Adult patient recently returned from travel, positive for streptococcal infection, on amoxicillin‑clavulanate for two days, now has right ear pain and a sensation of fullness; what are the likely diagnoses, recommended treatments, and appropriate diagnostic work‑up?

Management of Right Ear Pain and Fullness in Adult with Streptococcal Pharyngitis on Augmentin

Most Likely Diagnosis and Immediate Action

This patient most likely has acute otitis media (AOM) as a complication of streptococcal pharyngitis, and should continue the current Augmentin therapy while undergoing otoscopic examination to confirm the diagnosis. 1

The combination of confirmed streptococcal infection, ear pain, and sensation of fullness after only 2 days of antibiotic therapy suggests either:

• Acute otitis media (bacterial extension to the middle ear)
• Eustachian tube dysfunction secondary to pharyngeal inflammation
• Early treatment failure requiring reassessment

Diagnostic Work-Up

Essential Physical Examination

• Perform pneumatic otoscopy to assess tympanic membrane mobility, color, and presence of middle ear effusion—the gold standard for diagnosing AOM 1
• Examine for bulging, erythematous, or opaque tympanic membrane with decreased mobility, which confirms AOM 1
• Assess the oropharynx for tonsillar exudates, pharyngeal erythema, and cervical lymphadenopathy to gauge response to current therapy 1
• Palpate for tender anterior cervical adenopathy and evaluate for peritonsillar fullness or asymmetry to rule out abscess formation 2

Laboratory and Imaging Studies

• No additional microbiologic testing is needed if the original strep test was positive and the patient is on appropriate therapy 1
• Tympanocentesis is NOT indicated at this early stage unless there is treatment failure after completing the antibiotic course or severe, refractory symptoms 3
• Imaging (CT scan) should be reserved for patients with suspected suppurative complications such as mastoiditis, peritonsillar abscess, or intracranial extension 1

Treatment Approach

Continue Current Antibiotic Therapy

Augmentin (amoxicillin-clavulanate) is the appropriate choice for this clinical scenario and should be continued for the full course. 1, 4

• Amoxicillin-clavulanate provides coverage for both Group A Streptococcus (the confirmed pharyngeal pathogen) and the typical AOM pathogens including beta-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis 4, 5
• The standard adult dose is 875 mg twice daily or high-dose formulation (2000 mg twice daily) if drug-resistant Streptococcus pneumoniae is suspected based on local resistance patterns 1
• Complete a 10-day course for the streptococcal pharyngitis, which will simultaneously treat any concurrent AOM 1, 6

Rationale for Continuing Augmentin Rather Than Switching

• Two days is too early to declare treatment failure—antibiotics typically require 48-72 hours to show clinical improvement 1, 2
• Augmentin has superior coverage compared to penicillin alone for potential AOM pathogens, particularly beta-lactamase producers 4, 5
• Switching antibiotics prematurely increases the risk of resistance and is not indicated unless there is documented treatment failure after 72 hours 1

Symptomatic Management

• Prescribe analgesics immediately: acetaminophen 650-1000 mg every 6 hours or ibuprofen 400-600 mg every 6-8 hours for ear pain and fever 1, 2
• Consider topical anesthetic ear drops (benzocaine-antipyrine) for severe otalgia, though these provide only temporary relief 3
• Avoid corticosteroids as adjunctive therapy for pharyngitis, as they are not routinely recommended 1, 2

When to Reassess or Change Management

Indications for Clinical Reevaluation (48-72 Hours)

• Worsening symptoms including increased ear pain, fever >39°C, or development of new symptoms 1, 2
• No improvement in ear pain or pharyngeal symptoms after 72 hours of appropriate antibiotic therapy 1, 2
• Development of red-flag symptoms: difficulty swallowing, drooling, neck swelling, severe unilateral throat pain, or trismus suggesting peritonsillar abscess 2

Second-Line Treatment Options (If Treatment Failure Occurs)

• Intramuscular ceftriaxone 1-2 g daily for 1-3 doses if oral therapy fails or compliance is questionable 1, 3
• Respiratory fluoroquinolone (levofloxacin 750 mg daily or moxifloxacin 400 mg daily) for 5-7 days if beta-lactam allergy develops or documented resistance 1
• Tympanocentesis with culture should be considered if AOM persists despite two courses of appropriate antibiotics to guide targeted therapy 3

Critical Pitfalls to Avoid

• Do not discontinue antibiotics prematurely based on 2 days of therapy—this is insufficient time to assess treatment response and risks creating resistant organisms 1, 6
• Do not prescribe azithromycin or other macrolides as they have inferior efficacy for both streptococcal pharyngitis and AOM compared to beta-lactams, with resistance rates approaching 30-40% for S. pneumoniae 1, 2
• Do not assume viral etiology for the ear symptoms given the confirmed bacterial pharyngitis—bacterial extension to the middle ear is common 1
• Do not overlook suppurative complications: peritonsillar abscess, retropharyngeal abscess, or mastoiditis can present with ear pain and require urgent intervention 2
• Do not perform routine post-treatment cultures in asymptomatic patients, as this identifies carriers rather than treatment failures 1, 2

Special Consideration: Recent Travel

• Evaluate for emerging respiratory pathogens if the patient traveled to areas with endemic influenza subtypes (H1N1, H5N1) or other respiratory infections, though streptococcal pharyngitis remains the confirmed diagnosis 1
• Consider tuberculosis or atypical pathogens only if symptoms persist beyond expected treatment course or if travel was to high-prevalence areas with prolonged exposure 1