What is the diagnosis for a 13-year-old patient presenting with bilateral otalgia (ear pain) preceded by pharyngitis (sore throat), followed by nasal congestion and ear pressure, with the right ear being more severely affected than the left?

Differential Diagnosis for a 13-year-old with Bilateral Ear Pain

Single most likely diagnosis

• Acute Otitis Media (AOM): This is the most likely diagnosis given the progression from sore throat to ear pain and pressure, which is a common presentation for AOM, especially in children. The fact that one ear is worse than the other also supports this diagnosis, as AOM can be unilateral or bilateral.

Other Likely diagnoses

• Eustachian Tube Dysfunction (ETD): The symptoms of ear pressure and congestion suggest ETD, which can be caused by an upper respiratory infection and lead to middle ear problems.
• Viral Upper Respiratory Infection (URTI): The initial sore throat and subsequent congestion are consistent with a viral URTI, which can cause referred ear pain due to the shared nerve supply.
• Sinusitis: Given the congestion, sinusitis could be a contributing factor to the ear pain, especially if the infection has spread to involve the sinuses.

Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)

• Mastoiditis: Although less common, mastoiditis is a serious complication of AOM that requires prompt recognition and treatment to prevent severe consequences, including intracranial complications.
• Lemierre's Syndrome: This rare but potentially life-threatening condition involves thrombophlebitis of the internal jugular vein following a bacterial pharyngitis, which could initially present with sore throat and later with complications involving the ear or neck.
• Peritonsillar Abscess: While primarily causing throat pain, a peritonsillar abscess could lead to referred ear pain and is a medical emergency due to the risk of airway obstruction.

Rare diagnoses

• Temporal Bone Fracture: Although unlikely without a history of trauma, a temporal bone fracture could cause ear pain and should be considered if there's any relevant history.
• Relapsing Fever or Lyme Disease: In endemic areas, these conditions could present with a variety of symptoms including ear pain, especially if there's a history of tick exposure.
• Granulomatosis with Polyangiitis (formerly Wegener's Granulomatosis): This rare autoimmune disorder can affect the ears, sinuses, and kidneys, and while unlikely, it's an important consideration in a child with persistent or severe symptoms.