20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections
Key Takeaways
- Acute and chronic sinusitis, otitis media and externa, mastoiditis, common cold, pharyngitis, epiglottitis and deep head and neck infections are enumerated under upper respiratory tract infections.
- Acute bacterial rhinosinusitis is suggested by symptoms persisting beyond ten days, severe symptoms, or double worsening after initial improvement.
- Necrotizing otitis externa occurs in older adults with diabetes and requires imaging and prolonged antipseudomonal therapy.
- Sudden sensorineural hearing loss is an emergency in which prompt corticosteroids improve recovery.
- Asymmetric sensorineural hearing loss requires magnetic resonance imaging to exclude vestibular schwannoma.
1. Upper Respiratory Infections, Pharyngitis & Sinusitis
Acute Pharyngitis & Modified Centor (McIsaac) Criteria
Most adult pharyngitis is viral (rhinovirus, adenovirus, EBV, coronavirus). The primary clinical objective is identifying Group A Beta-Hemolytic Streptococcus (Streptococcus pyogenes / GAS) to initiate prompt treatment, shorten symptoms, prevent suppurative complications, and prevent Acute Rheumatic Fever.
Modified Centor (McIsaac) Scoring System:
- Fever history (>38.0°C / 100.4°F): +1 point
- Absence of cough: +1 point
- Tender anterior cervical lymphadenopathy: +1 point
- Tonsillar exudates or swelling: +1 point
- Age: 3–14 years (+1 point) | 15–44 years (0 points) | ≥45 years (-1 point)
Management Stratification Based on Centor Score:
- Score 0–1 (<10% risk of GAS): No diagnostic testing; supportive symptomatic care (NSAIDs, lozenges). No antibiotics.
- Score 2–3 (15–30% risk of GAS): Perform Rapid Antigen Detection Test (RADT). Treat with antibiotics ONLY if RADT is positive. In adults, negative RADT does not require confirmatory throat culture due to very low incidence of rheumatic fever.
- Score 4–5 (30–50% risk of GAS): Perform RADT (or empiric therapy in high-prevalence settings).
Antimicrobial Treatment of Confirmed GAS Pharyngitis:
- First-Line Standard: Oral Penicillin V (500 mg PO BID-TID for 10 days) OR Oral Amoxicillin (500 mg PO BID or 1000 mg PO once daily for 10 days). Zero documented GAS resistance worldwide.
- Non-Severe Penicillin Allergy (non-IgE): Cephalexin (500 mg PO BID for 10 days) or Cefdinir.
- Severe Penicillin Anaphylaxis (IgE-mediated): Oral Azithromycin (500 mg day 1, then 250 mg daily for 4 days) OR Oral Clindamycin (300 mg PO TID for 10 days).
Complication — Peritonsillar Abscess (Quinsy):
- Collection of pus between tonsillar capsule and pharyngeal constrictor muscle.
- Clinical Triad: Severe unilateral sore throat, "hot potato" muffled voice, and trismus (inability to open mouth due to irritation of internal pterygoid muscle).
- Physical Exam: Unilateral tonsillar bulge, erythematous soft palate, and deviation of the uvula to the contralateral unaffected side.
- Management: Emergency needle aspiration or surgical incision and drainage (I&D) + IV Ampicillin-Sulbactam (3 g IV q6h) or IV Clindamycin (600–900 mg IV q8h) + single-dose IV Dexamethasone.
Acute Rhinosinusitis: Viral vs. Acute Bacterial Rhinosinusitis (ABRS)
Over 90–98% of acute rhinosinusitis cases are viral. Antibiotic stewardship requires strict adherence to the IDSA Clinical Diagnostic Criteria for ABRS (requires ≥1 of 3 presentations):
- Persistent Symptoms: Signs and symptoms of rhinosinusitis (purulent nasal discharge, nasal obstruction, facial pain/pressure) lasting ≥10 days without any evidence of clinical improvement.
- Severe Onset: High fever (≥39.0°C / 102.2°F) accompanied by concurrent purulent nasal discharge and severe facial pain lasting for ≥3 to 4 consecutive days at the onset of illness.
- "Double-Sickening": Acute worsening of symptoms (new-onset fever, headache, increasing nasal congestion/discharge) following a typical 5–6 day viral upper respiratory infection that was initially improving.
Evidence-Based Treatment of ABRS:
- First-Line Empiric Therapy: Oral Amoxicillin-Clavulanate (Augmentin 875/125 mg PO BID for 5–7 days). (Covers beta-lactamase producing Haemophilus influenzae and Moraxella catarrhalis alongside Streptococcus pneumoniae).
- High-Dose Augmentin (2000/125 mg PO BID for 7–10 days): Indicated for patients aged ≥65 years, systemic comorbidities, recent antibiotic use within past 30 days, or moderate-to-severe infection.
- Penicillin Allergy: Oral Doxycycline (100 mg PO BID for 5–7 days) OR a respiratory fluoroquinolone (Levofloxacin 500 mg PO daily or Moxifloxacin 400 mg PO daily). Note: Macrolides (Azithromycin) and TMP-SMX are NOT recommended due to high pneumococcal resistance (>30–40%).
- Imaging Guidelines: Routine Sinus CT is NOT recommended for uncomplicated ABRS. Contrast-enhanced CT of paranasal sinuses/orbits is indicated only if orbital or intracranial complications are suspected (proptosis, ophthalmoplegia, visual changes, severe retro-orbital pain, altered mental status, meningismus).
2. Ear, Hearing & Skull Base Disorders
Sensorineural vs. Conductive Hearing Loss
Bedside evaluation using a 512-Hz tuning fork differentiates conductive hearing loss (CHL: external auditory canal or middle ear pathology) from sensorineural hearing loss (SNHL: cochlea or cranial nerve VIII pathology).
| Tuning Fork Examination | Normal Finding | Conductive Hearing Loss (CHL) | Sensorineural Hearing Loss (SNHL) |
|---|---|---|---|
| Weber Test (512-Hz fork on midline forehead/vertex) | Sound heard equally in both ears (midline) | Sound lateralizes to the AFFECTED ear (ambient room noise is blocked in affected ear, allowing bone conduction to sound louder) | Sound lateralizes to the NORMAL / UNAFFECTED ear (sensorineural apparatus in unaffected ear senses sound better) |
| Rinne Test (512-Hz fork on mastoid [BC] then 1-2 cm from ear canal [AC]) | Positive (AC > BC) in both ears (air conduction exceeds bone conduction) | Negative (BC ≥ AC) in affected ear (bone conduction equals or exceeds air conduction due to middle ear defect) | Positive (AC > BC) in affected ear (both AC and BC are reduced, but AC remains greater than BC) |
| Common Etiologies | — | Cerumen impaction, otitis media with effusion, otosclerosis, cholesteatoma, tympanic membrane perforation | Presbycusis (age-related high-frequency loss), noise trauma, Ménière disease, ototoxic drugs (aminoglycosides, cisplatin), Vestibular Schwannoma |
- Sudden Sensorineural Hearing Loss (SSNHL):
- Definition: Loss of ≥30 dB across ≥3 contiguous frequencies occurring over ≤72 hours.
- Management (Otologic Emergency): Immediate initiation of High-Dose Oral Corticosteroids (Prednisone 60 mg/day tapered over 14 days) or intratympanic steroid injections; greatest recovery occurs when treated within 1–2 weeks.
- Diagnostic Requirement: Contrast-enhanced Brain MRI with Internal Auditory Canal (IAC) protocol to rule out Vestibular Schwannoma (Acoustic Neuroma) in all patients with unilateral sensorineural hearing loss or asymmetric tinnitus.
Acute Otitis Externa vs. Malignant (Necrotizing) Otitis Externa
| Clinical Parameter | Acute Otitis Externa (AOE / "Swimmer's Ear") | Malignant (Necrotizing) Otitis Externa (MOE) |
|---|---|---|
| Etiology | Pseudomonas aeruginosa (40–50%) and Staphylococcus aureus (20–30%) | Pseudomonas aeruginosa (>95% of cases) causing invasive osteomyelitis of skull base |
| Host Demographics | Swimmers, humid environments, mechanical cleaning with cotton swabs | Elderly patients with diabetes mellitus (90%), immunocompromised, HIV, post-chemotherapy |
| Clinical Symptoms | Rapid onset of severe otalgia, intense tragal and pinna tenderness, canal pruritus, discharge | Excruciating, deep-seated nocturnal otalgia radiating to temporomandibular joint, persistent foul-smelling purulent otorrhea |
| Physical & Otoscopic Exam | Erythematous, edematous ear canal with moist debris; intact tympanic membrane | Granulation tissue on the floor of the external auditory canal at the osseocartilaginous junction; mucosal ulceration |
| Neurological Complications | Absent | Cranial Nerve Palsies: CN VII (Facial nerve) most common (ipsilateral facial droop in 50%), progressing to CN IX, X, XI (jugular foramen syndrome) and CN XII |
| Diagnostic Workup | Clinical diagnosis | Markedly elevated ESR and CRP (used to track treatment response); High-Resolution Temporal Bone CT (cortical bone erosion and demineralization); Technetium-99m / Gallium-67 bone scans; deep tissue biopsy |
| Treatment Regimen | Thorough ear canal debridement + Topical Otic Fluoroquinolone Drops (Ciprofloxacin 0.3% - Dexamethasone 0.1% or Ofloxacin 0.3% drops for 7–10 days).<br/>Warning: Avoid ototoxic neomycin/polymyxin drops if tympanic membrane perforation cannot be excluded. | EMERGENCY Hospitalization: Prolonged Systemic IV Antipseudomonal Antibiotics for 6 to 8 weeks (IV Cefepime 2 g q8h, IV Piperacillin-Tazobactam 4.5 g q6h, or IV/Oral Ciprofloxacin 750 mg BID if confirmed susceptible); strict glycemic control; surgical debridement of necrotic bone for refractory cases |
6. Meniere Disease, Cholesteatoma & Other Disorders of the Ear
The blueprint enumerates benign paroxysmal positional vertigo, vestibular neuronitis and acute labyrinthitis, Meniere disease, acoustic neuroma, presbycusis and other hearing loss, otitis media and externa, cholesteatoma, and other disorders of the ear and mastoid.
Meniere disease
Endolymphatic hydrops producing a distinctive four-symptom complex:
- Episodic vertigo lasting 20 minutes to several hours — long enough to distinguish it from the seconds of benign paroxysmal positional vertigo, short enough to distinguish it from the days of vestibular neuronitis
- Fluctuating sensorineural hearing loss, initially low-frequency, becoming permanent over years
- Tinnitus, often a low roaring sound
- Aural fullness in the affected ear
Attack duration is the highest-yield discriminator:
| Disorder | Duration of vertigo | Hearing loss |
|---|---|---|
| Benign paroxysmal positional vertigo | Seconds, positional | No |
| Meniere disease | 20 minutes to hours, spontaneous | Yes, fluctuating |
| Vestibular neuronitis | Days, continuous | No |
| Labyrinthitis | Days, continuous | Yes |
| Vertebrobasilar ischemia | Minutes, with other neurologic signs | Variable |
Diagnosis is clinical, supported by audiometry showing low-frequency sensorineural loss. MRI is obtained to exclude vestibular schwannoma, particularly with asymmetric loss. Management begins with sodium restriction and avoidance of caffeine, alcohol and nicotine, with diuretics, betahistine (outside the United States) and vestibular rehabilitation; intratympanic corticosteroid or gentamicin and surgical procedures are reserved for refractory disease.
Cholesteatoma
An expanding sac of keratinizing squamous epithelium in the middle ear or mastoid. It is not a neoplasm, but it behaves destructively, eroding the ossicles and surrounding bone.
Suspect it with chronic, painless, foul-smelling otorrhea that does not resolve with topical or oral antibiotics, together with conductive hearing loss. Otoscopy may show a retraction pocket, a perforation with white keratin debris, or a granulation-covered mass in the attic.
Complications result from bone erosion: conductive then sensorineural hearing loss, facial nerve palsy, labyrinthine fistula with vertigo, mastoiditis, and intracranial extension causing meningitis or brain abscess.
Treatment is surgical — antibiotics and drops do not resolve it — so the internist's task is to recognize chronic malodorous otorrhea unresponsive to medical therapy and refer promptly.
Other ear conditions
- Acoustic neuroma (vestibular schwannoma) — asymmetric sensorineural hearing loss with poor speech discrimination out of proportion to the pure-tone loss, tinnitus and unsteadiness; diagnosed by gadolinium-enhanced MRI of the internal auditory canals. Bilateral tumors indicate neurofibromatosis type 2.
- Otitis media with effusion in an adult — a unilateral effusion in an adult, particularly of Southeast Asian ancestry, requires nasopharyngeal evaluation for nasopharyngeal carcinoma obstructing the eustachian tube.
- Tympanic membrane perforation — most heal spontaneously; keep the ear dry and avoid ototoxic drops.
- Cerumen impaction — a common, immediately reversible cause of hearing loss that should be excluded before audiometry.
A 74-year-old man with longstanding, poorly controlled type 2 diabetes mellitus presents with a 4-week history of worsening, severe, deep-seated left ear pain that is particularly excruciating at night and radiates to his jaw. He has had persistent, foul-smelling purulent drainage from the left ear canal that failed to improve after a 10-day course of topical polymyxin B-neomycin ear drops. On examination, the left external auditory canal is markedly edematous with purulent exudate, and otoscopy reveals prominent pink granulation tissue at the floor of the canal at the bony-cartilaginous junction. There is weakness of the left upper and lower facial muscles when attempting to smile or close the left eye. Erythrocyte sedimentation rate (ESR) is 108 mm/hr. What is the most appropriate next step in management?
A 38-year-old woman presents to the clinic complaining of nasal congestion, facial pressure, and headache for the past 12 days. She initially had mild nasal congestion, clear rhinorrhea, and a low-grade temperature of 37.6°C (99.7°F) that began improving around day 5. However, on day 8, she developed a sudden recurrence and worsening of symptoms, including a fever of 38.8°C (101.8°F), severe throbbing left maxillary facial pain, and thick, yellowish-green nasal discharge. Anterior rhinoscopy shows purulent discharge draining from the left middle meatus and tenderness over the left maxillary sinus. She has no chronic medical conditions and has no drug allergies. What is the most appropriate management for this patient?