13.5 HEENT & Upper Respiratory Conditions: Conjunctivitis, Rhinitis, Pharyngitis, Sinusitis, Otitis & the Common Cold
Key Takeaways
Bacterial conjunctivitis causes purulent discharge and eyelids stuck together; contact lens wearers need fluoroquinolone drops for Pseudomonas coverage, and pain, photophobia, or vision loss require ophthalmology referral.
Intranasal corticosteroids are the most effective first-line treatment for allergic rhinitis, and topical decongestants should be limited to about 3 days to avoid rebound congestion.
Adults with suspected strep pharyngitis are tested with a rapid antigen test (a negative result does not need culture), and confirmed group A strep is treated with penicillin V or amoxicillin for 10 days.
Antibiotics for acute sinusitis are reserved for symptoms lasting 10 or more days without improvement, severe onset, or 'double sickening'; amoxicillin-clavulanate for 5–7 days is first-line in adults.
Most colds and coughs are viral; antibiotics do not help, and oral decongestants are avoided in early pregnancy and in uncontrolled hypertension.
Conjunctivitis
| Type | Features | Treatment |
|---|---|---|
| Viral (adenovirus) | Watery discharge, often starting in one eye and spreading, preauricular node, recent cold; highly contagious for 10–14 days | Supportive: cool compresses, artificial tears, hand hygiene, no shared towels |
| Bacterial | Purulent discharge, eyelids stuck together on waking | Topical erythromycin ointment or polymyxin B–trimethoprim drops for 5–7 days; contact lens wearers: fluoroquinolone drops (Pseudomonas) and stop lens wear |
| Allergic | Bilateral itching, watery discharge, seasonal pattern, other atopy | Antihistamine/mast-cell stabilizer drops (olopatadine, ketotifen), cold compresses, allergen avoidance |
| Gonococcal (adults) | Hyperacute, copious purulent discharge in a sexually active patient | Ceftriaxone 1 g IM once, saline irrigation, urgent ophthalmology; test and treat for chlamydia and treat partners |
Warning
Refer to ophthalmology the same day for eye pain, photophobia, decreased vision, a ciliary flush (redness concentrated around the cornea), corneal opacity, a fixed mid-dilated pupil, or contact-lens–associated keratitis. These suggest keratitis, iritis, or acute angle-closure glaucoma rather than conjunctivitis.
Rhinitis
- Allergic rhinitis: Sneezing, itching, clear rhinorrhea, pale boggy turbinates, and "allergic shiners." Intranasal corticosteroids (fluticasone, budesonide, mometasone) are the most effective first-line therapy, taken daily; second-generation oral antihistamines (cetirizine, loratadine, fexofenadine) and intranasal antihistamines add relief; allergen immunotherapy suits refractory cases.
- Rhinitis medicamentosa: Rebound congestion after more than about 3 days of topical decongestants (oxymetazoline); stop the spray and use an intranasal steroid.
- Pregnancy rhinitis: Congestion without allergy, from estrogen-driven mucosal swelling; saline sprays, nasal strips, and elevating the head of the bed help; intranasal steroids are acceptable.
- Nonallergic rhinitis: Triggered by irritants or temperature; intranasal ipratropium helps rhinorrhea.
Pharyngitis
Most sore throats are viral; group A streptococcus (GAS) causes about 5%–15% of adult cases.
- Centor criteria (1 point each): fever, tonsillar exudates, tender anterior cervical nodes, and absence of cough; the McIsaac modification adjusts for age. Test with a rapid antigen detection test when 2–3 or more criteria are present. In adults, a negative rapid test does not need a backup culture (unlike in children).
- Treatment of confirmed GAS: Penicillin V 500 mg twice daily or amoxicillin (500 mg twice daily or 1 g once daily) for 10 days. With penicillin allergy, use cephalexin if the reaction was not anaphylactic; otherwise azithromycin (resistance is rising) or clindamycin.
- Infectious mononucleosis (EBV): Fatigue, exudative pharyngitis, posterior cervical adenopathy, splenomegaly, atypical lymphocytes, and a positive heterophile antibody test. Treatment is supportive, contact sports are avoided for at least 3–4 weeks because of splenic rupture risk, and amoxicillin often causes a rash.
- Gonococcal pharyngitis follows oral sex and is usually asymptomatic; diagnose by pharyngeal NAAT and treat with ceftriaxone 500 mg IM, with a test of cure 7–14 days later.
- Red flags: Trismus, a muffled "hot potato" voice, uvular deviation (peritonsillar abscess), drooling, or stridor (epiglottitis) need emergency care.
Acute Rhinosinusitis
Most cases are viral and improve within 7–10 days. Suspect bacterial sinusitis (IDSA) with:
- Symptoms lasting 10 or more days without improvement;
- Severe onset: fever of 39 °C (102.2 °F) or higher with purulent discharge or facial pain for 3–4 consecutive days; or
- "Double sickening": worsening after initial improvement.
Treatment: Amoxicillin-clavulanate for 5–7 days in adults; doxycycline is an alternative outside pregnancy. Add saline irrigation and intranasal steroids. Refer urgently for periorbital swelling, vision change, severe headache, or altered mental status (orbital or intracranial spread).
Otitis
| Condition | Findings | Treatment |
|---|---|---|
| Acute otitis media (adult) | Ear pain, bulging, erythematous tympanic membrane with effusion | Amoxicillin (or amoxicillin-clavulanate); evaluate persistent unilateral effusion in adults for a nasopharyngeal mass |
| Otitis externa ("swimmer's ear") | Pain with tragal pressure or pinna traction, canal edema and debris | Topical antibiotic-steroid drops; use fluoroquinolone drops (ciprofloxacin-dexamethasone or ofloxacin) if the eardrum may be perforated (avoid aminoglycoside drops); keep the ear dry |
| Malignant (necrotizing) otitis externa | Severe pain and granulation tissue in an older patient with diabetes | Emergency: Pseudomonas osteomyelitis of the skull base |
The Common Cold and Acute Bronchitis
Upper respiratory infections are viral and self-limited (7–10 days; cough can last 3 weeks). Antibiotics do not shorten the illness and cause harm. Offer saline, honey (for anyone older than 1 year), fluids, rest, acetaminophen or NSAIDs, and dextromethorphan or guaifenesin.
Symptom Relief in Pregnancy
- Preferred: saline sprays, humidified air, honey, acetaminophen, guaifenesin, dextromethorphan, and an intranasal steroid.
- Avoid oral decongestants (pseudoephedrine, phenylephrine) in the first trimester (a small gastroschisis signal) and in hypertension or preeclampsia. Oral phenylephrine also works no better than placebo, and the FDA proposed removing it from OTC decongestants in 2024.
- Avoid NSAIDs after about 20 weeks of gestation.
- Treat influenza with oseltamivir promptly in pregnancy, regardless of symptom duration.
A 24-year-old contact lens wearer has 2 days of a red, painful left eye with purulent discharge and blurred vision. What is the most appropriate management?
Remove contact lenses, start fluoroquinolone drops, and arrange same-day ophthalmology review.
Prescribe erythromycin ophthalmic ointment and allow her to continue wearing contact lenses.
Prescribe olopatadine drops for presumed allergic conjunctivitis and cool compresses.
Reassure her that viral conjunctivitis resolves in 10–14 days with cool compresses alone.
A 30-year-old has had a sore throat for 2 days, a temperature of 38.6 °C (101.5 °F), tonsillar exudates, and tender anterior cervical nodes, with no cough. A rapid strep antigen test is negative. What is the most appropriate next step?
Send a throat culture and prescribe amoxicillin for 10 days while awaiting the culture results.
Prescribe azithromycin for 5 days because she meets all four modified Centor criteria.
Order a monospot test and admit her for intravenous antibiotics and fluid resuscitation.
Provide supportive care without antibiotics; adults with a negative rapid test need no backup culture.
A 38-year-old at 9 weeks of gestation has had nasal congestion, cough, and purulent nasal discharge for 12 days without improvement, with maxillary pressure. She has no penicillin allergy. What is the most appropriate treatment?
Doxycycline 100 mg twice daily for 7 days
Oral pseudoephedrine 60 mg every 6 hours for 10 days
Amoxicillin-clavulanate for 5–7 days with saline irrigation
Levofloxacin 750 mg daily for 5 days
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