In a large pot, bring generously salted water to a rapid boil. Add the orecchiette pasta and cook for 9–11 minutes until al dente. Drain and reserve pasta water.

In a large skillet over medium heat, add olive oil. Crumble the Italian sausage and cook for 6–8 minutes until browned. Transfer to a plate.

In the same skillet, add minced garlic and sauté for about 1 minute until fragrant.

Pour in the heavy cream and simmer for 3–4 minutes. Add grated Parmesan, salt, and pepper, stirring until smooth.

Return the sausage to the skillet and toss with the sauce. Add the drained orecchiette, stirring to coat. Adjust sauce consistency with reserved pasta water as needed.

Remove from heat, garnish with parsley or basil, and serve immediately.