OTC Cases: Ear Infections

Q: PJ is a 7-year-old boy with complaints of ringing in his ears followed by trouble hearing with a sudden onset. His mother, ET, reported that he had a cold this past week and that he appears to have poor balance when walking. She asks about ear wax removal kits to improve the hearing problems. What should the pharmacist recommend?

A: PJ’s symptoms are consistent with common presentation of labyrinthitis, and the pharmacist should refer him to his PCP for further evaluation and treatment. The symptoms of hearing loss and poor balance, especially in a child with a recent common cold, suggest viral etiology. Viral infections are a common trigger for labyrinthitis. PJ’s PCP may conduct testing and refer the child to a specialist. In some cases, corticosteroids or antiviral medications may be prescribed.^1,2

Q: MT, a 42-year-old man, has a prescription for ciprofloxacin and dexamethasone (Ciprodex). He has not used ear drops since he was a child, and his mother would pull his ear canal downward to apply the treatments. MT asks the pharmacist to walk him through the application for adults. How should the pharmacist instruct him to use the medication?

A: MT should first wash his hands with soap and water. He should then warm
the ciprofloxacin and dexamethasone bottle in his hands for 1 to 2 minutes prior to administration, as dizziness may occur if a cold otic suspension is instilled in the ear canal. The pharmacist should then instruct MT to remove the cap and place it on a clean dry surface. Unlike how children are administered ear drops, MT should tilt his head sideways and pull his affected ear up and back. He should then administer the ear drops using the applicator but avoid having the applicator tip enter the ear canal. To maximize the ciprofloxacin and dexamethasone exposure, he should lie down on his side with the affected ear up for 5 minutes or place a piece of cotton ball at the end of the outer ear canal of the affected ear for 20 minutes. Remind MT not to share this medication with others.³

Q: JP is a 3-year-old, 35-lb boy with mild to moderate ear pain who has had a 38 °C fever for the past 24 hours. His mother, MO, calls the pharmacy with questions about unilateral AOM. She noted that upon consultation, JP’s pediatrician recommended initial observation with pain control but without antibiotics. MO is concerned about the pediatrician’s recommendation and asks for the pharmacist’s input and what pain medications JP should take. What advice can the pharmacist give her?

A: Given that JP is an immunocompetent child older than age 2 without craniofacial abnormalities and ear discharge and with a temperature of less than 39 °C, study results support the approach of either immediate antibiotic treatment or initial observation. If his pain and symptoms worsen or do not improve after 48 to 72 hours, the pediatrician should give JP antibiotics. Typically, a pediatrician will choose either amoxicillin or amoxicillin-clavulanate antibiotic treatment for AOM if no recent allergies, antibiotic use, or resistance are noted. If JP’s symptoms improve in 48 hours, he should follow up with the pediatrician at the next health maintenance visit.^4-9

In terms of pain control, study results show that patients with AOM who received acetaminophen or ibuprofen experienced pain relief at 48 hours compared with a placebo. There are insufficient data to support the use of both acetaminophen and ibuprofen together. If using acetaminophen, give 160 mg oral liquid every 4 to 6 hours as needed, with a maximum of 5 doses per day and a maximum daily dose of 75 mg/kg or 4000 mg, whichever is less. If using ibuprofen, administer 100 mg oral liquid every 6 to 8 hours, with a maximum single dose of 400 mg and a maximum daily dose of 40 mg/kg per day.^10,11

Q: HP is a 68-year-old man who asks about a nonprescription product to help with painful, water-clogged ears with discharge. He just returned from a family trip to an all-inclusive beach resort, where he spent much of the time in the pool. HP’s temperature has been running high for the past 2 days since his return, and he is having trouble hearing on the phone, which is a necessity for his work-from- home job. His coworker mentioned that OTC ear drops relieve discomfort. What advice should the pharmacist give HP?

A: The symptoms of discharge, ear pain, and fever, combined with a lot of time swimming recently are consistent with the common presentation of swimmer’s ear. Given the virulent nature of swimmer’s ear, refer HP to his primary-care provider (PCP) for further evaluation and treatment. In the meantime, HP should be instructed to avoid using cotton swabs. The PCP will likely first clean HP’s ear canal using an otoscope and then treat the infection and inflammation with a topical steroid and/or an oral or topical antibiotic. The PCP may recommend an OTC analgesic such as ibuprofen or naproxen to treat the ear pain. Throughout the duration of treatment for swimmer’s ear, HP should protect his ears from water using petroleum jelly–coated cotton balls when bathing and avoid swimming for 7 to 10 days.^12,13

If HP had had water-clogged ears without discharge, fever, or pain, he could have self- treated with a cerumen removal kit, such as carbamide peroxide. To reduce the risk of swimmer’s ear in the future, he should use ear plugs when swimming, and if water does enter his ears, tilt his head to each side to shake his ears dry. HP can also consider blow drying his ears at the lowest heat setting after water exposure by holding the dryer 1 foot away from his ears.¹⁴

Rupal Patel Mansukhani, PharmD, FAPhA, NCTTP, is a clinical associate professor at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, and a transitions-of- care clinical pharmacist at Morristown Medical Center in New Jersey.

Ammie J. Patel, PharmD, BCPS, BCACP, is a clinical assistant professor of pharmacy practice and administration at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway, and an ambulatory care specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.

REFERENCES

1. Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med. 2003;348(11):1027-1032.doi:10.1056/NEJMcp0211542.
2. Strupp M, Zingler VC, Arbusow V, et al. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med.2004;351(4):354-361.doi:10.1056/NEJMoa0332803.
3. Ciprodex, otic suspension. Prescribing information. Alcon Laboratories Inc; 2019. Accessed May 20, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/021537s017lbl.pdf4.
4. Spiro DM, Tay KY, Arnold DH, DziuraJD, Baker MD, Shapiro ED. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA.2006;296(10):1235-1241. doi:10.1001/jama.296.10.12355.
5. Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media.BMJ.2001;322(7282):336-342.doi:10.1136/bmj.322.7282.3366.
6. Cates C. An evidence based approach to reducing antibiotic use in children with acute otitis media: controlled before and after study. BMJ.1999;318(7185):715-716.doi:10.1136/bmj.318.7185.7157.
7. Siegel RM, Kiely M, Bien JP, et al. Treatment of otitis media with observation and a safety-net antibiotic prescription. Pediatrics. 2003;112(3 pt 1):527-531.doi:10.1542/peds.112.3.5278.
8. Chao JH, Kunkov S, Reyes LB, Lichten S, Crain EF. Comparison of two approaches to observation therapy for acute otitis media in the emergency department. Pediatrics. 2008;121(5):e1352-e1356.doi:10.1542/peds.2007-2278
9. Uitti JM, Tähtinen PA, Laine MK, Ruohola A. Close follow-up in children with acute otitis media initially managed without antimicrobials. JAMA Pediatr.2016;170(11):1107-1108.doi:10.1001/jamapediatrics.2016.154210.
10. American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 6th ed. American Pain Society; 2009.11.
11. Kliegman RM, Stanton BF, St. Geme J, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Saunders; 2011.12.
12. Welch CM, Brown KD. Diseases of the external ear. In: Lalwani AK, ed. Current Diagnosis & Treatment: Otolaryngology–Head and Neck Surgery. 4th ed. McGraw-Hill Education; 2020:797-816.13.
13. Rosenfeld RM, Brown L, Cannon CR, et al; American Academy of Otolaryngology–Head and Neck Surgery Foundation. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2006;134(suppl 4):S4-S23.doi:10.1016/j.otohns.2006.02.01414.
14. Osguthorpe JD, Nielsen DR. Otitis externa: review and clinical update. Am Fam Physician. 2006;74(9):1510-1516.