What are the guidelines for treating common ear, nose, and throat (ENT) illnesses?

Guidelines for Treating Common Ear, Nose, and Throat Illnesses

Topical treatments should be the first-line therapy for most common ENT conditions, with oral antibiotics reserved only for specific indications where topical therapy is insufficient or inappropriate. 1

Acute Otitis Externa (Swimmer's Ear)

Diagnosis

• Hallmark sign: Intense tenderness of tragus, pinna, or both 1
• Symptoms: Pain, itching, fullness, hearing loss, discharge
• Nearly all (98%) AOE in North America is bacterial, with Pseudomonas aeruginosa (20-60%) and Staphylococcus aureus (10-70%) being most common pathogens 1

Treatment

1. Aural toilet: Remove debris/discharge from ear canal through suction, dry mopping, or irrigation 1
2. Topical antimicrobials: First-line treatment
   • Antibiotic drops with or without steroid component
   • Apply 3-4 times daily for 7-10 days
3. Pain management: Acetaminophen or NSAIDs for pain relief
4. Ear canal wick: Consider for severely swollen canals to facilitate medication delivery 1

Important Note

• Oral antibiotics have limited utility in AOE and should be avoided unless there's extension beyond the ear canal or in immunocompromised patients 1
• Despite limited utility, 20-40% of patients with AOE receive unnecessary oral antibiotics 1, 2

Cerumen Impaction

Diagnosis

• Symptoms: Hearing loss, fullness, itching, tinnitus, cough
• Definition: Accumulation of cerumen causing symptoms or preventing assessment of ear canal/tympanic membrane 1

Treatment

1. Cerumenolytic agents: Ear drops to soften and dissolve cerumen
2. Irrigation: Gentle ear canal irrigation with body-temperature water
3. Manual removal: Using appropriate instruments under direct visualization
4. Prevention: For recurrent cases, consider regular use of prophylactic drops or periodic cleaning 1

Special Considerations

• More common in elderly (19-65% prevalence) and developmentally delayed adults (28-36%) 1
• Can cause significant hearing loss (5-40 dB) depending on degree of occlusion 1

Acute Otitis Media

Diagnosis

• Confirm by identifying moderate to severe bulging of tympanic membrane or new onset otorrhea, with symptoms such as pain, irritability, or fever 3
• Tympanocentesis and culture of middle ear effusion required for definitive microbiologic diagnosis 1

Treatment

1. Pain management: Acetaminophen or ibuprofen regardless of antibiotic decision 3
2. Antibiotics:
   • First-line: High-dose amoxicillin (80-90 mg/kg/day divided twice daily) for 5-7 days 3, 4
   • For recent amoxicillin use or concurrent conjunctivitis: Amoxicillin-clavulanate 3
   • For penicillin allergy: Cephalosporins (if not allergic) or clindamycin 3
3. Observation option: For mild cases in children ≥24 months with unilateral AOM without severe symptoms 3

Pathogens

• Most common: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 4
• 20-30% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase 1

Ear Canal Complications in Specific Conditions

Ear Complications in Congenital Ichthyoses

• Issues include pruritus, external otitis, pain, discharge, ear deformities and obstruction 1
• Hearing evaluations recommended every 6 months for children under 6 years 1
• Treatment: Regular removal of ear wax/cerumen by ENT specialist 1-4 times yearly using microsuctioning, debridement, and curettage 1
• Refer to ENT for pruritus, pain, discharge, clogged feeling, or hearing loss 1

Prevention of ENT Infections

General Preventive Measures

• Pneumococcal and influenza vaccination to reduce risk of AOM 3
• Limit daycare attendance and avoid tobacco smoke exposure 3
• For swimmer's ear prevention: Dry ears after swimming, use acidifying ear drops, consider ear plugs 1

When to Refer to Specialist

1. Acute Otitis Media:

   • Recurrent episodes (3+ in 6 months or 4+ in 12 months) 3
   • Complications such as mastoiditis 3
   • Persistent middle ear effusion beyond 3 months with hearing loss 3

2. Otitis Externa:

   • Failure to respond to appropriate topical therapy
   • Diabetic or immunocompromised patients
   • Extension beyond the ear canal 1

3. Cerumen Impaction:

   • Failed attempts at removal
   • History of tympanic membrane perforation or ear surgery 1

Common Pitfalls to Avoid

1. Overuse of oral antibiotics for AOE: Topical therapy is more effective and has fewer side effects 1, 2
2. Inappropriate antibiotic selection for AOM: Ensure coverage for common pathogens including resistant strains 1, 5
3. Failure to provide adequate pain management: Always address pain regardless of antibiotic decision 3
4. Mistaking otitis media with effusion for acute otitis media: OME does not require antibiotics 3
5. Aggressive cerumen removal techniques: Can cause trauma to ear canal or tympanic membrane 1

Remember that most upper respiratory tract infections are viral in origin and even when bacterial species are implicated, recovery is usually spontaneous in many cases 5. Judicious use of antibiotics is essential to prevent antimicrobial resistance.