MKSAP Quiz: 5-day history of rhinitis, nasal congestion, and sneezing
An 84-year-old man is evaluated for a 5-day history of rhinitis, nasal congestion, sneezing, and nonproductive cough. The symptoms began with a sore throat, which resolved after 24 hours. He has mild ear pain when blowing his nose or coughing. He has a history of coronary artery disease and hypertension. Medications are aspirin, metoprolol, and hydrochlorothiazide. Following a physical exam, what is the most appropriate management?
An 84-year-old man is evaluated for a 5-day history of rhinitis, nasal congestion, sneezing, and nonproductive cough. The symptoms began with a sore throat, which resolved after 24 hours. He has mild ear pain when blowing his nose or coughing. He has a history of coronary artery disease and hypertension. Medications are aspirin, metoprolol, and hydrochlorothiazide.
On physical examination, temperature is 36.5 °C (97.7 °F), blood pressure is 130/72 mm Hg, pulse rate is 82/min, and respiration rate is 16/min. He has nasal congestion and has an occasional cough. There is mild clear nasal discharge with no sinus tenderness. The oropharynx is without injection or exudate. There is no lymphadenopathy. External auditory canals are normal. The tympanic membranes are dull bilaterally but without injection. A small left middle ear effusion is noted.
Which of the following is the most appropriate management?
A. Amoxicillin
B. Erythromycin
C. Referral to an otorhinolaryngologist
D. Reassurance and observation
MKSAP Answer and Critique
The correct answer is D: Reassurance and observation. This item is available to MKSAP 16 subscribers as item 114 in the General Internal Medicine section. More information is available online.
This patient presents with signs and symptoms of a viral upper respiratory tract infection (URI). The recent development of ear pain and the findings of a dull tympanic membrane with a small middle ear effusion are compatible with either otitis media or a viral URI without otitis media. Treatment of otitis media in adults has not been well studied. There are no guidelines for antibiotic use in adults separate from those for children. In children older than 2 years without severe illness, outcomes appear to be similar for observation without antibiotics compared with antibiotic treatment. This strategy to reduce use of antimicrobials has not been evaluated in adults, and it is not known if antibiotics are associated with improved short- or long-term outcomes. However, antibiotic use is associated with adverse effects and higher levels of antibiotic resistance that should be considered in conjunction with the lack of evidence regarding benefit. Considering the patient's equivocal diagnosis of otitis media and mild symptoms, it would be reasonable to withhold antibiotic therapy.
If an antibiotic was prescribed, amoxicillin is recommended as first-line therapy in adults. Erythromycin could be used in a penicillin-allergic patient, but there is no evidence that it is more efficacious.
An otorhinolaryngology consultation is not indicated at this time because the patient only has a URI.
Key Point
- Do not routinely prescribe antibiotic therapy for adults with otitis media.