Ears/Nose

Question 1

Cholesteatoma presentation

Answer 1

Unilateral hearing loss
Purulent, foul discharge
Perforated TM
Cauliflower-like/ pearly-white mass
H/o recurrent OM

Question 2

Cholesteatoma treatment

Answer 2

Antibiotics

Refer to ENT for surgical excision

Question 3

Conductive hearing loss PE

Answer 3

Lateralization to “bad” ear

BC > AC

Question 4

Sensorineural hearing loss PE

Answer 4

Lateralization to “good” ear

AC > BC

Question 5

Auricular Hematoma Presentation

Answer 5

Blunt trauma to ear
Bleeding in cartilage
If not drained can result in cauliflower ear

Question 6

Acoustic Neuroma CN VIII (Vestibular Schwannoma) presentation

Answer 6

Asians
50-60s
Lasting 3-4 years
Unilateral sensorineural hearing loss 
Tinnitus
Unsteady gait
Possible facial nerve involvement CNVII

Question 7

Acoustic Neuroma treatment

Answer 7

Refer to neurologist

Question 8

Battle sign presentation

Answer 8

Adult that fell/assaulted/MVA
Parietal bone linear fracture
Blue/purple color of TM
Otorrhea/rhinorrhea
After 1-3 days:
- Raccoon eyes
- Mastoid bruising

Question 9

Battle sign treatment

Answer 9

Refer to ED

Question 10

Tympanogram Normal vs Abnormal Result

Answer 10

Normal = peaked line
Abnormal = straight line (as seen in OM)

Question 11

AOM Presentation

Answer 11

Child
Ear pain
Popping noises
Muffled hearing
Recent cold/allergic rhinitis
Low-grade fever
TM may be ruptured (blood/pus discharge)

Question 12

Bullous Mygrinitis presentation

Answer 12

Type of AOM
more painful
Blisters on TM
Red bulging or retracting TM
Conductive hearing loss

Question 13

AOM abx treatment

Answer 13

If no abx in last 30 days
1. Amoxicillin 500 mg tid x 5-10 days
If no response in 48-72 hours
2. Amox-clav, cefdinir, cefprozil bid OR 
levofloxacin, moxifloxacin qd x 5 days

Question 14

How long can MEEs last after AOM is treated?

Answer 14

8 weeks

Question 15

Acute Bacterial Rhino-sinusitis presentation

Answer 15

Recent cold/allergic rhinitis
Facial pain
Nasal congestion >10 days
Purulent nasal drip
Hyposmia 
Postnasal drip cough
No relief from OTC decongestants

Question 16

Acute Bacterial Rhino-sinusitis PE

Answer 16

Dark yellow/green nasal discharge
Maxillary and frontal sinuses TTP
Boggy nasal turbinates
Transillumination dull on affected side
Possible fever

Question 17

Acute Bacterial Rhino-sinusitis and AOM symptomatic treatment

Answer 17

Pain relief
Hydration
Pseudoephedrine/Guaifenesin
Afrin (3 days max)
Saline nasal spray q 2-3 hrs

Question 18

Acute Bacterial Rhino-sinusitis abx treatment

Answer 18

1. Amox-clav 1-2k mg bid x 5-7 days
2. Cefdinir, cefpodoxime, cefuroxime
3. Levofloxacin, doxycycline

Question 19

When to initiate antibiotics for Acute Bacterial Rhino-sinusitis?

Answer 19

• high fever
• nasal discharge >3 days
• sxs > 10 days
• maxillary toothache
• unilateral facial pain
• bad odor in nose
• rebound sxs
• ## immunocompromised

Question 20

Recurrent Acute Bacterial Rhino-sinusitis treatment

Answer 20

Refer to ENT

Question 21

Meningitis presentation

Answer 21

Acute onset
High fever
Stuff neck
Severe headache
Photophobia 
\+ brudzinski or kernig signs

Question 22

Cavernous sinus thrombosis presentation

Answer 22

Acute onset
Severe headache
Reduced sleep
Confusion
Fever
Abnormal neuro exam

Question 23

EOM/SOM PE

Answer 23

TM not red

fluid bubbles seen behind TM

Question 24

EOM/SOM treatment

Answer 24

Oral decongestants
Steroid nasal spray
Saline nasal spray
+ Zyrtec if c/b allergic rhinitis

Question 25

Otitis Externa (swimmer’s ear) presentation

Answer 25

``` External and canal ear pain Swelling Purulent green discharge Itching Conductive hearing loss Recent swimming ```

Question 26

Otitis Externa (swimmer’s ear) abx treatment

Answer 26

Corticosporin 4 gtt qid x 7 days Ofloxacin, ciprofloxacin gtt bid x 7 days Add oral abx if immunocompromised

Question 27

Otitis Externa (swimmer’s ear) recurrent treatment prophylaxis

Answer 27

``` Otic domeboro (boric) Alcohol and vinegar (VoSol) ```

Question 28

Mono presentation

Answer 28

``` 15-24 year olds Fever Pharyngitis Lymphadenopathy (posterior cervical) + Fatigue Tonsillar exudate Abdominal pain (HSM) Recent kissing ```

Question 29

Mono labs

Answer 29

CBC - repeat until normal LFTs Monospot antibody Abdominal US if HSM - repeat in 4 weeks

Question 30

Mono treatment plan

Answer 30

No physical activity for 4 weeks Symptomatic treatment Avoid sharing saliva Do not give amoxicillin

Question 31

Ménière’s presentation

Answer 31

Recurrent vertigo Tinnitus Unilateral hearing loss N/V

Question 32

Ménière’s treatment

Answer 32

``` Salt restriction Avoid nicotine, caffeine, alcohol Vestibular suppressant PRN Antiemetic PRN Refer to ENT if persistent ```

Question 33

BPPV presentation

Answer 33

50-70s Brief vertigo episodes c/b sudden head movements and position changes Induced by trauma, aerobics, mtn biking

Question 34

BPPV diagnosis

Answer 34

Dix hall pike = gold standard

Question 35

BPPV treatment

Answer 35

``` Epley Meclizine (avoid in elderly) Avoid sleeping on affected side x 1 wk ```

Question 36

Ceruminosis treatment

Answer 36

OTC carbamide peroxide (debrox)

Question 37

Allergic Rhinitis presentation

Answer 37

``` H/o asthma, eczema Chronic or seasonal nasal congestion Clear mucus rhinorrhea Postnasal drip w/ cough Nasal itch Sneezing Palatal click ```

Question 38

Allergic Rhinitis PE

Answer 38

``` Boggy turbinates Allergic salute in children Cobblestoning Posterior pharynx with mucus Under eye “circles” ```

Question 39

Allergic rhinitis treatment

Answer 39

eliminate allergen 1. Nasal steroid - fluticasone, triamcinolone 2. + Azelastine 3. Cromolyn sodium 4. Decongestants PRN 5. Second gen antihistamine PRN

Question 40

Rhinitis medicamentosa treatment

Answer 40

Stop nasal decongestants | Nasal saline spray

Question 41

Epistaxis causes

Answer 41

Trauma (nose picking) Cocaine use Anticoags/NSAIDs Severe HTN

Question 42

Epistaxis treatment

Answer 42

Apply direct pressure Afrin to help shrink tissue Refer to ENT if recurrent for cauterization