Otitis Media Otitis media remains primarily a disease of children, but may affect adults, often secondary to a concurrent viral infection of the upper respiratory tract. Diagnosis in most cases reveals ﬂuid behind the tympanic membrane. Treatment is directed to symptoms and involves the use of antihistamines and decongestants, despite few data to support their use. Acute otitis media is usually a bacterial infection; Streptococcus pneumoniae and Hemophilus inﬂuenza are the most common pathogens. Symptoms include acute purulent otorrhea, fever, hearing loss, and leukocytosis. Physical examination of the ear reveals a red, bulging, or perforated membrane. Indicated treatment is broad-spectrum antibiotics such as amoxicillin/clavulanic acid, cefuroxime axetil, and trimethoprim-sulfamethoxazole.
Bronchitis Acute bronchitis is an inﬂammatory condition of the tracheobronchial tree. Most often it is viral in origin and occurs in winter. Common cold viruses (rhinovirus and coronavirus), adenovirus, inﬂuenza virus, and Mycoplasma pneumoniae (a nonviral pathogen) are the most common pathogens involved. Bacterial infections occur less commonly and may be secondary pathogens. Cough, hoarseness, and fever are the usual presenting symptoms. In the initial 3 to 4 days, the symptoms of rhinitis and sore throat are prominent; coughing may last as long as 3 weeks. The prolonged nature of these infections promotes the use of antibiotics to “clear up the infection” (8). Sputum production commonly occurs and may be prolonged in cigarette smokers. Most serious bacterial infections occur in cigarette smokers, who have damage to the lining of the upper respiratory tree and changes in the host ﬂora.
Physical examination discloses a variety of upper airway sounds, usually coarse rhonchi. Rales are usually not present on auscultation, and signs of consolidation and alveolar involvement are absent. During auscultation of the chest, signs of pneumonia such as fine rales, decreased breath sounds, and euphonia (“E to A changes”) should be sought. If the results of the physical examination are uncertain or the patient’s condition appears to be in respiratory distress chest radiography should be performed to detect the presence of parenchymal disease. Paradoxically, as the initial acute syndrome subsides, sputum production may become more purulent. Sputum cultures are of limited value because of the polymicrobial nature of infections. In the absence of complications, treatment is directed to relief of symptoms. The use of antibiotics is reserved for patients in whom chest radiography findings are consistent with pneumonia. Cough is usually the most aggravating symptom and may be treated with antitussive preparations containing either dextromethorphan or codeine. The efficacy of any expectorant is not proved.
Chronic bronchitis is defined as a productive cough from excessive secretions for at least 3 months in a year for 2 consecutive years. Prevalence is estimated to be between 10% and 25% of the adult population who are smokers. Previously the incidence was lower in women than men, but as the prevalence of cigarette smoking in women increased, so too has the incidence of bronchitis in women. Chronic bronchitis is classified as a form of chronic obstructive pulmonary disease (COPD; e.g., “blue bloaters”). Other causes include chronic infections and environmental pathogens found in dust. The cardinal manifestation of disease is an incessant cough, usually in the morning, with expectoration of sputum. Because of frequent exacerbations, the hospitalizations involved and the complexity of medical management, these patients should be referred to an internist.