Telemedicine changed how patients reach care. It connects people quickly, saves the drive, and handles a wide range of problems well. It also has limits, and two of them show up constantly: sore throats and ear pain.

Seeing a patient virtually costs me the physical exam. With strep, looking directly at the tonsils and the back of the throat is how I separate viral pharyngitis from bacterial infection. With ear pain, I can’t see the eardrum or check for fluid behind it. Small details. They’re also the ones that decide the diagnosis.

Palpation is the other thing I lose. In clinic, I’d press along the neck for lymph node swelling, and in front of and behind the ear for tenderness. On video I can only ask the patient to describe what they feel. Sometimes they will press the area themselves and report back, which helps, and it’s not the same as an examiner’s hands.

The differential for sore throat is wide. Viral infections dominate and usually arrive with cough and congestion. Group A strep climbs the list with fever, swollen tonsils, or white patches, and no cough. Mono belongs in the picture when there is heavy fatigue and node swelling. As of 2023, COVID-19 stayed on the list whenever fever came with loss of smell. Peritonsillar abscess is uncommon and worth real attention: severe pain, trouble swallowing, a muffled voice. And not every sore throat is an infection at all. TMJ dysfunction refers pain to the throat often enough to catch people out.

Ear pain has its own list. Otitis media brings pain and sometimes fever, usually trailing a cold. Otitis externa hurts when the outer ear is touched, and there’s often a swimming history behind it. Wax occlusion produces fullness. Eustachian tube dysfunction gives pressure and muffled hearing rather than a sharp ache. Mastoiditis is rare and serious, with severe pain, swelling behind the ear, and fever. TMJ turns up here too.

Separating otitis media from otitis externa without seeing the ear is genuinely hard. Patients hand me useful clues, and pain on tugging the outer ear points toward otitis externa, but a virtual diagnosis carries far less certainty than I’d like.

Which is why in-person evaluation still matters. When symptoms are severe, persistent, or simply not adding up, an office visit allows a clinician to look directly at the throat or ear, palpate the neck, and run a rapid strep test. That’s what produces an accurate call, whether the answer turns out to be antibiotics, symptom control, or reassurance.

None of this makes telemedicine less useful. Patients who describe their symptoms carefully give me a real chance at guiding early care, and for mild or clearly viral illness a virtual visit saves an unnecessary trip. The boundaries just need saying out loud. Some problems require hands and an otoscope.

Scott Rennie, D.O.

Sources

• Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):1279-1282.
• Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: otitis media with effusion. Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1-S41.
• Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1-S24.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.