What is the diagnosis for a patient presenting with right ear pain, fever, and runny nose?

Diagnosis: Viral Upper Respiratory Tract Infection (Common Cold) with Possible Acute Otitis Media

The most likely diagnosis is a viral upper respiratory tract infection (URI), commonly known as the common cold, and the ear pain requires pneumatic otoscopy to determine if concurrent acute otitis media (AOM) is present. 1, 2

Clinical Reasoning

Primary Diagnosis: Viral URI

The triad of ear pain, fever, and runny nose strongly suggests a viral upper respiratory infection, which is the most common illness in both children and adults. 3, 4

• Rhinovirus infections typically present with nasal discharge, nasal congestion, fever, and associated symptoms including ear pain. 3
• Ear pain commonly accompanies viral URIs and does not necessarily indicate true middle ear infection—it may represent referred pain from pharyngeal inflammation rather than actual otitis media. 1
• Most viral URIs are self-limiting and resolve within 7-10 days without antibiotics. 3

Critical Distinction: Ear Pain vs. Acute Otitis Media

You must perform pneumatic otoscopy to determine if true AOM is present—ear pain alone is insufficient for diagnosis. 1, 2

• AOM is a visual diagnosis requiring documentation of middle ear effusion with bulging tympanic membrane and impaired mobility on pneumatic otoscopy. 1, 5, 6
• Location of pain/tenderness and pneumatic otoscopy are crucial for differentiating between otitis externa and otitis media. 2
• Only 50-60% of children with confirmed AOM actually complain of ear pain, so its presence or absence is an unreliable indicator of middle ear disease. 1

Diagnostic Approach

Physical Examination Findings to Assess

Examine the tympanic membrane with pneumatic otoscopy looking for:

• Moderate-to-severe bulging of the tympanic membrane, OR
• Mild bulging with recent onset of ear pain (less than 48 hours), OR
• New-onset otorrhea not caused by otitis externa 6

Assess for otitis externa by:

• Palpating the tragus and manipulating the pinna—tenderness suggests otitis externa rather than AOM 2
• Examining the ear canal for edema, erythema, and debris 2

Evaluate for bacterial rhinosinusitis if:

• Symptoms persist beyond 10 days without improvement, OR
• Symptoms worsen after 5-7 days ("double sickening"), OR
• Severe symptoms are present in the first 3-4 days (high fever >39°C, purulent nasal discharge, facial pain) 7, 3

Management Based on Findings

If Viral URI Without AOM (Most Likely Scenario)

Provide symptomatic management only—antibiotics are not indicated: 3

• Analgesics (acetaminophen or NSAIDs) for pain and fever relief 1
• Reassure that symptoms typically resolve within 7-10 days 3
• Antibiotics are not effective for viral infections, and bacterial superinfection occurs in less than 2% of cases. 3

If Concurrent AOM Is Confirmed

Management depends on age and severity: 5, 6

• Pain management is essential regardless of antibiotic decision. 1, 5
• Antibiotic therapy can be deferred in children ≥2 years with mild symptoms and unilateral disease—observation for 48-72 hours is appropriate. 5
• High-dose amoxicillin (80-90 mg/kg/day in two divided doses) is first-line therapy when antibiotics are indicated. 5, 6
• Prescribe antibiotics immediately for children <6 months, bilateral AOM in children 6-23 months, or severe symptoms (moderate-to-severe otalgia, fever ≥39°C). 6

If Bacterial Rhinosinusitis Is Suspected

Consider bacterial rhinosinusitis only if: 7

• Purulent nasal discharge PLUS nasal obstruction OR facial pain/pressure, AND
• Symptoms persist ≥10 days, OR worsen within 10 days after initial improvement, OR are particularly severe in the first 3-4 days 7

Common Pitfalls to Avoid

• Do not assume ear pain equals AOM—perform pneumatic otoscopy to confirm middle ear disease before diagnosing concurrent otitis media. 1, 2
• Do not prescribe antibiotics for uncomplicated viral URI—bacterial superinfection is rare (<2%) and antibiotics do not hasten recovery. 3
• Do not diagnose bacterial rhinosinusitis before 10 days of symptoms unless there is clear worsening or severe presentation. 7
• Reassess if symptoms don't improve within 48-72 hours for suspected AOM or worsen after 5-7 days for viral URI. 2, 3