WHAT’S NEW: Pain relief is immediate
Family physicians have used topical anethestics for otitis externa for decades. This RCT adds evidence that topical anesthetics are useful for providing immediate pain relief from AOM, as well. The 2004 guidelines from the American Academy of Pediatrics and the American Academy of Family Physicians indicate that management of AOM should include the assessment and treatment of pain.
We think that topical agents such as lidocaine and benzocaine are useful adjuncts to oral analgesics in providing immediate pain relief, especially in the face of evidence showing that antibiotics do not offer significant pain relief.
Previous studies have shown that aqueous lidocaine is ineffective on uninflamed tympanic membrane.13 The results of this study are consistent with increased uptake of the drug through the inflamed tympanic membrane.
CAVEATS: Children >3 years studied
This trial included only children older than 3 years, so the results may not apply to younger children and infants.
This essentially was a study of ear pain treatment, which, in our view, does not detract from the clinical usefulness of the findings. Topical anesthetics seem to be useful for ear pain in general.
Concurrent analgesics
Some variability existed in the oral analgesics the children received, as these agents were given at the discretion of the parents and treating physicians. We think that this does not detract from the study findings, as it represents a practical, real-world setting, which is desirable in an effectiveness RCT. Moreover, the extent of pain reduction was over and above that conferred by analgesic administration.
CHALLENGES TO IMPLEMENTATION: Lidocaine is not sold in a dropper
Aqueous lidocaine is not sold in a bottle with a dropper: our search on www.drugstore.com and www.drugs.com did not yield an otic preparation with only aqueous lidocaine. However, 2% injectable lidocaine, which is readily available, can be used with a dropper. Aqueous lidocaine can be compounded at a compounding pharmacy and placed in a bottle with a dropper.
Benzocaine might be a suitable substitute
In preparing this PURL, we learned from several colleagues that they always keep a bottle of benzocaine in their pocket and they apply the drops to the ears of their pediatric patients with AOM when they see them in their offices or in the emergency department.
Benzocaine is available in various brand names (eg, Auralgan, Americaine, A/B otic drops, among others). These are oil suspensions and not an aqueous solution as used in this study, so it would be important not to use these preparations in the presence of a ruptured tympanic membrane because the oil suspension may not be absorbed. The aqueous solution will be absorbed so it can be used even if a ruptured tympanic membrane is suspected.
In most situations rupture of the tympanic membrane gives immediate pain relief. However, in some, the pain persists and it may be difficult to tell if the tympanic membrane has ruptured or the debris and pus is from otitis externa. In those situations, the aqueous lidocaine solution might be preferred.
Should parents give drops at home?
This study does not address home use of these drops. However, benzocaine preparations have been used safely for many years for otitis externa at home, and we cannot think of any reason why drops could not be prescribed for home use in acute otitis media.
PURLs methodology
This study was selected and evaluated using FPIN’s Priority Updates from the Research Literature (PURL) Surveillance System methodology. The criteria and findings leading to the selection of this study as a PURL can be accessed at www.jfponline.com/purls.
