What is the best treatment approach for a patient with ear fullness and sinusitis?

Treatment of Ear Fullness with Sinusitis

For patients with ear fullness and sinusitis, initiate antibiotic therapy combined with intranasal corticosteroids, as ear fullness typically represents Eustachian tube dysfunction secondary to sinus inflammation and will resolve with appropriate sinusitis treatment. 1

Understanding the Connection

Ear fullness in sinusitis patients reflects Eustachian tube dysfunction caused by middle ear effusion and associated inflammation. 1 This symptom is extremely common—affecting approximately 61% of chronic rhinosinusitis patients compared to only 18% of controls—and responds well to sinusitis treatment. 2

Initial Antibiotic Selection

For patients without recent antibiotic exposure (past 4-6 weeks):

• First-line: Amoxicillin 1.5-4 g/day for 10-14 days (or until symptom-free for 7 days) 1
• Alternative options: Amoxicillin-clavulanate 1.75-4 g/250 mg per day, cefpodoxime proxetil, cefuroxime axetil, or cefdinir 1

For patients with recent antibiotic use or moderate disease:

• Preferred: High-dose amoxicillin-clavulanate (4 g/250 mg per day) or respiratory fluoroquinolones (levofloxacin, moxifloxacin, gatifloxacin) 1
• These achieve 90-92% predicted clinical efficacy compared to 83-88% for standard-dose regimens 1

Essential Adjunctive Therapy

Add intranasal corticosteroids to all patients regardless of antibiotic choice. 1, 3 Fluticasone propionate nasal spray or equivalent corticosteroids improve outcomes by reducing mucosal edema that contributes to both sinus ostial obstruction and Eustachian tube dysfunction. 1, 3 Maximum benefit typically requires several days of treatment. 3

Treatment Monitoring Algorithm

Day 3-5 assessment: 1

• If improving: Continue current antibiotic until symptom-free for 7 days (typically 10-14 day total course) 1
• If no improvement: Switch to broader-spectrum antibiotic (high-dose amoxicillin-clavulanate, cefuroxime, or respiratory fluoroquinolone) 1

Day 21-28 assessment: 1

• If persistent symptoms: Consider pathogens not covered by prior antibiotics, nasal polyps, or non-compliance 1
• Escalate to broader-spectrum agents with or without anaerobic coverage (add clindamycin or metronidazole) 1

When Ear Fullness Persists

If ear fullness does not resolve with appropriate sinusitis treatment, this may indicate: 1, 2

• Chronic otitis media requiring separate evaluation 1
• Structural Eustachian tube dysfunction that will not respond to medical therapy alone 2
• Underlying conditions requiring specialist consultation 1

Referral Indications

Consult allergist-immunologist when: 1

• Recurrent sinusitis (≥3 episodes/year) 1
• Concurrent chronic otitis media 1
• Suspected immunodeficiency or allergic rhinitis 1

Consult otolaryngologist when: 1

• Failure to improve after 21-28 days of appropriate therapy 1
• Suspected structural abnormalities or nasal polyps 1
• Consideration for functional endoscopic sinus surgery 1

Critical Pitfalls to Avoid

Do not obtain imaging for uncomplicated acute sinusitis. 1 Plain radiographs have significant false-positive and false-negative results and are not necessary for diagnosis. 1

Do not assume ear fullness requires separate otologic intervention initially. 1, 2 In most cases, this symptom resolves with sinusitis treatment and decreases to levels comparable with non-sinusitis populations following endoscopic sinus surgery when medical therapy fails. 2

Do not use antibiotics for less than 10 days. 1 Inadequate treatment duration leads to relapse and incomplete organism eradication. 1

Do not overlook comfort measures: Adequate hydration, warm facial packs, sleeping with head elevated, and avoidance of cigarette smoke support recovery. 1