy.
Used for up to 4 wk to treat and relieve symptoms of active duodenal ulcers; may be used up to 8 wk to treat all grades of erosive esophagitis.
Adult
20-40 mg PO qd for 4-8 wk
Pediatric
Not established
Extensively metabolized by CYP2C19 and CYP3A4, also inhibits CYP2C19; coadministration with CYP2C19 and CYP3A4 inhibitors (eg, voriconazole) may increase esomeprazole levels, but dosage adjustment is not normally required; may decrease atazanavir plasma levels; decreases diazepam clearance by 45%; postmarketing surveillance found coadministration with warfarin may increase INR and prothrombin time; amoxicillin or clarithromycin may increase plasma levels of esomeprazole when used concurrently; may reduce absorption of dapsone; may increase levels of diazepam and GI absorption of digoxin; may decrease absorption of iron, ketoconazole and itraconazole
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Symptomatic relief with proton pump inhibitors may mask symptoms of gastric malignancy; frequently occurring (>1%) adverse effects include headache, diarrhea, nausea, flatulence, abdominal pain, constipation, and xerostomia
Analgesics
Pain control is essential to quality patient care.
Ibuprofen (Motrin, Advil)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-800 mg PO tid/qid
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Hydrocodone and acetaminophen (Lortab, Vicodin)
Drug combinations indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
Not established
Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or TCAs
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly patients; be aware of total daily dose of acetaminophen; not to exceed 4000 mg/d of acetaminophen; higher doses may cause liver toxicity; caution in severe renal or hepatic dysfunction
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for the relief of moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone q4-6h prn
Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in the elderly; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/24h of acetaminophen; higher doses may cause liver toxicity
More on Otalgia |
| Overview: Otalgia |
| Differential Diagnoses & Workup: Otalgia |
 Treatment & Medication: Otalgia |
| Follow-up: Otalgia |
| Multimedia: Otalgia |
| References |
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References
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Further Reading
Keywords
otalgia, chronic otalgia, chronic, otalgia definition, ear pain, earache, primary otalgia, referred otalgia, external otitis, otitis media, mastoiditis, auricular infections, tympanic membrane perforation, ear infections
