June 2003

Countless articles have been written and medical lectures given on antibiotic treatment for acute otitis media (AOM), but there are only a few articles regarding the management of earache. Most American children with AOM are brought to medical care because they are in pain and the parent suspects that AOM is the cause. This complaint is also one of the more frequent reasons for after-hours telephone calls. The pain from AOM falls on a continuum of intensity, ranging from severe pain associated with crying, interruptions of daytime activity or sleep, and incessant tugging or rubbing the ear, to mild pain associated with brief episodes of fussiness or sleep disturbance, to no parental suspicion of ear pain.

Forty percent of children with AOM will cry because of an earache. The more intense and prolonged the cry, the greater the probability of physician-confirmation of AOM. However, earache, irritability, or sleep disturbances are not invariably present, even when the child’s tympanic membrane (TM) has all the major signs of AOM. Hayden and Schwartz found that 17% of 335 consecutive episodes of AOM were apparently painless, and that 25% of children younger than 2-years of age did not appear to show they were in pain. Two studies of Finnish children with AOM confirmed these findings. The first study of 191 children with AOM found that 32% of those younger then 2 years had no apparent earache. The other study found that 40% of patients younger than 4 years — with symptoms of an upper respiratory infection — had no apparent earache. An earlier Scandinavian study of clinical features of AOM in 2,254 episodes reported the absence of earache in 26% of patients.

Rocking a suffering child or cupping the parent’s palm over the auricle are tried-and-true methods of bringing solace. Application of heat by means of radiation or conduction often provides some relief. In some aboriginal cultures, the parent gently may breathe into the external auditory meatus. Direct application of a heating pad or warmed washcloth against the external auditory meatus or installations of warm olive oil into the horizontally held ear are popular methods of providing pain relief. An absorbent cotton plug is then inserted into the ear canal to prevent the drops from draining out.

Pharmaceutical modalities

Oral administration of acetaminophen drops or suspension (15 to 20 mg/kg) every four to six hours or ibuprofen drops or suspension (10 mg/kg) every six hours can relieve mild or moderate earache, and may attenuate severe earache. For stronger pain relief, acetaminophen with codeine (12 mg/5ml) suspension at a dose of 1 mg/kg of the codeine component can allow the child to get back to sleep or to return to play within 20 to 30 minutes. An extra dose of plain acetaminophen suspension at 10 mg/kg can be administered in addition to that in the acetaminophen with codeine suspension. An old favorite for infants is the oral administration of anise-flavored paregoric suspension, now reformulated with anhydrous morphine, 1 mg/ml and alcohol 19%. This product however, is no longer recommended for children. Antipyrine-benzocaine otic solution is a decades-old popular method of relieving the severe pain of AOM. Holding a capped bottle of antipyrine-benzocaine under hot water can warm the liquid and may increase its analgesic effectiveness. Antipyrine-benzocaine has no known systemic effects but is reputed to induce analgesia rapidly, after coming into contact with the TM. Hoberman and colleagues proved that antipyrine-benzocaine was more effective than olive oil drops, but that it took 30 minutes for it to achieve superiority over olive oil.

Eardrops that are clear usually do not obscure clinical findings, because the drops leak out of the ear canal although there may be a wetness to the surface of the TM. As a cautionary note, instillation of oily drops into the ear canal is contraindicated when the eardrum has ruptured and the ear is draining.

A Cochrane review of the literature on the use of antibiotics for AOM and a study of 315 children with AOM (recruited from the offices of English general practitioners), concluded that one of the few benefits of antibiotic use was reduced pain in those children who suffer pain beyond 24-hours.

Surgical relief of pain

In the primary pediatrician’s office, timely myringotomy or tympanocentesis probably represents the most dramatic pain relief for a child who is experiencing severe pain caused by a bulging, intensely inflamed TM. Before the introduction of antibiotics, myringotomies were frequently performed on a kitchen table in the child’s home by primary care physicians who brought a straight myringotomy knife in their medical bag. The technique of tympanocentesis was discussed in an earlier article in this series and in a review article in Pediatric Infectious Disease Journal.

The uses of herbal and homeopathic treatments have been employed in many countries for relief of pain in children with AOM. Homeopathic preparations for earache may include aconite, belladonna (for sudden onset of earache), chamomilla, ferrum phosphoricum (for red, bulging eardrums), and mercurius, all in very dilute concentrations. In a study evaluating the efficacy of homeopathy in treating children with AOM, 230 children with otalgia were randomized to receive homeopathic drops, individualized according to symptoms elicited by history and administered sublingually on a lactose tablet, or placebo. If pain had not subsided within six hours, a different homeopathic medicine was administered. Pain control was achieved in 39% of the children by six hours and an additional 33% by the 12th hour. Resolution was 2.4 times faster in the experimental group than the control group. Children with persistent pain after 12 hours were given an antibiotic.

In another study, 103 children from 6 to 18 years with otalgia and AOM were randomized to receive Otikon Otic Solution (Healthy-On) containing allium sativum, verbascum thapsus, Calendula flores and Hypericum perforatum in olive oil. A second group was given a commercially available anesthetic eardrop containing ametocaine and phenazone in glycerin. Ear pain was assessed throughout the course of three days using two visual analog scales. The reduction in pain score was apparent in both groups. The pain scores were a comparison of scores initially, after 15 and 30 minutes and after 24 and 48 hours for each group, plus differences between the two groups. A similar study in the May 3, 2003 issue of Pediatrics, electronic pages, confirmed the results of the first trial.

Hypnosis or guided imagery can also be useful to relieve pain in children older than 3 or 4 years.

Treatment of moderate or severe pain is an important part of the management of AOM. It allows a suffering child, his or her parents, and often the primary care physician to restore homeostasis to the child and the family. There are a variety of effective treatment modalities for this purpose.

For more information:

• Sarrell EM, Cohen HA, Kahan E. Naturopathic treatment for ear pain in children. Pediatrics. 2003;111(5 Pt 1):e574-575.
• Little P, Gould C, Williamson I, et al. Pragmatic randomized controlled trial of two prescribing strategies for childhood acute otitis media. BMJ. 2001; 322(7282):336-342.
• Schwartz RH, Pichichero M. Myringotomy and tympanocentesis (CPT 69420): A lost skill revisited. Infect Dis Child. 2001;14(10):11,12,16-18.
• Frei H, Thurneysen A. Homeopathy in acute otitis media in children: treatment effect or spontaneous resolution. Brit Homeopathy J. 2001;90(4):178-9.
• Sarrell EM, Mandelberg A, Cohen A. Efficacy of naturopathic extracts in the management of ear pain associated with acute otitis media. Arch Pediatr Adolesc Med. 2001;155(7):796-99.
• Hoberman A, Paradise JL, Wald ER. Tympanocentesis technique revisited. Pediatr Infect Dis J. 1997;16(2 suppl):S25-S26.
• Hoberman A, Paradise JL, Reynolds EA, Urkin J. Efficacy of Auralgan for treating ear pain in children with acute otitis media. Arch Pediatr Adolesc Med. 1997;151(7):675-678.
• Heikkinen T, Ruuskanen O. Signs and symptoms predicting acute otitis media. Arch Pediatr Adolesc Med. 1995;149(1):26-29.
• Niemela M, Uhari M, Jounio-Ervasti K, et al. Lack of specific symptomatology in children with acute otitis media. Pediatr Infect Dis J. 1994;13(9):765.768.
• Hayden GF, Schwartz RH. Characteristics of earache among children with acute otitis media. Am J Dis Child. 1985:139(7):721-723.
• Pukander J. Clinical features of acute otitis media among children. Acta Otolaryngol. 1983;95(1-2):117-122.