What is the best course of treatment for a 51-year-old woman presenting with otitis (ear discharge), conjunctivitis (eye yellowish discharge), and a prolonged cough lasting 3 weeks?

Management of Ear Discharge, Eye Discharge, and Prolonged Cough in a 51-Year-Old Woman

This patient requires immediate treatment with topical antibiotic ear drops (fluoroquinolone-based) for otitis externa, oral antibiotics targeting H. influenzae for the conjunctivitis-otitis syndrome, and evaluation for chronic sinusitis or chronic bronchitis as the cause of the 3-week cough.

Immediate Assessment and Diagnosis

Ear Discharge (Otitis Externa)

• Examine the external auditory canal for signs of otitis externa: otalgia, tenderness, fever, and purulent discharge, with Pseudomonas aeruginosa and Staphylococcus aureus being the most common pathogens 1, 2.
• Assess for diabetes or immunocompromised state, as these patients are at high risk for necrotizing otitis externa and require systemic antibiotics in addition to topical therapy 1.
• Verify tympanic membrane integrity before prescribing treatment, as a perforated tympanic membrane or tympanostomy tube modifies management 1.

Eye Discharge (Conjunctivitis) with Ear Involvement

• The combination of purulent conjunctivitis and ear discharge strongly suggests H. influenzae as the causative organism, indicating the "conjunctivitis-otitis syndrome" 1, 3.
• This syndrome requires oral antibiotics rather than topical eye drops alone, as topical treatment does not prevent progression to otitis media 3.

Prolonged Cough (3 Weeks)

• A cough lasting 3 weeks warrants evaluation for chronic sinusitis or chronic bronchitis 1.
• Assess for upper airway cough syndrome (postnasal drip) by examining for rhinosinusitis symptoms: facial pressure, nasal discharge, or sinus tenderness 1.
• Consider imaging (CT sinuses) if sinusitis is suspected, particularly if symptoms persist despite initial antibiotic therapy 1.

Treatment Algorithm

For Otitis Externa (Ear Discharge)

• First-line: Fluoroquinolone ototopical drops (ciprofloxacin or ofloxacin) 5 drops 3 times daily for 3 weeks, as these provide broad-spectrum coverage including P. aeruginosa without ototoxicity concerns 1, 4.
• Avoid aminoglycoside drops (tobramycin, gentamicin) if tympanic membrane integrity is uncertain due to ototoxicity risk 1.
• Add systemic antibiotics (fluoroquinolone or amoxicillin-clavulanate) if the patient has diabetes, immunosuppression, or signs of necrotizing otitis externa (severe pain, granulation tissue, cranial nerve involvement) 1.

For Conjunctivitis-Otitis Syndrome (Eye and Ear Discharge)

• Oral antibiotics are mandatory: amoxicillin-clavulanate, cefuroxime-axetil, cefpodoxime-proxetil, or cefixime for 5 days in adults 1.
• These agents provide coverage against H. influenzae (including beta-lactamase-producing strains), S. pneumoniae, and M. catarrhalis 1.
• Amoxicillin-clavulanate 875 mg/125 mg twice daily for 5 days is the preferred regimen based on efficacy and tolerability 5.

For Prolonged Cough (3 Weeks)

• Initiate empiric treatment for upper airway cough syndrome: first-generation antihistamine/decongestant combination (e.g., chlorpheniramine with pseudoephedrine) twice daily for at least 3 weeks 1.
• If sinusitis is suspected clinically (facial pain, purulent nasal discharge, fever), add antibiotics effective against S. pneumoniae, H. influenzae, and anaerobes: amoxicillin-clavulanate 875 mg/125 mg twice daily for at least 3 weeks 1.
• Add intranasal corticosteroids (e.g., fluticasone, mometasone) for at least 3 months if cough resolves with antibiotic therapy, indicating chronic sinusitis 1.
• Obtain sinus CT imaging if symptoms persist after 1 week of appropriate antibiotic therapy to rule out anatomic obstruction requiring endoscopic sinus surgery 1.

Critical Pitfalls to Avoid

• Never prescribe topical antibiotics for conjunctivitis alone in this syndrome, as they fail to prevent otitis media and do not address the systemic H. influenzae infection 3.
• Do not use standard-dose amoxicillin (500 mg) for the conjunctivitis-otitis syndrome, as it lacks adequate coverage for beta-lactamase-producing H. influenzae 1.
• Avoid irrigating the ear canal if the patient has diabetes or immunosuppression, as this may predispose to necrotizing otitis externa 1.
• Do not prescribe aminoglycoside ear drops if tympanic membrane perforation is present or suspected, due to ototoxicity risk 1.
• Never dismiss a 3-week cough as viral without evaluating for chronic sinusitis, as bacterial sinusitis requires antibiotic therapy 1.

Reassessment and Follow-Up

• Reassess ear discharge at 48-72 hours: if symptoms worsen or fail to improve, obtain culture via tympanocentesis and switch to culture-directed systemic antibiotics 1, 6.
• Reassess cough after 1 week of treatment: if no improvement, obtain sinus imaging and consider referral to ENT for possible endoscopic evaluation 1.
• Monitor for complications: facial nerve paralysis (necrotizing otitis externa), hearing loss (chronic otitis media), or intracranial extension (meningitis, abscess) 1.