Chapter 68. Common Infections of the Ears, Nose, Neck, and Throat

This chapter is limited to infections of the ears, nose, neck, and throat. Further information can be found in Chapter 69 “Upper Respiratory Emergencies-Stridor and Drooling,” as well as Chapter 151 “Ear, Nose Emergencies,” and Chapter 153 “Neck and Upper Airway Disorders.”

Acute otitis media (AOM) accounts for 13% of all visits to emergency departments in the United States. AOM is an infection of the middle ear space that commonly affects young children because of relative immaturity of the upper respiratory tract, especially the eustachian tube. The most common pathogens in the post-pneumococcal vaccine era are Streptococcus pneumoniae (31%) and nontypeable Haemophilus influenzae (56%).

Clinical Features

Peak age is 6 to 36 months. Symptoms include fever, poor feeding, irritability, vomiting, ear pulling, and earache. Signs include bulging, pus behind the tympanic membrane (Fig. 68-1), an immobile tympanic membrane (TM), loss of visualization of bony landmarks within the middle ear, and bullae on the TM (bullous myringitis). Mastoiditis is the most common suppurative complication of AOM. The primary symptoms of mastoiditis include fever, protrusion of the auricle, and tenderness over the mastoid.

Diagnosis and Differential

Making an accurate diagnosis is the most important first step. The definition of acute otitis media requires three equally important components: (a) acute onset (< 48 hours) of signs and symptoms, (b) middle ear effusion (see Fig. 68-1), and (c) signs and symptoms of middle ear inflammation. A red TM alone does not indicate the presence of an ear infection. Fever and prolonged crying can cause hyperemia of the TM alone. Pneumatic otoscopy can be a helpful diagnostic tool; however, a retracted drum for whatever reason will demonstrate decreased mobility. Other common causes of acute otalgia are a foreign body in the external ear canal or otitis externa.

Emergency Department Care and Disposition

1. Treatment of pain is essential for all children diagnosed with AOM. Topical analgesics such as benzocaine-antipyrene are recommended for routine use, unless there is a known perforation of the TM. Acetaminophen 15 milligrams/kilogram or ibuprofen 10 milligrams/kilogram can be used.

2. Consider the use of a wait-and-see prescription for the treatment of uncomplicated AOM. Parents are given a prescription and told to wait and see for 48 to 72 hours, and if the child is not better or becomes worse, to fill the prescription. Contraindications to the use of a wait-and-see prescription are: age < 6 months, an immunocompromised state, ill-appearance, recent use of antibiotics or the diagnosis of another bacterial infection. If any of these conditions are met, the child should be prescribed an immediate antibiotic.

3. Amoxicillin 40-50 milligrams/kilogram/dose PO given twice daily (or 30 milligrams/kilogram/dose three times daily) times daily remains the first drug of choice for uncomplicated AOM.

4. Second line antibiotics include amoxicillin/clavulanate 40–50 milligrams/ kilogram/dose given twice daily. Cefpodoxime 5 milligrams/kilogram/dose PO twice daily, cefuroxime axetil 15 milligrams/kilogram/dose twice daily, cefdinir 7 milligrams/kilogram/dose PO once or twice daily, and ceftriaxone 50 milligrams/kilogram/dose IM for 3 daily doses are alternatives. For patients allergic to the previously mentioned antibiotics, azithromycin 10 milligrams/kilogram/dose PO on the first day followed by 5 milligrams/kilogram/dose PO for 4 more days can be used.

5. Infants younger than 60 days with AOM are at risk for infection with group B Streptococcus, Staphylococcus aureus, and gram-negative bacilli and should undergo evaluation and treatment for presumed sepsis.

6. In uncomplicated AOM, symptoms resolve within 48 to 72 hours; however, the middle ear effusion may persist as long as 8 to 12 weeks. Routine follow-up is not necessary unless the symptoms persist or worsen.

7. If mastoiditis is suspected, obtain a CT scan of the mastoid. If the diagnosis is confirmed, obtain consultation with an otolaryngologist and start parenteral antibiotics.

Uncomplicated AOM is treated as an outpatient while mastoiditis typically requires inpatient treatment.

Otitis externa (OE) is an inflammatory process involving the auricle, external auditory canal (EAC), and surface of the TM. It is commonly caused by Pseudomonas aeruginosa, Staphylococcus epidermidis, and Staphylococcus aureus, which often coexist.

Clinical Features

Peak seasons for OE are spring and summer, and the peak age is 9 to 19 years. Symptoms include earache, itching, and, less commonly, fever. Signs include erythema, edema of EAC, white exudate on EAC and TM, pain with motion of the tragus or auricle, and periauricular or cervical adenopathy.

Diagnosis and Differential

Diagnosis for OE is based on clinical signs and symptoms. A foreign body within the external canal should be excluded by carefully removing any debris that may be present.

Emergency Department Care and Disposition

1. Cleaning the ear canal with a small tuft of cotton attached to a wire applicator is the first step. Place a wick in the canal if significant edema obstructs the EAC.

2. Treat mild OE with acidifying agents alone, such as 2% acetic acid (VoSol).

3. Consider oral analgesics, such as ibuprofen at 10 milligrams/kilogram/dose every 6 hours.

4. Fluoroquinolone otic drops are now considered the preferred agents over neomycin containing drops. Ciprofloxacin with hydrocortisone, 0.2% and 1% suspension (Cipro HC), 3 drops twice daily or ofloxacin 0.3% solution 10 drops twice daily can be used. Ofloxacin is used when TM rupture is found or suspected.

5. Oral antibiotics are indicated if auricular cellulitis is present.

Follow-up should be advised if improvement does not occur within 48 hours; otherwise routine follow-up is not recommended. Malignant OE is characterized by systemic symptoms and auricular cellulitis. This condition can result in serious complications and requires hospitalization with parenteral antibiotics.

Sinusitis is an inflammation of the paranasal sinuses that may be secondary to infection or allergy and may be acute, subacute, or chronic. Acute bacterial sinusitis is defined as an infection of the paranasal sinuses with complete resolution in < 30 days. The major pathogens in childhood are Streptococcus pneumoniae, Moraxella catarrhalis, and nontypeable Haemophilus influenzae.

Clinical Features

Two major types of sinusitis may be differentiated on clinical grounds: acute severe sinusitis and mild subacute sinusitis. Acute severe sinusitis is associated with elevated temperature, headaches, and localized swelling and tenderness or erythema in the facial area corresponding to the sinuses. Such localized findings are seen most often in older adolescents. Mild subacute sinusitis is manifest in childhood as a protracted upper respiratory infection associated with purulent nasal discharge persisting in excess of 2 weeks. Fever is infrequent. Chronic sinusitis may be confused with allergies or upper respiratory infections.

Diagnosis and Differential

The diagnosis is made on clinical grounds without laboratory or radiographic studies. Transillumination of the maxillary or frontal sinuses is seldom helpful. Nasal congestion lasting 3 to 7 days often accompanies viral upper respiratory infections and should not be diagnosed as acute sinusitis and does not need treatment with antibiotics. Similarly, colored drainage from the nose as a solitary symptom does not suggest a diagnosis of sinusitis and should not be treated with antibiotics. Imaging studies are not needed to confirm a diagnosis of acute bacterial sinusitis in children < 6 years of age with persistent symptoms.

Emergency Department Care and Disposition

Patients with mild symptoms suggestive of a viral infection can be observed for 7 to 10 days, with no antibiotics prescribed. Suspect acute bacterial sinusitis if symptoms persist or are severe: fever > 39°C, purulent nasal drainage for > 3 days and ill-appearance.

1. For children with mild to moderate sinusitis, treat with amoxicillin (40–50 milligrams/kilogram/dose PO twice daily) for 10 to 14 days.

2. For children who present with severe symptoms, are in day care or have recently been treated with antibiotics, prescribe oral second- and third-generation cephalosporins such as cefprozil (7.5 to 15 milligrams/kilogram PO twice a day), cefuroxime (15 milligrams/kilogram PO twice a day), and cefpodoxime (5 milligrams/kilogram PO twice a day).

3. Intranasal steroids have shown modest benefits and are recommended if antibiotics do not result in improvement in the first 3 to 4 days of treatment.

Herpangina, hand, foot, and mouth disease (HFM), and herpes simplex gingivostomatitis are the primary infections that cause stomatitis in children and are all viral. The vast majority of pharyngitis is caused by viral infections, however, Group A β-hemolytic Streptococcus (GABHS) and Neisseria gonorrhea are bacterial infections that require accurate diagnoses. The identification and treatment of GABHS pharyngitis is important to prevent the suppurative complications and the sequelae of acute rheumatic fever.

Clinical Features

Herpangina causes a vesicular enanthem of the tonsils and soft palate, affecting children 6 months to 10 years of age during late summer and early fall. The vesicles are painful and can be associated with fever and dysphagia. HFM disease usually begins as macules which progress to vesicles of the palate, buccal mucosa, gingiva, and tongue. Similar lesions may present on the palms of hands, soles of feet, and buttocks. Herpes simplex gingivostomatitis often presents with abrupt onset of fever, irritability, and decreased oral intake with edematous and friable gingiva. Vesicular lesions often with ulcerations are seen in the anterior oral cavity.

Peak seasons for GABHS are late winter or early spring, the peak age is 5 to 15 years, and it is rare before the age of 2. Symptoms (sudden onset) include sore throat, fever, headache, abdominal pain, enlarged anterior cervical nodes, palatal petechiae, and hypertrophy of the tonsils. With GABHS there is usually the absence of cough, coryza, laryngitis, stridor, conjunctivitis, and diarrhea. A scarlatinaform rash associated with pharyngitis almost always indicates GABHS and is commonly referred to as scarlet fever.

Ebstein Barr Virus (EBV) is a herpes virus and often presents much like streptococcal pharyngitis. Common symptoms are fever, sore throat, and malaise. Cervical adenopathy may be prominent and often is posterior and anterior. Hepatosplenomegaly may be present. EBV should be suspected in the child with pharyngitis nonresponsive to antibiotics in the presence of a negative throat culture.

Gonococcal pharyngitis in children and nonsexually active adolescents should alert one to the possibility of sexual abuse. Gonococcal pharyngitis may be associated with infection elsewhere including proctitis, vaginitis, urethritis, or arthritis.

Diagnosis and Differential

The diagnoses of herpangina, HFM disease and herpes simplex gingivostomatitis are based on clinical findings. To diagnose GABHS, current guidelines recommend the use of Centor criteria to determine which patients require testing: (a) tonsillar exudates, (b) tender anterior cervical lymphadenopathy, (c) absence of cough, (d) history of fever. With 2 or more criteria, testing should be performed with a rapid antigen detection test and/or culture. If the rapid antigen test is negative, a confirmatory throat culture is recommended.

Diagnosis of EBV is often clinical. A heterophile antibody (monospot) can aid in the diagnosis. The monospot may be insensitive in children < 2 years of age and is often negative in the first week of illness. If obtained, the white blood cell count may show a lymphocytosis with a preponderance of atypical lymphocytes. Diagnosis of gonococcal pharyngitis is made by culture on Thayer-Martin medium. Vaginal, cervical, urethral, and rectal cultures also should be obtained if gonococcal pharyngitis is suspected.

Emergency Department Care and Disposition

1. Treatment of herpangina, HFM disease and herpes simplex gingivostomatitis is primarily supportive. Systemic analgesics such as a combination of ibuprofen and tylenol should be considered. Parenteral hydration may be necessary if the child cannot tolerate oral fluids. Occasionally oral narcotics may be required.

2. Antibiotics for the treatment of GABHS pharyngitis should be reserved for patients with a positive rapid antigen test or culture. Antibiotic choices for GABHS include penicillin V (children 250 milligrams PO twice daily, adolescent/adult 500 milligrams PO twice daily); benzathine penicillin G 1.2 million units IM (600,000 units IM for patients weighing less than 27 kg); and erythromycin ethylsuccinate 10 to 20 milligrams/kilogram/dose PO given twice daily for 10 days. Antipyretics and analgesics should be routinely prescribed until symptoms resolve.

3. Treat gonococcal pharyngitis with ceftriaxone 250 milligrams IM. When gonococcal pharyngitis is suspected, empiric treatment of chlamydia is recommended with azithromycin 1 gram PO given in the emergency department. Appropriate follow-up should be encouraged for treatment failure and symptomatic contacts. Follow-up for suspected gonococcal pharyngitis should include local reporting agencies and social service investigations.

4. EBV is usually self-limited and requires only supportive treatment including antipyretics, fluids, and rest. A dose of dexamethasone 0.5 milligrams/kilogram PO to a maximum of 10 milligrams once may be given for more severe disease presentations.

Acute, unilateral cervical lymphadenitis is commonly caused by Staphylococcus aureus or Streptococcus pyogenes. Bilateral cervical lymphadenitis is often caused by viral entities such as EBV and adenovirus. Chronic cervical lymphadenitis is less common but may be caused by Bartonella henselae (also called occuloglandular fever) or Mycobacterium species.

Clinical Features

Acute cervical lymphadenitis presents with tender, 2 to 6 cm nodes often with overlying erythema. Bilateral cervical lymphadenitis presents with small, rubbery lymph nodes and usually self-resolves. Bartonella results from the scratch of a kitten with ipsilateral cervical lymphadenitis and often concurrent conjunctivitis.

Diagnosis and Differential

Most cases are diagnosed clinically, although culture may guide effective antimicrobial treatment. Differential may also include sialoadenitis (infection of the salivary glands), which is usually caused by Staphyloccocus aureus or Streptococcus pyogenes, as well as gram-negative and anaerobic bacteria.

Emergency Department Care and Disposition

1. Either amoxicillin plus clavulanic acid, 30 to 40 milligrams/kilogram/dose given twice daily or clindamycin 10 to 15 milligrams/kilogram/dose given three times daily are recommended first line antibiotics for the treatment of acute cervical lymphadenitis.

2. The presence of a fluctuant mass may require incision and drainage in addition to antimicrobial therapy.

Most cases of acute bilateral cervical lymphadenitis resolve without antibiotics, as they often represent viral infection or reactive enlargement. Chronic cases of lymphadenitis are often treated surgically, with directed antimicrobial therapy in some cases depending on clinical diagnosis.