Upper Respiratory Symptoms, Including Earache, Sinus Symptoms, and Sore Throat¶
Chapter 37 | Part 2: Cardinal Manifestations and Presentation of Diseases
KEY CLINICAL POINTS¶
- Upper respiratory infections (URIs) are predominantly viral, with bacterial causes limited to AOM, sinusitis, streptococcal pharyngitis, and pneumonia.
- Antibiotics are only indicated for specific bacterial etiologies (AOM, sinusitis, streptococcal pharyngitis, pneumonia) and should be avoided for viral URIs.
- Centor criteria guide streptococcal pharyngitis diagnosis, with rapid antigen testing recommended for patients meeting 2–4 criteria.
- Otitis media (AOM) and sinusitis are common complications of viral URIs, with distinct clinical presentations and management strategies.
- Symptom-based management (analgesics, decongestants, antihistamines) is the cornerstone of nonspecific URI treatment, with antibiotics reserved for specific bacterial infections.
1. DEFINITION & OVERVIEW¶
Upper respiratory symptoms encompass a broad range of conditions affecting the nasal passages, pharynx, larynx, and ears. These include viral infections (common cold), bacterial infections (e.g., streptococcal pharyngitis), and inflammatory/immune-mediated processes (e.g., allergic rhinitis). Earache, sinus symptoms, and sore throat are common manifestations, often overlapping with other systemic conditions (e.g., HIV, COVID-19).
Table 36-4 OSHA Daily Permissible Noise Level Exposure¶
| SOUND LEVEL (dB) | DURATION PER DAY (h) |
|---|---|
| 90 | 8 |
| 92 | 6 |
| 95 | 4 |
| 97 | 3 |
| 100 | 2 |
| 102 | 1.5 |
| 105 | 1 |
| 110 | 0.5 |
| SOUND LEVEL (dB) | DURATION PER DAY (h) |
|---|---|
| 115 | £0.25 |
1.1 Nonspecific Upper Respiratory Infection (Common Cold)¶
Defined by no single symptom predominating, caused by respiratory viruses (rhinovirus, coronavirus, etc.). Symptoms include rhinorrhea, sore throat, cough, and low-grade fever. Self-limiting, typically resolving within 7–14 days.
1.2 Otitis Media¶
Inflammation of the middle ear, often secondary to viral URIs. Acute otitis media (AOM) presents with ear pain, fever, and otorrhea. Chronic otitis media with effusion (OME) involves fluid accumulation without acute infection.
1.3 Sinus Symptoms¶
Acute sinusitis is typically viral, with symptoms of facial pain, purulent nasal discharge, and nasal congestion. Chronic sinusitis persists >12 weeks, often associated with allergies, anatomical abnormalities, or immune dysfunction.
2. EPIDEMIOLOGY¶
URIs are the most common reason for ambulatory care in the U.S., with 2–4 episodes/year in adults and 6–10 in children. AOM is most common in children <2 years, with ~60% having at least one episode by age 6. Sinusitis and sore throat are prevalent in adults, with viral etiologies dominating. Risk factors include young age, immunocompromise, and environmental exposures (e.g., smoking, allergens).
2.1 Incidence and Prevalence¶
URIs account for ~100 million physician visits/year in the U.S. AOM peaks at 6–24 months, with ~60% of children having at least one episode by age 6. Sinusitis affects ~15% of adults annually, with viral causes predominating.
2.2 Risk Factors¶
Young age, immunocompromise (e.g., diabetes, HIV), anatomical abnormalities (e.g., deviated septum), allergies, and environmental exposures (smoking, pollution) increase risk. Swimming and mechanical trauma (e.g., cotton swabs) predispose to otitis externa.
3. ETIOLOGY & PATHOPHYSIOLOGY¶
Viral pathogens (rhinovirus, coronavirus, influenza) are the primary cause of URIs. Bacterial pathogens (Streptococcus, Haemophilus, Moraxella) contribute to AOM, sinusitis, and pharyngitis. Allergies, immune dysfunction, and anatomical abnormalities (e.g., enlarged adenoids) exacerbate symptoms. Inflammatory mediators and immune responses drive symptomatology.
3.1 Viral Etiology¶
Rhinovirus (most common), coronavirus, influenza, and adenovirus are primary viral causes. These induce nasal congestion, rhinorrhea, and cough via epithelial damage and immune activation.
3.2 Bacterial Etiology¶
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are common bacterial pathogens. They colonize the nasopharynx and cause secondary infections following viral URIs.
4. CLINICAL FEATURES¶
Symptoms vary by condition: viral URIs present with rhinorrhea, cough, and sore throat; bacterial infections (AOM, sinusitis) have fever and localized pain. Sore throat may indicate streptococcal pharyngitis, while ear pain suggests otitis media. Chronic symptoms (e.g., sinusitis) may include facial pressure and hyposmia.
4.1 Acute Otitis Media (AOM)¶
Ear pain, fever, otorrhea, and tympanic membrane bulging. Common in children; associated with viral URIs. Complications include mastoiditis and meningitis.
4.2 Sinusitis¶
Facial pain/pressure, purulent nasal discharge, and nasal congestion. Acute (<4 weeks) vs. chronic (>12 weeks). Viral etiology dominates, with bacterial causes in 2–5% of cases.
5. DIFFERENTIAL DIAGNOSIS¶
Differential diagnoses include allergic rhinitis, sinusitis, otitis media, and systemic conditions (e.g., HIV, COVID-19). For sore throat: streptococcal pharyngitis, mononucleosis, gonococcal infection, and tumors. Ear pain may arise from temporomandibular joint disorders or dental pathology.
5.1 Sore Throat¶
Streptococcal pharyngitis, viral pharyngitis, mononucleosis, gonococcal infection, diphtheria, and tumors. Differentiate using Centor criteria and rapid antigen testing.
5.2 Ear Pain¶
Otitis externa, otitis media, temporomandibular joint disorders, dental pathology, or referred pain from sinusitis. Consider temporal arteritis in >50-year-olds.
6. INVESTIGATIONS & DIAGNOSIS¶
Clinical evaluation and targeted investigations (e.g., rapid strep test, imaging) guide diagnosis. Centor criteria and symptom duration help distinguish viral vs. bacterial causes. Imaging (CT, MRI) is used for complications (e.g., mastoiditis, sinusitis).
Table 37-1 Indications for Antibiotic Treatment of Acute Otitis Media¶
| AGE | INDICATION |
|---|---|
| <6 months | Antibiotic treatment reasonable for all |
| 6 months to 2 years | Bilateral ear findings |
| ‡6 months | Otorrhea |
| >2 years | Symptoms worsening or not improving within 48–72 h |
| 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 | DEFINITION |
|---|---|
| Persistent | Symptoms lasting ‡10 days |
| Severe Fever | Fever of >102°F and purulent nasal discharge or nasal pain for at least 3–4 consecutive 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 |
6.1 Diagnostic Criteria¶
Centor criteria for strep pharyngitis: fever, absence of cough, tender cervical lymphadenopathy, and tonsillar exudate. Rapid antigen testing recommended for patients with 2–4 criteria.
6.2 Imaging¶
CT for sinusitis, mastoiditis, or head/neck abscesses. MRI for suspected fungal sinusitis or intracranial complications.
7. MANAGEMENT & TREATMENT¶
Symptom-based management (analgesics, decongestants, antihistamines) is primary. Antibiotics reserved for bacterial etiologies (AOM, sinusitis, streptococcal pharyngitis). Surgical interventions (tympanostomy, sinus surgery) for chronic conditions. Avoid unnecessary antibiotic use to prevent resistance.
Table 37-4 The Centor Criteria and the Probability of Streptococcal Pharyngitis for Adultsa¶
| NO. OF CRITERIA METb | POSTEVALUATION PROBABILITY (%) | RECOMMENDATION |
|---|---|---|
| 0 | 2 | No test, no antibiotic |
| 1 | 3 | No test, no antibiotic |
| 2 | 8 | Rapid test |
| 3 | 19 | Rapid test |
| 4 | 41 | Empirical antibiotic treatment or rapid test |
Table 37-5 Antibiotic Treatment of Group A Streptococcal Pharyngitis¶
| ANTIBIOTIC | DOSING |
|---|---|
| Penicillin | 500 mg PO qid or 1000 mg PO bid × 10 days |
| Amoxicillin | 500 mg PO bid or 1000 mg PO qd × 10 days |
| Cephalexin | 500 mg PO bid × 10 days |
| Cefadroxil | 1 g PO qd × 10 days |
| Erythromycin | 250–500 mg PO qid or 500–1000 mg PO bid × 5 days |
| Clarithromycin | 500 mg PO bid × 5 days |
| Clindamycin | 300 mg PO tid × 10 days |
7.1 Otitis Externa¶
Topical antibiotics (polymyxin B-neomycin-hydrocortisone) and corticosteroids. Avoid in tympanic membrane perforation. Malignant otitis externa requires IV antipseudomonal antibiotics.
7.2 Acute Otitis Media¶
Amoxicillin (875 mg bid × 10 days) or amoxicillin/clavulanate (875/125 mg bid × 10 days). Avoid in patients with recent antibiotic use; consider ceftriaxone or clindamycin for resistant strains.
7.3 Sinusitis¶
Antibiotics (amoxicillin/clavulanate, levofloxacin) for bacterial sinusitis. Nasal corticosteroids and saline irrigation for chronic cases. CT-guided drainage for complications.
8. PROGNOSIS & COMPLICATIONS¶
Most URIs are self-limiting with full recovery within 7–14 days. Complications include mastoiditis, meningitis, and sepsis. Chronic sinusitis and otitis media may persist for months. Antibiotic misuse increases resistance and adverse effects (e.g., Clostridioides difficile).
8.1 Complications¶
Acute complications: orbital cellulitis, meningitis, brain abscess. Chronic complications: sinus polyps, hearing loss, and recurrent infections. Invasive fungal sinusitis is life-threatening in immunocompromised patients.
8.2 Prognosis¶
Viral URIs resolve spontaneously. Bacterial infections require antibiotics for resolution. Chronic conditions (e.g., sinusitis) may require long-term management with corticosteroids or surgery.
9. SPECIAL CONSIDERATIONS¶
Pregnancy: Avoid NSAIDs in late pregnancy; use amoxicillin for AOM. Pediatrics: Avoid cough/cold medications in children <6 years. Elderly: Monitor for atypical presentations (e.g., confusion, falls). Immunocompromised: Risk of invasive fungal infections (e.g., mucormycosis).
9.1 Pregnancy¶
Avoid NSAIDs in third trimester. Amoxicillin is preferred for AOM. Monitor for fetal complications (e.g., preterm labor).
9.2 Pediatrics¶
Avoid cough/cold medications in children <6 years. Use acetaminophen for fever. Adenoidectomy may be indicated for recurrent AOM or OME.
10. KEY POINTS & CLINICAL PEARLS¶
- Viral URIs are the most common cause; antibiotics are only indicated for specific bacterial infections. 2. Centor criteria and rapid strep testing guide streptococcal pharyngitis management. 3. Otitis media and sinusitis require targeted antibiotic therapy based on age and severity. 4. Avoid unnecessary antibiotics to prevent resistance and adverse effects. 5. Symptom-based management (analgesics, decongestants) is the cornerstone of nonspecific URI treatment.