What is the diagnosis and treatment for a patient presenting with a 1-week cough producing greenish-brown sputum and a red tympanic membrane?

Dual Diagnosis: Acute Bronchitis with Concurrent Acute Otitis Media

This patient has two distinct conditions requiring separate management: acute bronchitis (explaining the productive cough with greenish-brown sputum) and acute otitis media (explaining the red tympanic membrane), with the bronchitis requiring symptomatic treatment only while the otitis media may warrant antibiotics depending on severity and patient age.

Understanding the Clinical Picture

The Cough and Sputum Component

• A 1-week cough with greenish-brown sputum in an otherwise healthy patient represents acute bronchitis, which is predominantly viral in origin 1
• The sputum color does not indicate bacterial infection requiring antibiotics—yellowish or greenish sputum has poor specificity (only 0.46) for bacterial infection and should not drive antibiotic prescribing 2
• Acute bronchitis is self-limited, with most cases resolving within 3 weeks without antibiotics 1
• The most critical pitfall: Approximately one-third of patients diagnosed with "acute bronchitis" actually have unrecognized asthma, so consider this if the patient has had similar episodes in the past 5 years 1

The Red Tympanic Membrane Component

• A red tympanic membrane alone is insufficient for diagnosing acute otitis media (AOM) 1
• Isolated redness of the tympanic membrane with normal landmarks is NOT an indication for antibiotic therapy 1
• True AOM requires three elements: (1) acute onset of symptoms, (2) middle ear effusion (bulging tympanic membrane, limited mobility, air-fluid level, or otorrhea), and (3) signs of middle ear inflammation 1
• The red tympanic membrane could represent early AOM, otitis media with effusion, or simply hyperemia from upper respiratory infection 1, 3

Diagnostic Approach

What You Must Assess Immediately

• Perform pneumatic otoscopy to assess tympanic membrane mobility—this is the gold standard for diagnosing middle ear effusion 1
• Look specifically for tympanic membrane bulging, which is the most consistent sign of AOM and predicts bacterial pathogens 1
• Assess for fever, otalgia (or ear tugging in young children), and irritability 1
• Rule out pneumonia by checking for focal lung findings, tachypnea (≥24 breaths/min), tachycardia (≥100 bpm), or fever ≥38°C 1
• Consider pertussis if the cough is paroxysmal with post-tussive vomiting—this requires immediate nasopharyngeal culture and macrolide antibiotics 4, 5

Age-Specific Considerations

• If patient is under 2 years old with confirmed AOM (bulging tympanic membrane + symptoms): antibiotics are recommended 1
• If patient is over 2 years old with confirmed AOM: observation with reassessment at 48-72 hours is reasonable unless there are marked symptoms (high fever, intense earache) 1

Treatment Algorithm

For the Acute Bronchitis (Cough Component)

Do NOT prescribe antibiotics for the bronchitis—they provide no benefit, contribute to resistance, and cause adverse effects including allergic reactions and C. difficile infection 1, 5, 6

Symptomatic management only:

• Recommend analgesics for discomfort 1
• Reassure that cough typically resolves within 3 weeks 1
• Advise return if cough persists beyond 3 weeks, as other diagnoses must then be considered (postinfectious cough, upper airway cough syndrome, asthma, GERD) 1

For the Red Tympanic Membrane

If pneumatic otoscopy confirms AOM (bulging tympanic membrane + acute symptoms):

• Children under 2 years: Prescribe antibiotics immediately 1

  • First-line: Amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil 1
  • These cover S. pneumoniae, H. influenzae, and M. catarrhalis 1
  • Duration: 8-10 days for children under 2 years, 5 days for older children 1

• Children over 2 years and adults: Consider observation with 48-72 hour reassessment unless marked symptoms present 1

  • If antibiotics needed, use same regimen as above 1

• Address pain management regardless of antibiotic decision—this is a strong recommendation 1

If only isolated redness without bulging or effusion:

• Do NOT prescribe antibiotics 1
• Reassess if symptoms persist beyond 3 days 1
• The redness likely represents hyperemia from the concurrent upper respiratory infection 3, 7

Critical Pitfalls to Avoid

• Never prescribe antibiotics for acute bronchitis based on sputum color alone—this is the most common error in primary care 1, 2
• Never diagnose AOM without confirming middle ear effusion—isolated tympanic membrane redness is not sufficient 1
• Never assume the patient doesn't have asthma—if they've had similar "bronchitis" episodes before, consider a trial of bronchodilators 1
• Never miss pertussis—ask specifically about paroxysmal coughing and post-tussive vomiting, as early macrolide treatment is critical 4, 5

When to Reassess

• 48-72 hours if observation approach chosen for possible AOM 1
• 3 weeks if cough persists, requiring evaluation for other causes 1
• Immediately if patient develops worsening symptoms, high fever, severe otalgia, or signs of complications 1