Management of Adult Patient with Throat and Ear Pain Who Improved on Amoxicillin
Complete the current course of amoxicillin (typically 10-14 days total) and provide symptomatic care, as this patient likely has acute bacterial rhinosinusitis with eustachian tube dysfunction rather than streptococcal pharyngitis. 1
Clinical Reasoning
Diagnosis Clarification
The negative strep test effectively rules out group A streptococcal pharyngitis as the primary diagnosis, according to the American Academy of Allergy, Asthma, and Immunology. 1
The ear examination findings (dull eardrum with pressure but no erythema) are classic for middle ear effusion and eustachian tube dysfunction associated with acute bacterial rhinosinusitis (ABRS), not isolated otitis media. 1
The clinical presentation—severe throat pain with ear pressure/pain and improvement on amoxicillin—strongly suggests ABRS with referred pain and eustachian tube involvement rather than primary pharyngitis. 1
Antibiotic Management
Continue amoxicillin until the patient has been symptom-free for 7 days, with a typical total course of 10-14 days. 1 This recommendation comes from the American Academy of Otolaryngology-Head and Neck Surgery.
Amoxicillin is the appropriate first-line antibiotic for ABRS in adults, as recommended by the American Academy of Allergy, Asthma, and Immunology, with effectiveness against the common pathogens Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1
Since the patient is already improving on amoxicillin, there is no indication to switch antibiotics or add additional antimicrobial coverage. 2
Failure to respond after 72 hours would warrant either switching antibiotics or reevaluation, but this patient demonstrated clinical improvement, confirming appropriate therapy. 2
Adjunctive Therapies to Recommend
Add intranasal saline irrigation, which the American College of Physicians suggests may alleviate symptoms and potentially decrease antibiotic duration in ABRS. 1
Consider intranasal corticosteroids as adjunctive therapy, particularly helpful if marked mucosal edema is present, per the American Academy of Allergy, Asthma, and Immunology. 1
Common Pitfalls to Avoid
Do not stop antibiotics prematurely just because symptoms improved—complete the full 10-14 day course to prevent relapse and ensure adequate treatment of ABRS. 1
Do not add or switch to amoxicillin-clavulanate unless the patient fails initial therapy after 72 hours, as this patient is already responding to amoxicillin alone. 2
Do not pursue additional imaging or specialist referral at this point, as the patient is improving with appropriate first-line therapy. These interventions are reserved for patients who deteriorate despite antibiotics or have recurrent episodes. 2
Follow-Up Considerations
Instruct the patient to return if symptoms worsen or fail to continue improving over the next 48-72 hours. 2
If the patient were to fail therapy (worsening after initial improvement or no improvement by 72 hours), switch to high-dose amoxicillin-clavulanate (4g/250mg daily) or a respiratory fluoroquinolone (levofloxacin or moxifloxacin). 2