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Upper Respiratory Symptoms, Including Earache, Sinus Symptoms, and SoreThroat¶

Part 2: Cardinal Manifestations and Presentation of Disease · Part 2 – Cardinal Manifestations & Presentation · Chapter 37

Key Clinical Points¶

Nonspecific URI (common cold) is typically caused by respiratory viruses (rhinoviruses, coronaviruses, etc.) and is self-limited (5–14 days).
Antibiotics are indicated for AOM, sinusitis, streptococcal pharyngitis, and pneumonia; they do not speed resolution for viral URIs.
Centor Criteria for GAS Pharyngitis: Fever, absence of cough, tender anterior cervical lymphadenopathy, and tonsillar exudate (1 point each).
Red Flags for Mastoiditis: Postauricular erythema, tenderness, warmth, fluctuance, protrusion of auricle, and cranial nerve involvement.
Red Flags for Sinusitis Complications: Confusion, unilateral weakness, proptosis, limited ocular movements, or acute vision changes.
Invasive Fungal Sinusitis is a medical emergency in immunocompromised patients (e.g., uncontrolled diabetes, transplant) and requires IV antifungals and surgical debridement.
OSHA Noise Exposure: 90 dB for 8 hours; the allowed time halves for every 5 dB increase above 85 dB. Peak sound pressure must not exceed 140 dB.
AOM Antibiotics: Amoxicillin (90 mg/kg/d) is first-line; Amoxicillin/Clavulanate is used for penicillin allergy or treatment failure.
Chronic Sinusitis is defined as inflammation lasting >12 weeks, categorized into non-polyp, polyp, and allergic fungal types.
Otitis Externa requires topical antibacterial with glucocorticoid (e.g., Polymyxin B–neomycin–hydrocortisone) for 7–10 days.
Delayed antibiotic prescriptions are clinically flawed as they ignore the natural history of illness and cause patient confusion.

1. DEFINITION & OVERVIEW¶

Upper respiratory infections (URIs) are acute respiratory infections occurring above the vocal cords and represent the most common reason for seeking care in the U.S.

• Nonspecific URI (Common Cold): A respiratory tract infection where no single symptom predominates. • Ear Pain: Most commonly caused by otitis externa, acute otitis media (AOM), otitis media with effusion (OME), and acute mastoiditis. • Sinus Symptoms: Can be caused by acute sinusitis, invasive fungal sinusitis, nosocomial sinusitis, and chronic sinusitis. • Sore Throat & Neck Pain: Not synonymous with pharyngitis; can also be caused by submandibular spasm.

1.1 Upper Respiratory Infections (URIs)¶

• Clinical Scope: Overlaps with lower respiratory infections (influenza, acute bronchitis, pneumonia) and noninfectious cough. • COVID-19: Can cause any upper respiratory symptom; loss of taste or smell is specifically associated with COVID-19.

1.2 Ear Pain¶

• Common Causes: Otitis externa, AOM, OME, and acute mastoiditis. • Age/Risk Considerations: ◦ >50 years: Consider temporal arteritis if headache, malaise, weight loss, fever, and anorexia are present with a normal ear exam. ◦ Children: Consider foreign bodies. • Referred Pain Sources: ◦ Dental pathology (caries, abscesses). ◦ Salivary gland pathology or cervical adenopathy. ◦ Sinusitis, tonsillitis, or pharyngitis (via CN IX). ◦ Myocardial infarction (via CN X). • Other Causes: Neuropathic/myopathic syndromes (trigeminal neuralgia), Ramsay Hunt syndrome, Bell's palsy, and relapsing polychondritis.

1.3 Sinus Symptoms¶

• Common Cause: Respiratory viruses. • Rhinitis Differentials: Common cold, allergic rhinitis, vasomotor rhinitis, rhinitis medicamentosa (topical decongestants), drug-induced (aspirin, ibuprofen, beta blockers), autoimmune disease (granulomatosis with polyangiitis), and CSF leak. • Non-infectious Pain: Headaches, facial pain syndromes, TMJ, dental pathology, and GERD. • High-Risk Scenarios: ◦ Immunocompromised/Uncontrolled Diabetes → Risk of rapidly progressing invasive fungal infections. ◦ Recurrent/Nonresolving → Consider indolent fungal infections. ◦ Children → Consider foreign bodies.

1.4 Sore Throat and Neck Pain¶

• Primary Goal: Identify patients likely to have Group A Streptococcus (GAS) pharyngitis. • Treatment Goal: Prompt antibiotic treatment of GAS reduces symptoms, prevents spread, and reduces suppurative complications (e.g., peritonsillar abscess).

2. EPIDEMIOLOGY¶

• URI Frequency: 2–4 per year in adults; 6–10 per year in children. • AOM Prevalence: Predominantly a disease of children (peak age 6–24 months); ~60% of children have AOM by age 6. • GAS Pharyngitis: ◦ Adults: ~10% prevalence. ◦ Children: Up to 35% prevalence (peaks ages 5–15). ◦ Seasonality: Higher in winter and early spring. ◦ Risk Groups: Healthcare/childcare workers, teachers, parents of young children. • Sinusitis Risk Factors: Age 45–65, smoking, asthma, air travel, and allergies. • Chronic Sinusitis Demographics: ◦ Without polyps: More common in women; develops in childhood/young adulthood; characterized by facial pain. ◦ With polyps: More common in men; develops in adulthood; characterized by loss of smell, asthma, or aspirin sensitivity.

• OSHA Noise Exposure (Table 36-4): ◦ Threshold: 85 dB is the baseline for protection. ◦ Rule: Halving of allowed exposure time for each 5 dB increment above 85 dB. ◦ Specific Limits: 1. 90 dB → 8 hours 2. 95 dB → 4 hours 3. 100 dB → 2 hours 4. 105 dB → 1 hour 5. 110 dB → 0.5 hours 6. 115 dB → ≤0.25 hours ◦ Max Peak: 140-dB for impulsive/impact noise.

3. ETIOLOGY & PATHOPHYSIOLOGY¶

• Nonspecific URI: ◦ Pathogens: Rhinoviruses (>100 serotypes), coronaviruses, parainfluenza, RSV, influenza, adenovirus (57 serotypes), metapneumovirus, and bocavirus. ◦ Immunity: Weak/short for most except specific rhinoviruses and adenoviruses. • AOM: ◦ Mechanism: Viral URI → nasopharyngeal edema → Eustachian tube obstruction → fluid collection → bacterial infection. ◦ Bacteria: S. pneumoniae, non-typeable H. influenzae, and M. catarrhalis. • Mastoiditis: ◦ Mechanism: Spread from middle-ear spaces through aditus ad antrum to mastoid air cells. ◦ Progression: Incipient (fluid only) → Coalescent (bone destruction). ◦ Organisms: S. pneumoniae, S. pyogenes, H. influenzae, S. aureus (including MRSA), and P. aeruginosa. • Chronic Sinusitis: ◦ Etiology: Inflammatory, infectious, allergic, structural (deviated septum, polyps), or immunologic. ◦ Non-polyp Type: T1 lymphocyte predominance; associated with bacterial infection/colonization. ◦ Polyp Type: T2 lymphocyte predominance; associated with eosinophilic inflammation, asthma, and aspirin sensitivity. • Allergic Fungal Rhinosinusitis: ◦ Features: IgE-mediated, eosinophils, greenish-brown mucus (peanut butter consistency), contains viable hyphae (Aspergillus). • Invasive Fungal Sinusitis: Caused by Mucorales or Aspergillus.

• Otitis Externa Etiology: ◦ Pathogens: P. aeruginosa, S. aureus, fungi (Aspergillus, Candida). ◦ Risk Factors: Swimming, trauma (swabs), narrow canals, cerumen, eczema, psoriasis. ◦ Malignant Otitis Externa: Life-threatening; involves temporal bone; common in diabetics/immunocompromised; can affect CN VII, IX, XI, or XII.

3.1 Acute Mastoiditis Pathogenesis¶

• Path: Middle-ear space → aditus ad antrum → mastoid air cells. • Clinical Progression: Incipient (fluid) → Coalescent (bone destruction) → Subperiosteal abscess.

3.2 Chronic Sinusitis Pathophysiology¶

• Non-polyp Type: More common in women; facial pain; T1 lymphocyte predominance. • Polyp Type: More common in men; loss of smell, asthma, aspirin sensitivity; T2 lymphocyte predominance.

4. CLINICAL FEATURES¶

• Nonspecific URI: ◦ Symptoms: Nasal fullness/obstruction, rhinorrhea, sore throat, laryngitis, lymphadenopathy, cough, low-grade fever. ◦ Physical Exam: Conjunctivitis, pharyngeal erythema, exudates, cobblestoning; nasal mucosa may be pale, boggy, or red. • AOM: ◦ Symptoms: Ear pain, fever, irritability, otorrhea, anorexia. ◦ Examination: Bulging, inflamed, cloudy tympanic membrane (TM); obscured landmarks; immobility on pneumotoscopy/Valsalva. ◦ Severity Criteria: Moderate to severe otalgia, duration ≥ 2 days, or temperature >102.2^{circ}F. • OME: ◦ Symptoms: Decreased sound conduction, hearing loss, ear fullness, tinnitus, balance problems. ◦ Examination: Translucent/gray TM with fluid (colorless/amber), air-fluid levels, bubbles; loss of light reflex; decreased mobility on pneumotoscopy. • Acute Mastoiditis: ◦ Symptoms: Ear pain, fever, lethargy, fussiness despite AOM treatment. ◦ Examination: Postaurical erythema, tenderness, warmth, fluctuance, protrusion of auricle. • Chronic Sinusitis: ◦ Cardinal Symptoms: Facial pain/pressure, nasal discharge/postnasal drip, congestion, hyposmia/anosmia. ◦ Associated: Fatigue, malaise, ear pressure, hoarseness, cough. ◦ Rhinoscopy: Polyps seen as white/gray/tan/yellow translucent growths in middle meatus.

• Red Flags for URI: ◦ Fever >102^{circ}F, chest pain (non-muscular), shortness of breath, dizziness, confusion, new ear/sinus pain, symptoms >14 days.

• Otitis Externa Features: ◦ Pain on movement of auricle or tragus; erythema, edema, exudate in canal. ◦ Fungal: Pruritus and discharge, less pain.

• Sinusitis Complications (Red Flags): ◦ Confusion, unilateral weakness, proptosis, limited ocular movements, acute vision changes.

4.1 Otitis Externa Clinical Features¶

• Physical Exam: Pain on movement of auricle/tragus; erythema/edema of canal. • Fungal Distinction: Pruritus and discharge, less pain.

4.2 Acute Mastoiditis Clinical Features¶

• Signs: Postaurical erythema, tenderness, warmth, fluctuance, protrusion of auricle. ◦ Complications: Facial nerve palsy, labyrinthitis, skull osteomyelitis, temporal lobe abscess, meningitis, epidural/subdural abscess, venous sinus thrombosis, Bezold's abscess.

4.3 Chronic Sinusitis Clinical Features¶

• Diagnosis Requirement: Must be confirmed via rhinoscopy, endoscopy, or imaging (40% of patients with symptoms have no mucosal changes).

5. DIFFERENTIAL DIAGNOSIS¶

• Ear Pain Differential: ◦ Infections: Otitis externa, AOM, Mastoiditis. ◦ Referred Pain: Dental (caries/absurd), Salivary gland pathology, Cervical adenopathy, Sinusitis, Tonsillitis, Pharyngitis (via CN IX), Myocardial Infarction (via CN X). ◦ Neuropathic/Myopathic: Trigeminal neuralgia, Ramsay Hunt syndrome, Bell's palsy. ◦ Other: TMJ disorder, Bruxism, Relapsing polychondritis.

• Sore Throat Differential: ◦ Non-strep Pharyngitis (Table 37-3): ◦ Scarlatiniform rash → GAS or Arcanobacterium haemolyticum. ◦ Sex/Urogenital symptoms → Neisseria gonorrhoeae. ◦ Bronchopulmonary symptoms → Mycoplasma pneumoniae. ◦ New partner/fever/rash/myalgias → Acute HIV infection. ◦ Other: Submandibular spasm, Epiglottitis, Laryngitis, Lemierre syndrome, Gonococcal pharyngitis, Diphtheria.

5.1 Sinus Symptoms Differential¶

• Rhinitis Differentials: Common cold, allergic rhinitis, vasomotor rhinitis, rhinitis medicamentosa, drug-induced (NSAIDs/Beta blockers), autoimmune (GPA), CSF leak. ◦ Non-infectious Pain: Headache, facial pain syndromes, TMJ, dental pathology.

6. INVESTIGATIONS & DIAGNOSIS¶

Acute Otitis Media (AOM) Diagnosis (Table 37-1):
Step 1: Assess age.
Age <6 months → Antibiotic treatment reasonable for all.
Age ≥ 6 months → Antibiotics if otorrhea is present.
Step 2: Evaluate severity (all ages).
Antibiotics indicated if:
Severe otalgia
Otalgia lasting ≥ 2 days
Temperature >102.2^{circ}F
Acute Sinusitis Diagnosis (Table 37-2):
Step 1: Determine duration.
Persistent → Symptoms lasting ≥ 10 days.
Step 2: Identify worsening.
Worsening → New fever, headache, or increase in nasal discharge following an upper respiratory tract infection that lasted for 5–6 days and was initially improving.
Sore Throat (GAS) Diagnosis (Table 37-4):
Step 1: Calculate Centor Score based on:
History of fever
Absence of cough
Tender anterior cervical lymphadenopathy
Tonsillar swelling or exudate
Step 2: Determine action based on score:
Score 0 → No test, no antibiotic.
Score 2 → Rapid test.
Score 4 → Empirical antibiotic treatment or rapid test.

7. MANAGEMENT & TREATMENT¶

Nonspecific URI Treatment:
Support care: Rest and plenty of fluids to avoid dehydration.
Otitis Externa Treatment:
Topical therapy: Antibacterial with glucocorticoid (e.g., Polymyxin B–neomycin–hydrocortisone) for 7–10 days.
Acute Otitis Media Treatment:
First-line: Amoxicillin (90 mg/kg/d).
Alternative (Penicillin allergy or failure): Amoxicillin/Clavulanate.
Acute Mastoiditis Treatment:
Management: Antibiotics and surgical intervention if required for complications.
Acute Sinusitis Treatment:
Indications: Based on 'Persistent' (≥ 10 days) or 'Worsening' (new fever/headache after 5–6 days of improvement).
Chronic Sinusitis Treatment:
Management based on specific type (non-polyp, polyp, or allergic fungal).
Sore Throat (GAS) Treatment (Table 37-5):
Antibiotic of Choice: Penicillin (500 mg PO qid or 1000 mg PO bid imes 10 days).
Non-Penicillin-Allergic Patients: Cephalexin (500 mg PO bid imes 10 days) or Cefadroxil (1 g PO qd imes 10 days).
Severe Penicillin Allergy: Erythromycin or Clarithromycin.

8. PROGNOSIS & COMPLICATIONS¶

• AOM Prognosis: Generally good, but requires monitoring for complications. • Sinusitis Complications: - Orbital cellulitis, proptosis, vision changes (requiring urgent evaluation). - Invasive fungal infections in immunocompromised patients (requires IV antifungals and surgical debridement). • Mastoiditis Complications: - Facial nerve palsy, labyrinthitis, skull osteomyelitis, temporal lobe abscess, meningitis, epidural/subdural abscess, venous sinus thrombosis, Bezold's abscess. • Chronic Sinusitis Prognosis: Varies by type; allergic fungal rhinosinusitis requires specific management of IgE-mediated response.

9. SPECIAL CONSIDERATIONS¶

• Immunocompromised Patients: - High risk for invasive fungal sinusitis (Mucorales, Aspergillus). - Malignant otitis externa in diabetics/immunocompromised. • Children: - Higher prevalence of AOM and GAS pharyngitis. - Risk of foreign bodies in ear/sinus. • Recurrent Disease: - Chronic sinusitis may be associated with allergic rhinitis and asthma.

10. KEY PEARLS & CLINICAL TRAPS¶

• Antibiotic Stewardship: Do not prescribe antibiotics for viral URIs; they do not speed resolution. • Sore Throat Rule: Only GAS pharyngitis requires routine antibiotic treatment in adults. • Mastoiditis Red Flags: Postaurical erythema and fluctuance are critical indicators of mastoiditis. • Sinusitis Distinction: Persistent (≥ 10 days) vs. Worsening (new fever/headache after 5–6 days of improvement). • Otitis Externa: Treat with topical antibiotics + steroids; not a systemic antibiotic indication unless complicated. • Centor Criteria: Used to triage patients for GAS pharyngitis based on clinical score (0, 2, 4).

Reference Tables¶

TABLE 36-4 OSHA Daily Permissible Noise Level Exposure¶

Harrison's 22e, p.252

SOUND LEVEL (dB)	DURATION PER DAY (h)
90	8
95	4
100	2
105	1
115	≤0.25
37	Upper Respiratory Symptoms, Including Earache, Sinus Symptoms, and Sore Throat Rachel L. Amdur, Jeffrey A. Linder

TABLE 37-1 Indications for Antibiotic Treatment of Acute Otitis Media AGE <6 months 6 months to 2 years ≥6 months >2…¶

Harrison's 22e, p.254

AGE	INDICATION
<6 months	Antibiotic treatment reasonable for all
≥6 months	Otorrhea
All ages	Ear findings with severe otalgia, otalgia lasting at least 2 days, or temperature of >102.2°F

TABLE 37-2 Indications for Antibiotic Treatment of Acute Sinusitis INDICATION Persistent Severe Worsening¶

Harrison's 22e, p.256

INDICATION	DEFINITION
Persistent	Symptoms lasting ≥10 days
Worsening	New fever, headache, or increase in nasal discharge following an upper respiratory tract infection that lasted for 5–6 days and was initially improving

TABLE 37-3 Clinical Findings That Suggest Various Forms of Nonstreptococcal Pharyngitis¶

Harrison's 22e, p.257

CLINICAL FINDING(S) OR BEHAVIORAL FACTOR	SUSPECTED DIAGNOSIS
Scarlatiniform rash	Group A β-hemolytic streptococci or Arcanobacterium haemolyticum
Sex between men with associated urogenital symptoms, fellatio between a woman and a man who has current urogenital symptoms, persistent sore throat unresponsive to penicillin	Neisseria gonorrhoeae
Persistent sore throat with bronchopulmonary symptoms	Mycoplasma pneumoniae
New sexual partner in the previous month; fever, rash, myalgias, headache	Acute HIV infection

TABLE 37-4 The Centor Criteria and the Probability of Streptococcal Pharyngitis for Adults a NO. OF¶

Harrison's 22e, p.258

NO. OF CRITERIA METb	POSTEVALUATION PROBABILITY (%)	RECOMMENDATION
0	2	No test, no antibiotic
	3
2	8	Rapid test
	19
4	41	Empirical antibiotic treatment or rapid test

TABLE 37-5 Antibiotic Treatment of Group A Streptococcal Pharyngitis ANTIBIOTIC Antibiotic of Choice Penicillin…¶

Harrison's 22e, p.258

ANTIBIOTIC	DOSING
Antibiotic of Choice
Penicillin	500 mg PO qid or 1000 mg PO bid × 10 days
Alternative for Non-Penicillin-Allergic Patients
Alternatives for Non-Anaphylactic Penicillin-Allergic Patients
Cephalexin	500 mg PO bid × 10 days
Cefadroxil	1 g PO qd × 10 days
Alternatives for Patients with Severe Penicillin Allergy