A 55-year-old man comes to the office due to hearing loss and a feeling of fullness in the right ear. He took a few days of antibiotics leftover from his daughter's ear infection but had no improvement. The patient has had no pain or fever. Physical examination shows a normal, translucent tympanic membrane with a clear, amber-colored effusion in the right middle ear. The remainder of the examination, including left ear examination, is normal. He is treated with antihistamines, oral decongestants, and nasal corticosteroids. The patient returns 3 months later and has had no change in symptoms. Physical examination is also unchanged. The patient has no other medical conditions. Which of the following is the most appropriate statement regarding management of this patient's condition?

Question

A 55-year-old man comes to the office due to hearing loss and a feeling of fullness in the right ear.  He took a few days of antibiotics leftover from his daughter's ear infection but had no improvement.  The patient has had no pain or fever.  Physical examination shows a normal, translucent tympanic membrane with a clear, amber-colored effusion in the right middle ear.  The remainder of the examination, including left ear examination, is normal.  He is treated with antihistamines, oral decongestants, and nasal corticosteroids.  The patient returns 3 months later and has had no change in symptoms.  Physical examination is also unchanged.  The patient has no other medical conditions.  Which of the following is the most appropriate statement regarding management of this patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bea9_4f44_8f63_eba57d88bca9_MD0005_00 This patient has a unilateral middle ear effusion that has persisted for over 3 months. In adults, this presentation should raise suspicion for eustachian tube obstruction due to a nasopharyngeal mass. The eustachian tube opens intermittently, typically during swallowing or yawning, to equalize pressure in the middle ear. Failure to adequately open leads to negative pressure, which causes a transudative effusion (clear, amber, or yellow in color), as in this patient. Most commonly, this is due to functional obstruction from infections, allergic rhinitis, or irritants (eg, tobacco smoke). However, when a middle ear effusion is unilateral, persistent (ie, >3 months), and unaccompanied by signs of infection (eg, pain, fever, erythema or bulging of the tympanic membrane), it raises concern for anatomic obstruction due to a nasopharyngeal mass (eg, nasopharyngeal carcinoma). eustachian tube The classic triad of nasopharyngeal carcinoma (neck mass; nasal obstruction with epistaxis; unilateral, persistent middle ear effusion) is rarely seen, but patients typically have ≥1 of these symptoms. Patients from China, Southeast Asia, and Northern Africa are at increased risk. Workup includes examination via nasal endoscopy and possibly imaging (CT scan or MRI). (Choice A) A salt-restricted diet and diuretics are appropriate initial treatment for Ménière disease, which can present with aural fullness and hearing loss. However, patients also have episodic vertigo. In addition, the excess fluid in Ménière disease is in the labyrinth rather than the middle ear and is therefore not seen on otoscopic examination. (Choice B) Upper respiratory infections (URIs) can cause inflammation-induced middle ear effusion, for which a short trial (≤3 days) of topical nasal decongestants may be considered. However, URI-induced eustachian tube obstruction would not persist for 3 months in the absence of infectious symptoms. (Choice C) Culture-directed antibiotics may be required in patients with acute otitis media who have severe infections, who are likely to be infected with resistant organisms, or whose condition does not respond to appropriate first- and second-line antibiotic therapy. However, this patient does not have signs of infection (eg, pain, fever, erythema or bulging of the tympanic membrane); therefore, antibiotics are not required. (Choice E) Immunotherapy may be recommended for long-term management of allergic rhinitis, which can cause middle ear effusions. However, these effusions are often bilateral, and patients would have other symptoms of allergic rhinitis (eg, sneezing, itchy eyes, nasal congestion). Educational objective: A persistent, unilateral middle ear effusion requires examination of the nasopharynx to look for a mass lesion (eg, nasopharyngeal carcinoma) obstructing the eustachian tube orifice.

A 55-Year-Old Man Comes to the Office Due to Hearing