Ear, Nose, Throat

Question 1

Identify the indications, contraindications, precautions, and patient preparation involved in removal of a foreign body from the ear

Answer 1

If the cerumen is deeper in the canal or is not cleared with the ceruminolytic agent and/or curette, irrigation with water or normal saline at body temperature using an ear syringe, a device specifically designed for ear irrigation, or a regular syringe with a flexible catheter can be performed.
• If not already used, a ceruminolytic agent may be instilled in the canal for 15 to 20 minutes before the irrigation to soften the cerumen and aid in its removal.
• The auricle should be straightened as much as possible and the irrigant directed upward in the canal to minimize the pressure against the TM.
• The canal should be irrigated until clear unless the patient experiences pain or dizziness.
• If the patient is immunocompromised, a sterile solution should be used

Question 2

Tinnitus

Answer 2

Perception of sound when there is none (buzzing, ringing)
Low pitch may indicate idiopathic cause or Menaire Disease
High pitch is noise exposure or ototoxicity
Pulsing, rumbling = vascular echo

Check for impaction, check for cause, refer for audiogram

Question 3

Tympanic Membrane Perforation

Answer 3

Refer to ENT if hearing loss, vertigo, or other signs occur

Will heal on its own, but protect from infection - avoid swimming or immersion in water

May be caused by trauma, infection, neoplasm = rule out causes that can be treated

Question 4

Meniere Disease

Answer 4

Recurrent vertigo and hearing loss from excess fluid in ear
-vertigo, low frequency tinnitus/loss, ear fullness
Rule out other causes including thyroid and lyme disease
Refer to ENT

Response to steroids may indicate autoimmune cause

Question 5

Acute Otitis Media

Answer 5

Fever, ear pain, hearing loss
TM may be red, inflamed

Watchful waiting, then consider antibiotics (usually PCN or Augmentin)

Question 6

Otitis Media with Effusion

Answer 6

Fever, hearing loss, ear pain
May have infection elsewhere in ENT space (often pharyngitis)
TM are retracted, white pearly appearance due to fluid excess

Antibiotics (PCN usual medication choice) or watchful waiting
Antihistamines, nasal steroids may help

Question 7

Otitis Externa

Answer 7

Severe ear pain or auricle pain (esp when moved)
Feeling of ear fullness, drainage may occur
Canal is red and sloughs, debris may be present

Culture the drainage only if no improvement in 14 days

Treat with NSAIDs for pain, topical antibiotics but not ototoxic drugs, lavage may help

High fever, severe pain, necrotizing appearance is referral to ENT

Question 8

Vestibular Neuritis

Answer 8

Unilateral labrythine dysfucntion
brief vertigo, N/V, loss of peripheral vestibular function
—especially with head movement
Diagnosis by exclusion, may be caused by herpes simpex

Symptomatic treatment, treat suspected infections

Question 9

Identify the indications, contraindications, precautions, and patient preparation involved in tympanometry

Answer 9

Indications
• Determine the degree of mobility of the tympanic membrane.
• Evaluate hearing loss and middle ear function.
• Evaluate the cause of ear pain.
• Make a diagnosis of or monitor recovery in middle ear infections and effusions or tympanic membrane perforations.
• Determine the effectiveness of pressure-equalization tubes in children.
• Evaluate the cause of developmental delays in hearing or speaking in children.
Contraindications
• Children younger than 5 months
• Otitis externa
• Obstruction of the ear canal with cerumen or foreign body

Question 10

Identify the indications, contraindications, precautions, and patient preparation involved in audiometry

Answer 10

indications
• Evaluation of suspected hearing loss
• Complaints of tinnitus or exposure to loud noises
• Evaluation for pathology in children who have speech and language development delays, behavior problems, poor academic progress, and/or difficulties in interpersonal skills
• Unexplained behavior changes in the older adult that are suggestive of dementia.
Contraindications
• Children younger than 6 months (inaccurate readings)
• Active otitis external infection
• Cerumen impaction

Question 11

Allergic Rhinitis

Answer 11

Pruritus of nose, eyes, mouth
Excess tearing, puffiness around eyes, rhinorrhea, pale or bluish nasal turbinates

Steroid nasal spray, 2 sprays each nostril
Beclomethasone dipropionate (Beconase) twice daily OR Fluticasone propionate (Flonase) 4 times daily

Antihistamine daily
Loratadine 10 mg OR Cetirizine 10 mg OR Fexofenadine 180 mg

Antihistamine nasal sprays each nostril bid
a) Azelastine OR Azelastine/fluticasone OR Montelukast (Singulair)

Question 12

Acute Bacterial Rhinosinusitis

Answer 12

mucopurulent discharge, nasal obstruction, and facial pain or pressure

Antibiotics for 5-7 days
-Amoxicillin or Augment first choice, Doxycycline or Cephalosporin next

If complicated infection (no improvement in 7 days)
-Increase antibiotics to 10 days
-Switch to Augmentin or Levofloxacin or Doxycycline

Question 13

Chronic Rhinosinusitis

Answer 13

Nasal steroids are best treatment
Humidifier
Antihistamines
Antibiotics as needed

Question 14

Pharyngitis

Answer 14

Usually Viral
If bacteria suspected, Amoxicillin is first choice
If tonsils severely swollen, test for strep and consider steroids if strep negative

Question 15

Influenza

Answer 15

Antivirals must start within 72 hours, <48 hours is best, five days of treatment

Question 16

Aphtous Ulcers

Answer 16

Sores on inside of lip
Steroid mouthwash
Consider PPIs / GERD eval

Question 17

Gingivitis

Answer 17

Antibiotics for 10 days, usually cefadroxil or clindamycin
Refer to dental

Question 18

Group A streptococcus Bacteria pharyngitis

Answer 18

Common presentation of GABHS
Acute-onset sore throat with erythema and tonsillar exudates, Fever, H/A, Tender/enlarged cervical nodes, May have sandpaper rash on torso and petechiae of soft palate, Children may present with N/V and stomach pain

Absence of cough and stuffy nose

Amoxicillin 500 mg tid or 875 mg bid for 10 days or Azithromycin / Cephalosporin

If the tonsils and pharynx are severely swollen, consider prednisone; start with 30 to 50 mg qd and taper over

No school for 24 hours or until fever resolves, throw away toothbrush

Question 19

Peritonsillar Abscess

Answer 19

fever, chills, and a severe sore throat, muffled voice, foul breath
marked edema and erythema of the peritonsillar tissue

Strep test, immediate refer to ENT for I&D and antibiotics

Question 20

indications, contraindications, precautions, and patient preparation involved in foreign body removal from the nose.

Answer 20

A child or adult who has a retained nasal foreign body often presents with a foul odor from the nostrils, unilateral purulent rhinorrhea, or persistent epistaxis. More commonly, the patient presents with the request for object removal.

Do not attempt if item cannot be visualize or large
Do not push it further into the nose trying to dislodge into pharynx
Do not irrigate
Coin batteries are an emergent removal

Question 21

Describe the management for post tooth avulsion or fracture

Answer 21

• If the tooth can be reimplanted, do not dislodge it from the socket.
• Clenching the tooth gently may allow for support of the tooth.
• Avoid talking, drinking, or chewing.
• Seek dental attention as soon as possible.

Question 22

Identify nasal procedure concerns that warrant emergency evaluation or emergent ear, nose, and throat (ENT) consult.

Answer 22

Epistaxis with hemodynamic instability
Posterior epistaxis
Recurrent bleeding
Epistaxis > 1 hour
Epistaxis despite packing or bilateral packing
Button/Coin batteries in nose or magnets in nose

Question 23

Identify the indications, contraindications, precautions, and patient preparation involved in nasal packing for epistaxis

Answer 23

This procedure is performed to control nasal hemorrhage that has not been alleviated with firm pressure, in the correct location, immediately distal to the bony portion of the septum for at least 10 to 15 minutes continuously.

Contraindications
Granulocytopenia is present.
Tissue Necrosis
History of stroke, MI
Low PaO2
Severe hypertension