A 27-year-old woman comes to the physician for ear pain and decreased hearing. Eight days ago, she developed rhinorrhea and a mild sore throat. Three days later, she had decreased hearing and pain in her right ear. The patient went to an urgent care clinic and was prescribed amoxicillin, which she has taken since. Despite the amoxicillin, she continues to have ear pain and diminished hearing. She has no ear drainage, fever, chills, or headache. She is in good health and her only medication is birth control pills.
Vital signs are normal. There is no nystagmus. Otoscopic examination shows a cloudy, red, bulging tympanic membrane. Hearing is diminished in her right ear. A tuning fork placed in the center of her head lateralizes to the right. There is no posterior ear pain. There is no pharyngeal abnormality on examination. Her neck is supple, and gait and balance appear normal. All cranial nerves are intact.
Which of the following is the best management for this patient?

Question

A 27-year-old woman comes to the physician for ear pain and decreased hearing.  Eight days ago, she developed rhinorrhea and a mild sore throat.  Three days later, she had decreased hearing and pain in her right ear.  The patient went to an urgent care clinic and was prescribed amoxicillin, which she has taken since.  Despite the amoxicillin, she continues to have ear pain and diminished hearing.  She has no ear drainage, fever, chills, or headache.  She is in good health and her only medication is birth control pills.
Vital signs are normal.  There is no nystagmus.  Otoscopic examination shows a cloudy, red, bulging tympanic membrane.  Hearing is diminished in her right ear.  A tuning fork placed in the center of her head lateralizes to the right.  There is no posterior ear pain.  There is no pharyngeal abnormality on examination.  Her neck is supple, and gait and balance appear normal.  All cranial nerves are intact.
Which of the following is the best management for this patient?

Quizplus · Accepted Answer

This patient has acute otitis media. An allergic rhinitis or upper respiratory illness commonly precedes the onset of otitis media. Eustachian tube dysfunction or occlusion from inflammation is the primary factor in the pathogenesis. Blockage of the Eustachian tube causes fluid accumulation in middle ear, with subsequent bacterial growth. The 3 most common organisms are Streptococcus pneumoniae, followed by nontypeable Hemophilus influenzae and Moraxella catarrhalis. Patients usually complain of severe ear pain and hearing loss. Fever may not be present. An otoscopic examination may show redness, opacification, air-fluid level, and bulging of the tympanic membrane. Use of a pneumatic otoscope would reveal poor movability of the tympanic membrane when pneumatic pressure is applied. A tuning fork examination can add to the diagnosis by revealing conductive hearing loss. In an immunocompetent host with no previous history of otitis media, amoxicillin is considered first-line treatment. If symptoms do not improve within 48-72 hours, the patient should be re-examined for a possible new area of infection or inadequate therapy. In cases of antibiotic failure, amoxicillin-clavulanate is the next best therapy to cover beta-lactamase-producing H influenzae. For patients allergic to penicillin, alternatives to amoxicillin therapy are second-generation (eg, cefuroxime) or third-generation (eg, cefdinir) cephalosporins. In patients allergic to beta-lactam antibiotics, a macrolide (eg, azithromycin) can be used. (Choice C) A CT scan is usually done in patients who do not respond and/or develop complications despite being on an adequate antibiotic regimen. Common complications include mastoiditis, brain abscess, and lateral sinus thrombosis (need an MRI). This patient has no posterior ear pain, fever, or headache that would suggest extension of an infection. (Choice D) Myringotomy is used to aid middle ear drainage for individuals with unresolved chronic otitis media with effusion or mastoiditis. Neither is present in this patient. (Choice E) Nasopharyngoscopy can be considered in patients with recurrent otitis media (> 2 episodes in a 6-month period) to evaluate for other possible causes of Eustachian tube or nasopharyngeal obstruction (eg, malignancy). Educational objective: Adult otitis media is a clinical diagnosis based on the history of ear pain and conductive hearing loss as well as otoscopic findings of erythema, opacification, bulging, or air-fluid level of the tympanic membrane. Although amoxicillin is first-line antibiotic therapy, amoxicillin-clavulanate is a better choice if otitis media is unresolved in 48-72 hours. __________ References: Purulent otitis media in adults. (http://www.ncbi.nlm.nih.gov/pubmed/1444690) Acute complications of otitis media in adults. (http://www.ncbi.nlm.nih.gov/pubmed/16402975)

A 27-Year-Old Woman Comes to the Physician for Ear Pain