What are the treatment options for a sore throat and ear fullness?

Treatment of Sore Throat and Ear Fullness

Start with ibuprofen or paracetamol (acetaminophen) for symptom relief, as these are the most effective first-line treatments for acute sore throat, and evaluate for potential complications that may be causing the ear fullness. 1, 2

Initial Symptom Management

• Ibuprofen or paracetamol are strongly recommended as first-line analgesics for acute sore throat symptoms, with ibuprofen showing slightly better efficacy for pain relief, particularly after 2 hours of administration. 1, 2

• Both medications are safe for short-term use when used according to directions, with a low risk of adverse effects. 2

• Pain relief should be administered at adequate doses and frequent intervals—consider fixed-interval dosing rather than "as needed" to maintain adequate pain control. 1

Evaluating the Need for Antibiotics

The decision to use antibiotics depends on clinical severity and likelihood of bacterial infection:

For Patients with Low Severity (0-2 Centor Criteria):

• Do NOT use antibiotics for symptom relief in patients with less severe presentations. 1, 2

• Continue symptomatic treatment with ibuprofen or paracetamol only. 1

• Most sore throats (65-85%) are viral and self-limiting within 7 days without antibiotics. 3

For Patients with High Severity (3-4 Centor Criteria):

• Consider discussing the modest benefits of antibiotics with patients, weighing them against side effects, impact on microbiota, antibiotic resistance, medicalization, and costs. 1, 2

• If antibiotics are indicated, prescribe penicillin V twice or three times daily for 10 days as the first-line agent. 1, 2

• Alternatively, amoxicillin can be used for upper respiratory tract infections due to susceptible Streptococcus species (β-lactamase-negative isolates only). 4

• Corticosteroids can be considered in conjunction with antibiotic therapy for adult patients with severe presentations (3-4 Centor criteria), though this is not routinely recommended. 1, 2

Addressing Ear Fullness: Critical Differential Diagnosis

The ear fullness requires specific evaluation to rule out complications or alternative diagnoses:

Referred Otalgia from Pharyngitis:

• Ear fullness or pain without ear canal swelling or middle ear disease suggests referred pain from the throat, which is common with acute pharyngitis. 1

• This typically responds to treatment of the underlying sore throat with analgesics. 1

Acute Otitis Media (AOM):

• Assess for middle ear effusion indicated by bulging tympanic membrane, limited or absent mobility, air-fluid level, or otorrhea. 1

• If AOM is diagnosed, amoxicillin 80-90 mg/kg/day is the first-line antibiotic for most children and adults. 1

• Pain management remains essential—recommend analgesic treatment based on severity. 1

Acute Otitis Externa (AOE):

• Look for tenderness of the tragus or pinna, which is often intense and disproportionate to visual findings. 1

• AOE presents with ear canal inflammation, edema, and pain, often with ear fullness sensation. 1

• Topical antimicrobials are the treatment of choice for AOE—oral antibiotics have limited utility and should not be routinely used. 1

• Adequate pain control with systemic analgesics (ibuprofen or acetaminophen) is essential, as AOE pain can be severe. 1

Temporomandibular Joint (TMJ) Syndrome:

• Consider TMJ dysfunction if there is pain radiating to the periauricular area, temple, or neck, with history of gum chewing, bruxism, or recent dental procedures. 1

• Patients are tender over the affected TMJ and may have associated crepitus on examination. 1

What NOT to Use

• Do NOT use zinc gluconate for sore throat treatment—it is not recommended due to conflicting efficacy results and increased adverse effects. 1, 2

• Do NOT use herbal treatments or acupuncture—there is inconsistent evidence supporting their efficacy. 1, 2

• Do NOT use local antibiotics or antiseptics for sore throat treatment due to the mainly viral origin and lack of efficacy data. 2

• Do NOT routinely use biomarkers (C-reactive protein, procalcitonin) in the assessment of acute sore throat. 1

Red Flags Requiring Urgent Evaluation

• Severe difficulty swallowing or breathing requires immediate evaluation for potential epiglottitis, peritonsillar abscess, or retropharyngeal abscess. 1, 3, 5

• Fever with constitutional symptoms, weight loss, or persistent symptoms despite appropriate treatment warrant further investigation. 6

• Unilateral ear pain with severe sore throat may indicate peritonsillar abscess (quinsy), which requires prompt medical attention and possible drainage. 1, 3

• Painful ear swelling without improvement on antibiotics should prompt consideration of alternative diagnoses such as relapsing polychondritis. 7

Key Clinical Pitfalls to Avoid

• Do NOT prescribe antibiotics to prevent complications such as rheumatic fever, acute glomerulonephritis, acute otitis media, or sinusitis in low-risk patients—the evidence does not support this practice. 1, 3

• Do NOT assume ear fullness is always from middle ear disease—referred otalgia from pharyngitis is common and does not require ear-specific treatment. 1

• Do NOT use rapid antigen tests (RATs) or throat cultures routinely in patients with low likelihood of streptococcal infection (0-2 Centor criteria). 1

• Clinical scoring systems and rapid tests can be helpful in targeting antibiotic use when used appropriately in patients with higher clinical scores. 1