Primary Diagnosis: Common cold secondary to Notalgia.
Primary Diagnosis: Common cold secondary to Notalgia.
Acute upper respiratory tract infection (URI), also called the common cold, is the most common acute illness in the United States and the industrialized world. Patients typically present with nasal congestion, rhinorrhea, sore throat, cough, general malaise, and/or low-grade fever. Symptoms are self-limited, often lasting up to 10 days. Viruses such as rhinovirus are the predominant cause of acute URI; transmission occurs through contact with the nasal secretions and saliva of infected people (Kim.,et al, 2015 ). The cause of secondary otalgia is often difficult to determine because the innervation of the ear is complex and there are many potential sources of referred pain. The most common causes are temporomandibular joint syndrome, pharyngitis, dental disease, and cervical spine arthritis. If the diagnosis is not clear from the history and physical examination, options include a trial of symptomatic treatment without a clear diagnosis; imaging studies; and consultation with an otolaryngologist.
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Differential Diagnosis:
Acute Otitis Media:
Acute otitis media (AOM) is an acute, suppurative infectious process marked by the presence of infected middle ear fluid and inflammation of the mucosa lining the middle ear space. The infection is most frequently precipitated by impaired function of the Eustachian tube, resulting in the retention and suppuration of retained secretions. AOM may also be associated with purulent otorrhea if there is a ruptured tympanic membrane. AOM usually responds promptly to antimicrobial therapy.AOM is a complication of eustachian tube dysfunction that occurred during an acute viral upper respiratory tract infection. Bacteria can be isolated from middle ear fluid cultures in 50% to 90% of cases of AOM. Streptococcus pneumoniae, Haemophilus influenzae (nontypable), and Moraxella catarrhalis are the most common organisms.
Otitis Externa:
Acute otitis externa is a common condition involving inflammation of the ear canal. The acute form is caused primarily by bacterial infection, with Pseudomonas aeruginosa and Staphylococcus aureus the most common pathogens. Acute otitis externa presents with the rapid onset of ear canal inflammation, resulting in otalgia, itching, canal edema, canal erythema, and otorrhea, and often occurs following swimming or minor trauma from inappropriate cleaning. Tenderness with movement of the tragus or pinna is a classic finding. Topical antimicrobials or antibiotics such as acetic acid, aminoglycosides, polymyxin B, and quinolones are the treatment of choice in uncomplicated cases. These agents come in preparations with or without topical corticosteroids; the addition of corticosteroids may help resolve symptoms more quickly. However, there is no good evidence that any one antimicrobial or antibiotic preparation is clinically superior to another. The choice of treatment is based on a number of factors, including tympanic membrane status, adverse effect profiles, adherence issues, and cost. Neomycin/polymyxin B/hydrocortisone preparations are a reasonable first-line therapy when the tympanic membrane is intact (Schaefer & Baugh, 2012). Oral antibiotics are reserved for cases in which the infection has spread beyond the ear canal or in patients at risk of a rapidly progressing infection.
Allergic Rhinitis:
Allergic rhinitis is a common and chronic immunoglobulin E–mediated respiratory illness that can affect quality of life and productivity, as well as exacerbate other conditions such as asthma. Treatment should be based on the patient’s age and severity of symptoms. Patients should be educated about their condition and advised to avoid known allergens. Intranasal corticosteroids are the most effective treatment and should be first-line therapy for persistent symptoms affecting quality of life (Seidman, Gurgel 2015). More severe disease that does not respond to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation.
P.
Plan: Given history and physical exam findings, presentation most consistent with common cold secondary otalgia. The differential diagnosis includes otitis media, otitis externa, allergic rhinitis however these are less likely given data presented thus far. Advised to use Tylenol/ibuprofen for pain and fevers. Flonase spray Q6hrs PRN and any OTC decongestants. I agree with my preceptor, there were not enough diagnostic evidence for the patient to be diagnosed with otitis media or otitis externa. Otoscopic assessment did not show any bacterial evidence for antibiotic treatment. Patients fever could be related to her viral infection, so as her ear discomfort. In this case I would educate the patient to return for new or worsening symptoms such as persistent fevers, persistent vomiting, dehydration, altered mental status, severe headaches. Referral to an ENT specialist was sent for further diagnosis of her ear pain. I’ve learned in this case that if you listen to patient long enough, they will tell you exactly what is wrong with them.
References:
CDC – NCHS – National Center for health statistics. (2021, March 2). https://www.cdc.gov/nchs/index.htm
Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician. 2012 Dec 1;86(11):1055-61. PMID: 23198673.
Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis executive summary. Otolaryngol Head Neck Surg. 2015;152(2):197–206.