Otalgia medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S[2]

Overview

Treatment of otalgia lies in identifying the pathology, whether it exists within the ear or elsewhere. Antibiotics are used to treat infectious causes like otitis media, otitis externa, tonsillitis, and pharyngitis. Antivirals can be used for viral causes such as herpes zoster oticus, and antifungals can be used for oral thrush. NSAIDs are used if myalgias and neuralgias are suspected. The patient should be re-examined after a 2 week trial on the NSAIDs. Appropriate consultation with a neurologist, dentist, gastroenterologist etc., should be done.

Medical Therapy

Primary Otalgia

• Antibiotics are the mainstay of treatment of uncomplicated acute otitis media (AOM) in adults. The preferred antibacterial drug for the patient with AOM must be active against Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis. Amoxicillin remains the drug of choice for initial therapy of AOM.
  • Mild to moderate disease: 500 mg every 12 hours, or 250 mg every 8 hours for 5 - 7 days.
  • Severe disease: 875 mg every 12 hours, or 500 mg every 8 hours for 10 days.

Alternatives to amoxicillin in case of penicillin allergy include Cefdinir (300 mg twice a day or 600 mg once daily), Cefpodoxime (200 mg twice a day), Cefuroxime (500 mg every 12 hours), and Ceftriaxone (2 g IM or IV once).

• Treatment of otitis externa includes:
  • Pain management using NSAIDs.
  • Gently cleansing the debris from the external auditory canal with irrigation or by using a soft plastic curette or cotton swab under direct visualization.
  • Topical medical therapy which includes a combination of mild acid, corticosteroids and either an antibiotic or antifungal. Mild disease can be treated by using an acidifying agent and a corticosteroid. As an alternative a 2:1 mixture of 70% isopropyl alcohol and acetic acid can be used. More severe disease requires addition of an antibacterial or antifungal to the above.
  • Oral antistaphylococcal and IV antipseudomonal antibiotics are generally preferred in patients with fevers, immunosuppression, diabetes, adenopathy, or in those individuals with extension of the infection outside of the ear canal.
  • Chronic, noninfectious, therapy-resistant external otitis can be treated using 0.1% Tacrolimus cream according to a prospective study by Caffier et al.

• Cholesteatomas are preferably treated by surgery. If the patient refuses surgery or if the medical condition of the patient contraindicates use of general anesthesia, then routine cleaning will help control infection and growth of cholesteatoma, but it does not stop further expansion and does not eliminate risk.

• Antibiotics are the main stay of treatment for mastoiditis. Ceftriaxone is used as the initial drug of choice. Further choice of an antibiotic depends on culture studies and Grams staining. If open mastoid surgery is not undertaken, use of single, high-dose, intravenous steroids is warranted to decrease mucosal swelling and to promote natural drainage through the aditus ad antrum into the middle ear.

• Cerumenolysis is performed to remove ear wax and it is achieved using a solution known as a cerumenolytic agent which is introduced into the ear canal. The common agents used are:
  • Carbamide peroxide (6.5%) and glycerine
  • Sodium bicarbonate B.P.C. (sodium bicarbonate and glycerine)
  • Various organic liquids (glycerol, almond oil, mineral oil, baby oil)
  • Cerumol (arachis oil, turpentine and dichlorobenzene)
  • Cerumenex (Triethanolamine, polypeptides and oleate-condensate)
  • Urea, hydrogen peroxide and glycerine
  • Docusate, a detergent,an active ingredient found in laxatives

Syringing and curette methods are other alternatives for cerumen removal.

• Furunculosis of the external ear can be treated by:
  • 10% Ichthammol in glycerine wick pack
  • Polymyxin B, Neomycin, or hydrocortisone ear drops
  • Systemic anti-staphylococcal antibiotics
  • NSAIDs

Referred Otalgia

Pathologies of pharynx, tonsil, temporomandibular joint, teeth, etc., can cause referred pain to the ear. Management of such pain mostly lies in understanding the differential causes, obtained thorough a history followed by systemic examination.

• NSAIDs, throat lozenges, mouth gargling and antibiotics are the main stay of treatment for acute pharyngitis.

• Pain killers and antibiotics form the main stay of treatment for tonsillitis.

• Temporomandibular joint disorders can be managed conservatively by:
  • Applying moist heat or cold packs
  • Eating soft foods
  • NSAIDs
  • Low-level laser therapy
  • Wearing a splint or night guard
  • Undergoing corrective dental treatments
  • Avoiding extreme jaw movements
  • Not resting chin on hand
  • Learning relaxation techniques

Some novel techniques include Transcutaneous electrical nerve stimulation (TENS), trigger-point injections, and radio wave therapy.

• Decongestants, antihistamines and steroids for barotrauma.

• Neuralgias can be treated using NSAIDs, Amitriptyline, Gabapentin, Narcotic analgesics, nerve blocks, trigger-point injections, radiofrequency ablation, etc.