Ear, Nose, and Throat Conditions

In this section, we review the management of various ear, nose, and throat (ENT) issues seen in the urgent care setting.

• Otitis Externa

• Croup

• Mononucleosis

• Group A Streptococcal Pharyngitis

• Oral Ulcers: Aphthous Stomatitis, Herpangina, and Viral Stomatitis

Other topics pertinent to this section are included in the following rotation guides:

• Acute Otitis Media, Upper Respiratory Tract Infections (Pediatric Infectious Diseases)

• Rhinitis, Sinusitis, and Conjunctivitis (Pediatric Allergy and Immunology)

• Retropharyngeal Abscess, Peritonsillar Abscess (Pediatric Emergency Medicine)

• Acute Injuries, Foreign Body Removal (Pediatric Urgent Care)

Otitis Externa

Otitis externa (colloquially known as “swimmer’s ear”) refers to inflammation of the external auditory canal. It often presents in the summer after swimming, especially in water with high bacteria levels, although a history of swimming is not necessary for the diagnosis. The most common causative organisms are Pseudomonas aeruginosa and Staphylococcus aureus.

(Source: Otitis Externa. Getty Images. Accessed October 30, 2022.)

Risk factors include aggressive ear cleaning, placing foreign objects in the ear, using earbuds or hearing devices, or skin irritation.

Symptoms usually develop within 48 hours of water exposure, with pain, pruritus, a sense of fullness, and sometimes clear drainage. On examination, pain can be elicited with manipulation of the pinna or tragus and findings include varying degrees of erythema, swelling, and debris in the ear canal. Patients may also have fever or lymphadenopathy. Otitis externa is diagnosed clinically.

Differential diagnosis: The following concerning symptoms on exam should prompt further evaluation:

• proptosis of the ear (raises suspicion for mastoiditis)

• signs of trauma (clear fluid in ear canal can represent cerebrospinal fluid leak)

• purulent drainage (also associated with acute otitis media with perforation)

Management: Topical antibiotics are the preferred treatment and can be combined with topical glucocorticoids (e.g., ciprofloxacin-hydrocortisone drops or polymyxin B-neomycin-hydrocortisone drops). An ear wick can aid in treatment when severe swelling is present. Culture is not necessary in most cases. Acetic acid may be used topically to restrict bacterial and fungal growth. This method, however, should not be used when the tympanic membrane is perforated.

Croup

Croup (also known as laryngotracheobronchitis) is an upper respiratory viral infection most commonly seen in children between ages 3 months and 3 years, typically in the late fall to early winter months. The most common causative organism is parainfluenza, but it can also be due to other respiratory viruses, such as influenza and respiratory syncytial virus (RSV). SARS-CoV-2 has also been associated with croup. In the prevaccination era, measles was a significant cause of croup. Unimmunized children should be closely monitored for severe croup if there is concern for measles.

Symptoms: Children with croup typically present with a few days of cough, congestion, and subsequent worsening of respiratory symptoms due to inflammation of the upper airway. Some patients may have a hoarse or raspy voice or a barky cough. Symptoms are classically worse at night. Croup is easily discernible from other upper respiratory tract infections because of the presence of inspiratory stridor and the distinctive barky cough. Unlike bronchiolitis, patients with croup generally only have mild-to-moderate tachypnea. In severe cases, swelling in the upper airway can result in respiratory distress and airway obstruction.

Differential diagnosis: Although patients with croup may have respiratory distress, they do not typically present with drooling or toxic appearance. An alternative diagnosis should be considered in patients with these symptoms. Radiographs are not necessary to make the diagnosis, but soft-tissue neck films may show the classic steeple sign and can help in the evaluation for other conditions in the differential diagnosis, including epiglottitis, bacterial tracheitis, retropharyngeal abscess, and foreign body aspiration (see the Pediatric Emergency Medicine rotation guide).

(Source: Steeple Sign of Croup. N Engl J Med 2012.)

Management: Treatment for croup is dependent on the severity. The Westley Croup Score (see also MDCalc) is used to classify croup as mild, moderate, or severe (impending respiratory failure). Mild croup may be treated with a single dose of oral dexamethasone. Nebulized epinephrine or racemic epinephrine, which vasoconstricts the mucosa and reduces subglottic edema, is added in cases of moderate-to-severe croup when patients exhibit stridor at rest. Patients should be observed for rebound stridor post-nebulized epinephrine treatment. Those who show persistent symptoms of stridor or respiratory distress despite treatment with racemic epinephrine should be considered for admission.

(Source: Emergency Department and Inpatient Clinical Pathway for Evaluation/Treatment of Children with Croup. Copyright 2023 by Children’s Hospital of Philadelphia, all rights reserved.)

Mononucleosis

Mononucleosis (mono) is a clinical syndrome most commonly caused by Epstein-Barr virus (EBV) but also by cytomegalovirus (CMV).

Symptoms: Patients present with fever, pharyngitis (often with petechiae or exudates), fatigue, and lymphadenopathy. Hepatosplenomegaly may occur as well. Complications of mononucleosis include aseptic meningitis, encephalitis, transverse myelitis, or Guillain-Barré syndrome. Other conditions that should be considered include streptococcal pharyngitis, viral pharyngitis, toxoplasmosis, and acute HIV infection.

Diagnosis: Some cases of mononucleosis may be diagnosed after initiation of antibiotics, because patients with EBV treated with amoxicillin can develop an eruptive rash (see image below). The heterophile antibody test (monospot test) is associated with high false-negative rates in children younger than 4 years and in the early stages of infection for all ages. Typically, a complete blood count shows an increase in atypical lymphocytes. Viral studies are helpful when the heterophile antibody test is negative and monocleosis is suspected. Serologic antibodies for viral capsid antigen (VCA), early antigen (EA), and Epstein-Barr nuclear antigen (EBNA) are useful for both diagnosis and to measure the progression of illness.

(Source: Amoxicillin Rash in Infectious Mononucleosis. N Engl J Med 2021.)

Management: Treatment for mononucleosis is primarily supportive with close follow-up. However, due to the risk of splenic rupture during the first month of illness, patients should be observed and excused from contact sports and strenuous activity for 3-4 weeks. After this observation time, limited noncontact aerobic activities are allowed in asymptomatic patients who have no splenomegaly. Clearance to resume all activity, including contact sports, is determined on a case-by-case basis, generally after 4-6 weeks, if patients continue to be asymptomatic and without splenomegaly. Glucocorticoids are controversial but may be recommended in patients with significant tonsillar inflammation, airway obstruction, or massive splenomegaly.

Group A Streptococcal Pharyngitis

Symptoms of group A streptococcal (GAS) pharyngitis include:

• sore throat

• fever

• tonsillar exudate

• palatal petechiae

• tender cervical adenopathy

• strawberry tongue

• scarlatiniform rash (erythematous, sandpaper-like rash that spares palms/soles)

• peeling of extremities (typically present as scarlatiniform rash is healing)

Suppurative complications include:

• acute pharyngitis (may also be associated with a strawberry tongue, palatal petechiae, or both)

• otitis media

• sinusitis

• skin infections: cellulitis, impetigo, erysipelas, or abscess

• peritonsillar or retropharyngeal abscess

• cervical adenitis

Nonsuppurative complications may also occur after GAS infection. Nonsuppurative complications of GAS include:

• rheumatic fever

• poststreptococcal glomerulonephritis

• toxic shock syndrome

• neuropsychiatric complications

  • obsessive-compulsive behavior

  • tics

  • pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)

(Source: Strawberry Tongue. N Engl J Med 2021.)

(Source: Scarlet Fever. N Engl J Med 2017.)

Diagnosis: Testing for GAS pharyngitis most commonly involves a throat swab for a rapid antigen detection test (RADT) and confirmatory throat culture (if rapid antigen is negative). Newly approved isothermal nucleic acid amplification tests (NAATs) may be as sensitive as a throat culture. Although home testing is FDA approved, it is not recommended because of the rate of false negatives (due to variable sensitivity) and false positives (due to colonization). The Centor criteria are used in adult populations to determine who should be tested or treated for GAS pharyngitis. However, these criteria have not been shown to be effective in the pediatric population.

• Who should be tested?

  • Children with acute onset of symptoms consistent with GAS pharyngitis

  • Children without viral symptoms

  • Children with an ill contact with GAS

• Who should not be tested?

  • Children with viral symptoms (e.g., cough, coryza, conjunctivitis, hoarseness, discrete oral ulcerative lesions)

  • Children younger than 3 years should not be tested because acute rheumatic fever is rare in this group. Testing can be considered in select children younger than 3 years (e.g., those who have a sibling with GAS).

  • Children with asymptomatic household contacts (unless at increased risk of sequelae)

Management: Most cases of GAS pharyngitis will resolve without antibiotics. Antibiotics are effective in reducing acute morbidity, suppurative and nonsuppurative complications, and transmission to others. However, antibiotics will not prevent the development of acute poststreptococcal glomerulonephritis. Patients should be treated with antibiotics only if they test positive for GAS with a rapid test or throat culture. Resistance to penicillins or cephalosporins has never been reported for Streptococcus pyogenes; therefore, susceptibility testing is only required when treating with non-beta-lactam antibiotics.

Patients may return to school or day care 24 hours after starting the antibiotic as they are no longer considered infectious.

Children with pharyngitis can also develop a peritonsillar abscess or retropharyngeal abscess. These children will present with drooling, trismus, or both. In these situations, it is imperative to maintain the airway and ensure the child is transferred to the emergency department for further evaluation.

Oral Ulcers: Aphthous Stomatitis, Herpangina, and Viral Stomatitis

Oral ulcers, particularly when associated with decreased intake or fever, are commonly seen in pediatric urgent care. For all three ulcer types, treatment is supportive with pain control and hydration.

(Source: Acute Pharyngitis. N Engl J Med 2001.)