What is the recommended treatment for a patient with preauricular and cervical lymphadenopathy, hearing difficulties, and sore throat?

Management of Preauricular and Cervical Lymphadenopathy with Hearing Difficulties and Sore Throat

This clinical presentation requires immediate audiometric evaluation to distinguish sudden sensorineural hearing loss (SSNHL) from conductive hearing loss, combined with targeted assessment of the lymphadenopathy and pharyngitis to determine if specific treatment beyond symptomatic management is warranted. 1

Immediate Hearing Assessment

Obtain audiometry within 14 days of symptom onset to confirm whether hearing loss is sensorineural or conductive. 1 This distinction is critical because:

• Conductive hearing loss (CHL) may result from middle ear effusion secondary to pharyngitis or lymphadenopathy causing Eustachian tube dysfunction, requiring different management than SSNHL 1
• Sudden sensorineural hearing loss (SSNHL) is defined as ≥30 dB hearing loss over at least three contiguous frequencies occurring within 72 hours and requires urgent consideration of corticosteroid therapy 1

If SSNHL is Confirmed:

• Offer oral corticosteroids within 2 weeks of symptom onset as initial therapy, though this is an option rather than a strong recommendation given mixed evidence 1
• Approximately one-third to two-thirds of patients may recover spontaneously within 2 weeks, making watchful waiting a reasonable alternative 1
• Do not routinely prescribe antivirals for SSNHL despite common practice, as insufficient evidence supports their effectiveness 1
• Consider MRI or auditory brainstem response (ABR) testing to evaluate for retrocochlear pathology such as vestibular schwannoma 1

Lymphadenopathy Evaluation

The combination of preauricular and cervical lymphadenopathy requires systematic assessment:

Key Historical and Physical Examination Features:

• Duration of lymphadenopathy (nodes persisting >4 weeks warrant further investigation) 2, 3
• Node characteristics: Size >2 cm, hard consistency, or matted/fused nodes suggest malignancy or granulomatous disease 2, 3, 4
• Location matters: Preauricular nodes drain the conjunctiva, eyelids, and temporal scalp; cervical nodes drain the oropharynx 2, 3
• Supraclavicular or epitrochlear nodes are always abnormal and require biopsy 2, 3
• Systemic symptoms: Fever, night sweats, unintentional weight loss suggest malignancy or systemic disease 2, 3

Differential Diagnosis Considerations:

• Infectious mononucleosis (EBV) classically presents with pharyngitis, posterior cervical lymphadenopathy, and splenomegaly 5
• Rubella presents with rash, sore throat, and posterior cervical/posterior auricular lymphadenopathy 6
• Nontuberculous mycobacterial (NTM) cervical lymphadenitis occurs predominantly in children under age 3, with preauricular node involvement suggesting high surgical risk due to facial nerve proximity 1
• Viral pharyngitis with reactive lymphadenopathy is most common, suggested by conjunctivitis, cough, hoarseness, or coryza 5

Diagnostic Workup:

• Ultrasound is the initial imaging modality of choice for cervical lymphadenopathy, providing critical diagnostic information 4
• If lymphadenopathy persists >4 weeks or systemic symptoms present: obtain CBC, CRP, ESR, and tuberculosis testing 2
• Biopsy indications: Nodes >2 cm, multiple levels of adenopathy, supraclavicular location, or suspicious ultrasound findings 2, 3, 4

Sore Throat Management

Risk Stratification Using Centor Criteria:

Apply the following scoring system (1 point each): 7, 8, 5

• Fever (temperature ≥38.3°C/101°F)
• Tonsillar exudates
• Tender anterior cervical lymphadenopathy
• Absence of cough

Treatment Algorithm Based on Centor Score:

Score 0-2 (Low probability of GABHS):

• Do NOT prescribe antibiotics 7, 8, 5
• Provide symptomatic relief with ibuprofen or paracetamol 7, 8
• Antibiotics provide no meaningful benefit and risk side effects, antimicrobial resistance, and unnecessary costs 7, 5

Score 3-4 (Higher probability of GABHS):

• Consider rapid antigen detection test (RADT) or throat culture before prescribing antibiotics 5
• Discuss modest benefits (1-2 days faster symptom resolution) versus risks with the patient 7, 8
• If antibiotics indicated: Penicillin V twice or three times daily for 10 days is first-line 7, 8, 5
• Antibiotics do NOT prevent suppurative complications (quinsy, otitis media, sinusitis) in most cases 7
• Antibiotics do NOT prevent rheumatic fever or glomerulonephritis in low-risk patients without prior rheumatic fever history 7

Symptomatic Management:

• Either ibuprofen or paracetamol for acute sore throat and associated symptoms 7, 8, 5
• Encourage adequate hydration with cool liquids 8, 5
• Do NOT use zinc gluconate, herbal treatments, or acupuncture due to inconsistent evidence 7

Critical Pitfalls to Avoid

• Do NOT obtain routine CT imaging for initial evaluation of hearing loss 1
• Do NOT obtain routine laboratory tests for SSNHL without specific clinical indications 1
• Avoid incisional biopsy alone for suspected NTM lymphadenitis, as this frequently leads to sinus tract formation and chronic drainage 1
• Do NOT use corticosteroids for lymphadenopathy workup without appropriate diagnosis, as they can mask histologic findings of lymphoma 2, 3
• Recognize chronic GABHS carriers (10.9% in children, 2.3% in adults) who present with intercurrent viral infections—these patients do NOT require antibiotic treatment 5

Follow-Up Requirements

• Obtain follow-up audiometry at conclusion of treatment and within 6 months for any confirmed SSNHL 1
• Counsel patients with residual hearing loss about audiologic rehabilitation and supportive measures 1
• Safety-net advice: Return if symptoms worsen rapidly, do not improve within expected timeframe, or patient becomes systemically unwell 8
• Re-evaluate lymphadenopathy if nodes persist beyond 4 weeks or increase in size 2, 3