Abstract
Ear, nose, and throat complaints are very common in the urgent care setting. Otitis media, otitis externa, sinusitis, rhinitis, pharyngitis, and tonsillitis are among the most common diseases seen in urgent care. This chapter will cover what every practitioner needs to know.
Keywords
mastoiditis, otalgia, otitis externa, otitis media, pharyngitis, rhinitis, sinusitis, tonsillitis
1
What are the common causes of otalgia?
Common causes are otitis media, cerumen impaction, and otitis externa, as well as referred pain from the throat or temporal bone. Less common causes include foreign body in the ear canal, mastoiditis, perichondritis, external ear dermatitis/cellulitis, or ear tumors (such as eosinophilic granulomas or rhabdosarcomas).
4
Which organisms typically cause otitis media?
Bacterial causes include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis . Viruses (including respiratory syncytial virus [RSV], adenovirus, rhinovirus, or influenza) account for less than 10% of otitis media; however, coinfection with bacteria is common in children.
5
What is the recommended treatment for otitis media?
Duration on first-line treatment may be 5–7 days; if recurrent otitis media, duration is recommended to be 7–10 days ( Table 3.1 ). Azithromycin and trimethoprim/sulfamethoxazole are no longer recommended for routine use for acute otitis media due to increased antibiotic resistance.
| Recommended First-Line Treatment | Recommended First-Line Treatment if Penicillin Allergic | Second-Line Treatment, After Failure to First-Line Antibiotic |
|---|---|---|
| Amoxicillin 875 mg po bid | Cefdinir 300 mg po bid | Clindamycin 300 mg po tid/qid |
| Amoxicillin/clavulanate 875 mg/125 mg po bid | Cefuroxime 500 mg po bid | Levofloxacin 500 mg po qd |
| Cefpodoxime 200 mg po bid | Moxifloxacin 400 mg po qd | |
| Ceftriaxone 2 g IM/IV qd x 1 or 3 days | May use amoxicillin/clavulanate or ceftriaxone IM/IV, if not used previously |
7
How does mastoiditis present?
Pain located over the mastoid. Patients often complain of pain deep within the ear or behind the ear, with associated tenderness over the mastoid process. Mastoiditis can present at any age but is most common at age 2 years and younger, thus making localization of pain a difficult diagnostic indicator. There may also be a persistent fever (despite adequate antibiotic treatment for acute otitis media), mastoid erythema, or proptosis of the auricle.
9
What are the treatment recommendations for mastoiditis?
Subacute mastoiditis (mastoiditis without osteitis or periostitis) may be treated with purely medical management. Patients should be prescribed antibiotic coverage similar to otitis media with close follow-up. If worsening of pain or no significant improvement in 48 hours, patients should be referred to ENT as they will most likely require tympanoplasty (treatment and diagnostic for bacterial culture), imaging (CT scan or MRI for evaluation of extension of disease), and/or mastoidectomy.
11
How is a perforated tympanic membrane best managed in the urgent care setting?
The ear canal may be cleaned using gentle suction; do not irrigate the ear canal, as water in the middle ear may introduce bacteria and cause infection. Treat concurrent otitis media with antibiotic drops or oral antibiotics. In regard to antibiotic ear drops, avoid gentamicin, neomycin sulfate, or tobramycin, as they carry the risk of ototoxicity. May use ofloxacin otic, ciprofloxacin eye drops, or Ciprodex. Prophylactic antibiotics (for perforated tympanic membrane in absence of acute infection) is only advised if the injury involved contamination with lake water, seawater, or a dirty object such as a tree branch. Advise patient to keep ear dry: use ear plugs for showering and avoid submerging head underwater. Recommend appropriate analgesia; oral nonsteroidal antiinflammatory drugs (NSAIDs) typically are sufficient.
12
What symptoms or physical exam findings warrant referral to an otolaryngologist?
The majority (80%–90%) of tympanic membrane perforations will heal spontaneously in 4–6 weeks. Referral to an otolaryngologist is advised for large or marginal perforations (as they may require surgery) and for patients with nystagmus, vertigo, profound hearing loss, or disruption of the ossicles.
13
How does otitis externa typically present?
Patients with otitis externa will often complain of ear pain, pruritus, otorrhea, and hearing loss. Pain may be exacerbated by chewing and other auricle movement. Inspection of otorrhea can act as a diagnostic indicator to the cause of otitis externa, as acute bacterial otitis externa will often have a white purulent drainage, whereas fungal otitis externa (otomycosis) will have a fluffy cottonlike grayish or black material.
15
How is otitis externa best treated?
Otitis externa is treated first with removal of the debris/purulent drainage with ear canal suctioning or ear irrigation, second with prescription ear drops specific to causative agent ( Table 3.2 ), and third with management of pain either using topical analgesic agents such as Auralgan or tetracaine or oral analgesic agents such as NSAIDs. Often otitis externa will require placement of an ear wick to allow for medication penetration.
| Uncomplicated Bacterial infection | Uncomplicated Fungal infection |
|---|---|
| Neomycin-polymyxin B-hydrocortisone otic 4 drops in the affected ear tid or qid for 10 days | Acetic acid 2% with or without hydrocortisone otic 4 drops in the affected ear qid for 7 days |
| Ofloxacin 0.3% otic 10 drops in the affected ear once daily for 7 days | Clotrimazole 1% otic 4 drops in the affected ear qid for 7 days |
| Ciprofloxacin-hydrocortisone otic 3 drops in the affected ear bid for 7 days |
18
What causes cerumen impaction?
Cerumen, or earwax, is a naturally occurring substance in the ear canal, composed of secretions, sloughed epithelial cells, and hair. Typically, cerumen is naturally extruded, although sometimes it can accumulate and occlude the canal. Cerumen impaction can present with otalgia, hearing loss, clogged sensation, tinnitus, dizziness, and chronic cough (due to irritation of the auricular branch of the vagus nerve).
19
How is cerumen impaction treated?
Removal of cerumen can be performed with use of cerumenolytic agents (acetic acid, hydrogen peroxide, carbamide peroxide, or mineral oil), manual removal (using ear curette or forceps for large clumps of cerumen), and/or ear irrigation. Studies have shown no significant difference between effectiveness of varying cerumenolytic agents. Approximately 40% of patients with cerumen impaction can clear ear wax with use of a cerumenolytic agent alone (without irrigation).
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