A 47-year-old woman recovering from an upper respiratory infection comes to the office with a 3-day history of ear discomfort. The patient feels that her right ear is "plugged" and hears popping sounds in the ear when chewing or yawning. She also reports some pressure and slight pain in the ear.
Her temperature is 37.2 C (99 F), blood pressure is 134/80 mm Hg, pulse is 84/min, and respirations are 14/min. Neck examination is normal and there is no lymphadenopathy. The left tympanic membrane is normal, but the right one appears mildly retracted. Romberg test and heel-to-toe gait are normal. A tuning fork placed in the middle of the head lateralizes to the right. The remainder of the physical examination is unremarkable.
What is the best next step in management of this patient?

Question

A 47-year-old woman recovering from an upper respiratory infection comes to the office with a 3-day history of ear discomfort.  The patient feels that her right ear is "plugged" and hears popping sounds in the ear when chewing or yawning.  She also reports some pressure and slight pain in the ear.
Her temperature is 37.2 C (99 F), blood pressure is 134/80 mm Hg, pulse is 84/min, and respirations are 14/min.  Neck examination is normal and there is no lymphadenopathy.  The left tympanic membrane is normal, but the right one appears mildly retracted.  Romberg test and heel-to-toe gait are normal.  A tuning fork placed in the middle of the head lateralizes to the right.  The remainder of the physical examination is unremarkable.
What is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient, with ear discomfort and associated auditory symptoms in the setting of an acute upper respiratory infection, most likely has eustachian tube dysfunction. The eustachian tube connects the air-filled middle ear to the nasopharynx and equalizes pressure across the tympanic membrane. Functional obstruction (eg, viral upper respiratory infection, allergic rhinitis) or structural blockage (eg, nasopharyngeal tumor) can lead to muffled hearing, crackling or popping sounds, a feeling of pain or pressure, and accumulation of a middle ear effusion. Persistent obstruction can increase the risk of acute otitis media. The diagnosis of eustachian dysfunction is clinical. Otoscopic examination may reveal an erythematous or retracted tympanic membrane and/or effusion. Conductive hearing loss may be appreciated on testing with a tuning fork (eg, Weber test, Rinne test). High-quality evidence on interventions for eustachian dysfunction is scant, and management is directed primarily at the underlying disorder. For symptoms associated with an acute viral infection, a short-term trial of decongestants is often effective. (Choice A) Audiometric evaluation in this patient will confirm conductive hearing loss, but will not affect initial management. Additional evaluation may be needed if there is no response to decongestants. (Choice B) A head CT scan to rule out a nasopharyngeal neoplasm is indicated when unilateral symptoms are present for more than 3 months. (Choice C) Nasal endoscopy may be indicated for cases not responding to decongestants or for recurrent cases. (Choice E) Glucocorticoid nasal sprays and antihistamines are often advised for eustachian dysfunction associated with allergic rhinitis. Oral glucocorticoids have not been studied for eustachian dysfunction in human subjects and are not recommended. Educational objective: Ear fullness, popping sounds, and decreased hearing sometimes can be due to obstruction of the eustachian tube during or following an upper respiratory infection. A short-term trial of decongestants is often effective. __________ References: Therapeutic improvement of eustachian tube function: a review. (http://www.ncbi.nlm.nih.gov/pubmed/11903373)

A 47-Year-Old Woman Recovering from an Upper Respiratory Infection Comes