ENT Conditions in OPD: Ear Pain, Sinusitis, and Throat Infections — Clinical Guide for Indian Doctors

ENT complaints account for nearly one-third of all OPD visits in India. Most are straightforward infections — but some presentations (sudden hearing loss, peritonsillar abscess, foreign body in ear canal) are time-sensitive emergencies. This guide covers the high-frequency ENT conditions every clinic doctor manages daily.

Ear Pain (Otalgia): Differential Diagnosis

Most ear pain in adults is referred from non-ear structures. Ask: is there discharge, hearing loss, or fever? If not, consider referred causes first:

• Temporomandibular joint: Pain worse with chewing, tenderness on TMJ palpation, clicking — very common in Indians
• Dental disease: Upper molar pain refers to ear; examine teeth before ear canal
• Cervical spine: C2–C3 dermatomes include the ear — check neck mobility
• Pharyngeal pathology: Tonsillitis, post-tonsillectomy pain, base of tongue lesions
• Ramsay Hunt syndrome: Herpes zoster of geniculate ganglion — painful vesicles in ear canal/concha + facial palsy. Treat with high-dose aciclovir within 72 hours

Acute Otitis Media: When to Use Antibiotics

Acute otitis media (AOM) is the most common reason for antibiotic prescriptions in children. Indian paediatricians overprescribe significantly. Apply watchful waiting in appropriate cases:

Start antibiotics immediately:

• Child <2 years with bilateral AOM or any AOM with otorrhoea
• Severe illness (temperature >39°C, severe ear pain, toxic appearance)
• AOM in immunocompromised patients

Watchful waiting (observe 48–72 hours):

• Child ≥2 years with unilateral AOM, mild symptoms, no otorrhoea
• Adults with AOM and mild symptoms

When antibiotics are needed: Amoxicillin 90mg/kg/day (high-dose) for 5 days in children, 500mg TDS for 5 days in adults. High-dose amoxicillin overcomes penicillin-resistant S. pneumoniae which is common in India. If penicillin allergy: Azithromycin 10mg/kg/day for 5 days in children.

Otitis Externa: Management

Swimmer's ear — pain worse with tragal pressure and ear canal manipulation. Canal red, oedematous, +/- discharge. Tympanic membrane normal if visible.

Treatment:

• Aural toilet (gentle syringing or dry mopping if canal not too swollen)
• Topical antibiotic + steroid drops: Ciprofloxacin + Dexamethasone ear drops 4 drops TDS for 7 days
• If canal very oedematous: Pope wick to deliver drops
• Analgesia: Ibuprofen 400mg TDS
• Keep ear dry — no swimming, protect while bathing

Necrotising (malignant) otitis externa: Diabetic or immunocompromised patient with severe ear pain + granulation at bony-cartilaginous junction + high ESR = emergency. This is osteomyelitis of skull base. Refer to ENT + CT temporal bone urgently.

Sinusitis: Viral vs Bacterial

90% of acute sinusitis is viral (part of URTI) and resolves without antibiotics in 10–14 days. The challenge is identifying the 10% that are bacterial.

Signs favouring bacterial sinusitis (prescribe antibiotics if ≥2 present):

• Symptoms persisting >10 days without improvement
• High fever (>39°C) with purulent nasal discharge and facial pain
• "Double sickening" — initial improvement then deterioration
• Unilateral maxillary pain + toothache

Antibiotic choice: Amoxicillin-clavulanate 625mg TDS for 5–7 days. If penicillin allergy: Doxycycline 100mg BD. Add nasal saline irrigation (10ml each nostril BD) — reduces symptom duration. Topical steroid spray (Mometasone furoate) helps in recurrent sinusitis.

Chronic sinusitis (>12 weeks of symptoms): Refer ENT. Often requires CT sinuses and endoscopic surgery.

Tonsillitis and Sore Throat

Use the Centor/McIsaac Score to guide antibiotic decisions:

Score ≤1: No antibiotics. Score 2–3: Consider rapid strep test or empiric antibiotics. Score ≥4: Prescribe antibiotics. Choice: Phenoxymethylpenicillin (Pen V) 500mg BD for 10 days, or Amoxicillin 500mg TDS for 10 days. Avoid Amoxicillin if Infectious Mononucleosis is possible (rash risk).

Sudden Hearing Loss: ENT Emergency

Sudden sensorineural hearing loss (SSNHL) — unilateral hearing loss developing over <72 hours with no obvious cause — is an ENT emergency. Time to treatment is critical.

Treat within 24–72 hours for best outcome:

• Oral Prednisolone 1mg/kg/day (max 60mg) for 10–14 days, then taper
• Refer ENT urgently for audiogram and consideration of intratympanic steroids
• MRI brain to exclude acoustic neuroma (vestibular schwannoma)

Do not wait for ENT appointment — start oral steroids in your OPD and expedite referral simultaneously.

Epistaxis in OPD

90% of nosebleeds are anterior (Little's area, Kiesselbach's plexus) and manageable in OPD.

ENT Referral Criteria

Refer to ENT without delay for:

• Sudden unilateral sensorineural hearing loss (within 24 hours)
• Suspected peritonsillar abscess or deep neck space infection
• Facial palsy with ear symptoms (Ramsay Hunt syndrome needs antiviral within 72 hours)
• Foreign body in ear canal — do not attempt removal if not trained, risk of TM perforation
• Epistaxis not controlled after two anterior packing attempts
• Neck mass + throat symptoms (exclude malignancy)
• Unilateral nasal obstruction + epistaxis (exclude nasopharyngeal carcinoma)
• AOM complications: mastoid swelling, facial weakness, meningism

Efficient OPD management means documenting ENT examination findings and referral decisions clearly in the patient record. CliniqFlo's digital prescriptions and referral letters streamline ENT follow-up →