ENT UWORLD

A 40 year old man comes to the office for evaluation of recurrent epistaxis. Every morning, pt wakes up with significant nasal congestion. When he blows his nose- crusting and blood clots are seen on the tissue. After that (several times a week) its strats bleeding. It stops with <5min of pinching his nasal alae. Medical history- obese, HTN, OSA- treated with CPAP. Vitals- normal. On exam- nose has bilateral crusting with excoriation on both sides of the nasal septum but no bleeding. Whats the next step in management? A- Biopsy nasal septum B- CBC + coagulation profile C- CPAP humidification D- Nasal corticosteroids spray E- Oxymetazoline daily in morning

C- CPAP humidification recurrent epistaxis - due to CPAP because of the drying effect on nasal mucosa

8 year old is brought to the office due to small amount of left sided ear discharge that persisted for more the 3 weeks. She was seen twice over the last 2 months and completed two courses of antibiotics but discharge persists. No pain, no fever, but hearing loss on the left side. Pt has had recurrent ear infections and had a tympanostomy tube placed at 2 years old. HAs all vaccinations. Vitals normal, otoscopy- scarring on left TM with peripheral granulation and skin debris. Dx? A- Cholesteatoma B- Malignant otitis externa C- Meniere disease D- Osteoma E- Otosclerosis

A- Cholesteatoma Malignant OE- represnts osteomyelitis of external auditory canal and skull base. Seen in eldery with DM- have discharge, hearing loss and severe pain. Meniere Disease- accumulation of fluid in the inner ear leading to hearing loss, vertigo, and tinnitus. Occurs in adults. Otosclerosis- boney overgrowth of the stapes footplate that results in conductive hearing loss. No ear drainage.

a 5 year old boy is brought it office for ear pain- 2 days ago pt got low grade fever and pain in left ear. Parents think he has trouble hearing from left ear as they noticed him tilt his right ear to the TV. For the past week - runny nose and cough- after the family came back from vacation. No history of previous OM, or illness. Temp is 38, BP 110/60, pulse 110. Exam- bulging of left tympanic membrane- pales yellow- immobile pneumatic insufflation. Right TM and bilateral auditory canal - normal. Nasal mucosa boggy, and post nasal drip present, Sinuses- not tender. whats the dx? A- AOM B- Barotrauma C- Bullous myringitis D- Cholesteatoma E- Chronic suppurative OM F- OM with effusion

A- AOM

20 month old girl- fever and fussiness for the past 5 days. SHe is less playful than usual and not eating well today. Pt had several episodes of AOM in the last year which resolved with oral antibiotics. Temp is 38.6, BP 100/60, pulse 120. Exam- right ear reveals a protruded auricle with tenderness and swelling behind the ear. Otoscopy reveals narrowing of the external ear canal, the tympanic membranes cannot be seen. Left ear exam is normal. Which of the following is the likely diagnosis ? A- Acute mastoiditis B- Cholesteatoma C- Necrotizing otitis externa D- Parotitis E- Perichondritis

A- Acute mastoiditis Acute mastoiditis is the most common complication of AOM. Pt present with : bulging TM, mastoid tenderness, and displacement of the auricle. The mastoid air cells are in continuity with the middle ear- easy spread of infection. MC seen in kids less than 2 years old and usually caused by S. Pneumoniae. Dx is clinically, and treat with IV antibiotics, drainage is also required. This can be done by tympanostomy or mastoidectomy.

A 36 year old woman comes to the ER with worsening fever and sore throat. 4 days ago the patient accidentally swallowed a fish bone that scratched her throat and caused some discomfort. She felt better after some time and did not seek medical attention, but for the past 2 days she has had severe sore throat and difficulty swallowing. The patient reports neck pain and stiffness. Her temp is 39, BP 126/80, pulse is 106. Examination shows pooling of saliva in hypopharynx. The posterior pharyngeal wall is red and bulging. Neck stiff with reduced passive motion. Lung- normal. Lateral radiographs of the neck- increased thickness of prevertebral soft tissue with air fluid level. Due to potential contiguous spread of the disease process, this patient is at greatest risk of developing which of the following? A- Acute necrotizing mediastinitis B- Cranial subdural empyema C- Ludwig angina D- Septic cavernous sinus thrombosis E- Spinal epidural abscess

A- Acute necrotizing mediastinitis The retropharyngeal space is a deep compartment of the neck defined anteriorly by the buccopharyngeal fascia and constrictor muscles of the pharynx and posteriorly by the alar fascia. Laterally it communicates with the parapharyngeal space. This pt has a retropharyngeal abscess with neck pain, odynophagia, and fever post trauma. Infection in the retropharyngeal space- drains inferiorly to the superior mediastinum- spread to carotid sheath - can cause thrombosis to internal jugular and cause palsy is cn 9,10,11,12. IF it goes through alar fascia "danger space: rapidly transmit infection into posterior mediastinum to the level of the diaphragm. Acute necrotizing mediastinitis - life threatening complication that requires urgent surgical care.

35 year old woman comes to the office due to left ear pain and itching that began yesterday that began yesterday. The patient is an avid long-distance runner and uses earbuds to listen to music while training. After a long run yesterday, she took out her earbuds and noticed a thick green discharge on the left side. She used cotton-tipped applicators to clean out both ears. This morning, she was unable to insert her left earbud due to significant pain. A similar episode occurred 9 months ago and resolved with appropriate treatment. She takes no meds. Temp 37, BP 110/70, pulse 70. Exam- of the left ear causes significant pain. The ear canal is red and swollen with green drainage that obscures the TM. The right ear appears normal. The scalp and hair are normal. Which of the following in the likely diagnosis? A- Acute otitis externa B- Allergic contact dermatitis C- Otitis media with effusion D- Relapsing polychondritis E- TM perforation

A- Acute otitis externa

A 73 year old man is seen in the hospital for severe left facial pain and inability to fully open his mouth. Symptoms began earlier today. 8 days ago, the pt had a laparotomy for intestinal obstruction. The procedure went well and has had several bowel movements since the operation. Medical history is significant for dementia, colon cancer (dx 5 years ago) and she is remission. Temp 38.9, BP 150/80, pulse 90, rr 16. Exam- swelling, erythema and severe tenderness in the left preauricular area. Labs- WBC count 15,600. Which of the following would most likely have prevented this complication? A- Adequate fluid intake and oral hygiene B- Administration of polysaccharide vaccine C- Administration of tetanus toxoid D- Avoidance of extreme jaw opening during intubation E- Avoidance of volatile anesthetic agents during surgery F- Encouragement of incentive spirometry G- Initiation of early ambulation

A- Adequate fluid intake and oral hygiene Suppurative Parotitis Risks- Elderely, post operations, dehydrated, medications (anticholinergics), obstruction (calculi, neoplasm) Clinical- firm, Erythematous pre/postauricular swelling, tenderness exacerbated by chewing, trismus, elevated serum amylase Management: hydration, oral hygiene, antibiotics, massage (milk puss out), sialagogues

A 43 year old man is found wandering in the street in winter and brought to ER by a passing motorist. The pt is confused and unable to provide any history. No hospital record, On exam - mildly hypothermia - temp 35, other vitals were normal. Pt is disheveled and lethargic but follows command, The oral mucosa is moist and there are extensive dental caries. Pts has no cervical lymphadenopathy but has bilateral non tender swelling of the cheeks consistent with salivary gland enlargement. Which of the following is the most likely cause of the latter finding? A- Alcoholism B- Mumps C- Pleomorphic adenoma D- Salivary gland stone E- Sjorgren syndrome F- Vit A deficiency

A- Alcoholism bilateral non tender swelling of the parotid is consistent with sialadenosis. It is a benign noninflamm swelling of the salivary glands. Its caused by an over accumulation of secretory granules in acinar cells in pt with chronic alcohol use, bulimia, or malnutrition, It can also occur in DM or liver disease- fat infiltration.

A 34 year old woman comes to the office due to difficulties hearing especially in her left ear. The hearing loss worsened over the past year, and now she can't hear people at work. However when its noisy she can understand speech better than when she is in a quiet room. The pt also hears ringing in her left ear. She has no dizziness, vertigo or ear pain. No noise exposure. The pt is medically free. Her mom had surgery for hearing loss in her 40s. On exam- TM normal. Slight reddish hue behind the left TM. What is the most likely mechanism of this pt condition? A- Boney overgrowth of the ossicles B- Degeneration of neuronal cell bodies C- Increased fluid in the cochlea D- Lamellated basement membrane E- Neoplastic growth involving CN 8

A- Boney overgrowth of the ossicles Otosclerosis -- Occurs due to an imbalance of bone resorption and deposition that leads to stiffening and ultimately fixed stapes. Epidemiology - younger mid 30s pt, woman, AD with incomplete penetrance. Clinical- progressive conductive hearing loss, paradoxical improvement in speech discrimination in noisy environment, reddish hue behind TM Tx is hearing amplification or surgical reconstruction of stapes. B- Degeneration of neuronal cell bodies - SNHL - worse speech in noisy places C- Increased fluid in the cochlea - meniere disease- present with vertigo, aural fulness, hearing loss D- Lamellated basement membrane - alport syndrome- hereditary SNHL and presents with recurrent hematuria in childhood E- Neoplastic growth involving CN 8- schwannoma -

2 hour old boy evaluated for cyanosis in newborn nursery. Born at 38 weeks gestation via spontaneous vaginal delivery to a primigravida mom- uncomplicated pregnancy. When attempting to feed- he turns blue. When he cries it goes back to normal. He has voided and passed meconium. Patients weight is appropriate for gestational age. HR and all 4 extremities pressures are normal. On exam - nondysmorphic neonate with mild cyanosis at rest. Heart and lungs normal on auscultation. Whats the dx? A- Choanal Atresia B- Laryngomalacia C- Tetralogy of Fallot D- Tracheoesophageal fistula with esophageal atresia E- Transient tachypnea of the new born F- Transposition of the great arteries

A- Choanal Atresia D- Tracheoesophageal fistula with esophageal atresia - smae but pt will have coughing, choking with feeds as well

6 year old boy- evaluation of a neck lump. Mom noticed it 2 weeks ago when he had cold like symptoms. Hos nasal congestion and fever resolved within days with symptomatic treatment but the mass didnt improve. Boy was full term, no complications and is healthy. He is fully vaccinated. Pt afebrile, weight and hight are at 60th percentile. Physical- shows a 1.5 cm soft, mildly tender mass in the midline of the upper neck. Moves up and down when pt swallows. NAsal turbinates are pink- no rhinorrhea and tonsils normal. WHat is the most likely cause of this pt condition? A- embryonic anomaly B- glandular duct obstruction C- Granulomatous inflammation D- NEoplastic Proliferation E- Reactive lymphadenopathy F- Suppurative bacterial infection

A- Embryonal Anomaly Thyroglossal duct cyst- midline mass, present post URTI, associated with ectopic thyroid tissue. Moves superiorly with swallowing or tongue protrusion. Due to risk of infection- TDC usually removed (do thyroid scan before- it may be the only thyroid tissue pt has)

A 27 year old primigravida at 8 weeks gestation is found to have a thyroid nodule during her initial prenatal visit. She has fatigue and frequent nausea with vomiting. The patient has no heat or cold intolerance and no skin changes. She has no dysphagia to solids or liquids although she has been eating more carbs. Medical history- insignificant. The patient does not use tobacco, alcohol or drugs. Temp 36, BP 110.70, pulse 86 and resp 18. Physical exam- 1.5 cm nodule in her right thyroid. Serum TSH is normal. U/S- 1.5 cm hypoechoic nodule with irregular margins. internal micro-calcifications and internal vascularity. Whats the next step? A- FNA biopsy B- MRI of neck C- Radionuclide scan D- Reassurance and follow up after delivery E- Serum thyroglobulin F- Total thyroidectomy in the second trimester

A- FNA biopsy Thyroid nodules -->physical exam--> TSH If TSH is normal--> thyroid u/s --> if its larger than 1cm and has high risk features (microcalcification, irregular margins, internal vascularity)--> FNA

A 23 year old woman comes to the physician because of a 4 week history of a whistling noise during respirations. She underwent a difficult rhinoplasty a few months ago. The noise is getting louder and annoying. Whats the dx? A- Nasal septum perforation B- Nasal polyp C- Nasal foreign body D- Allergic rhinitis E- Nasal furunculosis

A- Nasal septum perforation Following a nasal surgery- septal perforation is typically the result of a septal hematoma or septal abscess--> cause whistle. Other cause of perforation - nose picking, syphilis, TB, cocaine, sarcoidosis and wegener's E- Nasal furunculosis - from staphylococcal folliculitis- following nose picking or nasal hair plucking. Life threatening- spread to cavernous sinus. Patients complain of pain, tenderness, and erythema in nasal vestibule.

12 month old girl, 3 days of fever, rhinorrhea, nasal congestion. Pt completed a course of antibiotics for an ear infection 3 weeks ago and noted to have persistent middle ear effusion at well child visit last week. No history of medical issues or other infection. no allergies, parents both smokers. Older sibling received tympanostomy tubes as infant. Temp 39, pt irritable but consoled by mom. External ear normal, patent. Otoscopy shows bilateral bulging and pink tympanic membranes with poor mobility on insufflation. Oropharynx - normal, lungs clear. Which of the following is an appropriate step for management? A- oral antibiotics B- Ototopical antibiotics C- Supprotive care and observation D- Temporal CT scan E- Tympanocentesis and culture F- Viral nasopharyngeal PCR testing

A- Oral antibiotics Acute otitis media - tx with amoxicillin in infants <6months or children >6months with high fever (>39), sever pain or bilateral disease Second line- amoxicillin- clavulanate for refractory symptoms after 2-3 days of antibiotics or recurrent AOM (within 30 days) after antibiotic therapy. So for this patient- we give amoxicillin - clavulanate She has high fever, recurrent, bilateral AOM after antibiotic therapy. Ototopical antibiotics- given for otitis externa OME- without TM inflamm- observe - if more than 3 months or associated with more than 3 AOM in 6 months we put a tympanostomy.

28 year old man comes to ER for resp distress. A week ago he developed a sore throat that is getting worse. Over the last hour, he had difficulty breathing. The patient diagnosed with HIV at 23 and has been inconsistent with daily antiretroviral therapy. Temp 38.3, pulse 126, rr 30. Pulse oximetry is 78% on room air. Pt is leaning forward with neck extended, drooling, with hoarse voice. The posterior oropharynx had white plaques. There are suprasternal retractions. Exam of lungs- diminished breath sounds bilaterally. Pulse oximetry remains 78% when given 100% oxygen bag valve mask. Endotracheal intubation using a video laryngoscope is attempted but unsuccessful. Pulse oximetry is decreasing and now 70%. Whats the best next step? A- Perform surgical cricothyrotomy B- Place a laryngeal mask airway C- Provide bilevel positive airway pressure D- Reattempt endotracheal intubation E- Switch to nasotracheal intubation

A- Perform surgical cricothyrotomy The patient with HIV - developed acute hypoxemic resp failure with tripod position- raising suspicion for epiglottitis. Pt is put on the bag- valve- mask. If the BVM cant keep oxygen over 88%- we do endotracheal intubation using video laryngoscope- now because of the rapid detrioration the pateint is experiencing- next step is surgical cricothyrotomy. B- Place a laryngeal mask airway- this is supraglottic- above the obstruction so wont help me D- Reattempt endotracheal intubation - only if it failed the first tine without assisted video, then we repeat with assisted video

A 55 year old man comes to the office for follow up of an oral lesion. HE first noticed the white patch on the mucosal surface of his lower ip 2 years ago. At the time a biopsy was done, and the patient was told to stop chewing tobacco and to have regular checkups. He stopped using tobacco for 6 months but then resumed. Over the past 3 months, the white patch has been getting thicker. The patient has also noticed a taste of blood while chewing food, which he attributes to accidental bite trauma. Medical history - HTN, asthma, DM2. Vitals normal. On exam- dentition is poor with several cavities and dark stained teeth. On the mucosal surface of the right lower lip, there is a 4cm white patch, the central region of which is thicker and feels firm to palpation. Which of the following is the next best step in management? A- Acyclovir treatment B- Biopsy of the lesion C- Dental evaluation D- Fluconazole therapy E- Topical steroids F- Topical tacrolimus

B- Biopsy of the lesion Leukplakia is benign and asymptomatic, but the since it is evolving, friable (tasting blood)- now we are concerned for squamous cell carcinoma.

A 12 year old boy is brought to the office due to left neck mass. One month ago he had a fever and URTI. A week later he noticed a painful lump in the left side of his neck. He also has leakage of fluid from a hole below the mass. On exam- cystic left neck mass and small pit anterior to sternocleidomastoid muscle that leaks mucopurulent fluid. Whats the dx? A- Acinomyces lymphadenitis B- Branchial cleft cyst C- Cystic hygroma D- Laryngocele E- Thyroglossal duct cyst

B- Branchial cleft cyst Since its lateral it may be Branchial cleft cyst- tract may extend to the tonsillar fossa or pyriform recess, anterior to sternocleidomastoid Reactive adenopathy- firm, often tender, multible nodules Mycobacterium avium lymphadenitis- nectrotic lymph node, violaceous discoloration of the skin, frequent fistula formation Midline : Thyrglossal duct cyst Dermoid cyst midline - cystic mass with trapped epithelial debris, occurs along embryonic fusion planes. No displacement with tongue protrusion. Posterior- Cystic hygroma

A 64 year old man comes to the office due to a month of slowly progressive left sided neck swelling. The swelling is not painful or erythematous. He also had persistent nasal congestion, frequent epistaxis and headaches. The pt has a history of rhinosinusitis and attributes his current symptoms to another episode of infection. He has been taking over the counter decongestants and antihistamines, but these didn't provide relief. No medical issues. Takes daily multivitamin and occasionally uses NSAIDS for aches and pains. He is an immigrant from china - 15 years ago. Vitals normal. Several enlarged and hard cervical lymph nodes are present. Nasopharyngoscopy reveals a mass in the posterior nasal cavity, and biopsy demonstrates poorly diff carcinoma, Which of the following os most strongly associated with this pt condition? A- Aflotoxin B1 exposure B- EBV infection C- Excessive use of NSAIDs D- Recurrent bacterial sinusitis E- Vitamin A supplements

B- EBV infection Pt has nasopharyngeal carcinoma- associated with EBV. NPC is endemic in southern china- (risk higher due to diet and genetic predisposition ) The tumor obstruct the nasopharynx and invade tissues- resulting in nasal congestion with epistaxis, headache, CN palsies, serous otitis media. Early metastasis to cervical lymph nodes. A- Aflotoxin B1 exposure - hepatocellular carcinoma C- Excessive use of NSAIDs- kidney injury and gastric ulcers D- Recurrent bacterial sinusitis - nasal polyposis E- Vitamin A supplements - increase risk of lung cancer is smokers

9 year old girl- with ringing in her ear over the past week. She noticed a popping sensation in the ears when she swallows and difficulty hearing soft sounds. Pt has nasal congestion during this time but otherwise healthy. She and her family flew home from a ski trip a few days before her symptoms began. Vitals are normal. Otoscopic exam- retracted right TM with surrounding dilated blood vessels. Left TM is normal. Pupils equal, round, reactive. Coordination and balance - normal. Cranial nerve testing- mild reduction in hearing on right side. What's the ddx? A- AOM B- Eustachian tube dysfunction C- Meniere disease D- Otosclerosis E- TM rupture

B- Eustachian tube dysfunction Eustachian tube : Physio- equalize middle ear pressure, drain middle ear, prevent reflux of nasopharyngeal secretions Pathophysio- inflammation (infection, allergies, environmental irritation)- tube obstructed Signs and symptoms - Ear fullness, discomfort, tinnitus, conductive hearing loss, "popping sensation" , retracted TM due to negative pressure within in the middle ear Management - treat the underlying cause

5 year old boy- hearling loss- over the past year ot has increased difficulty hearing normal conversations. Born at 36 weeks, small for gestational age but otherwise normal. He is in the 50-70 percentile. Tuning fork held over midline sounds louder on left ear. Tuning fork also louder with air conduction bilaterally. Which of the following is the likely eitiology? A- Cholesteatoma B- Chronic otitis media C- Congenital Infection D- Foreign body E- Noise exposure F- Otosclerosis

C- Congenital Infection Findings of weber test localize to left unaffected ear- and air conduction is louder than bone bilaterally. This suggests right sided sensorineural hearing loss- damage to inner ear or auditory nerve. Most common cause of non hereditary SNHL in child is - congenital CMV infection. Usually child is asymptomatic- may present from birth or onset is delayed until childhood. one ear or both ears can be affected.

59 year old man comes to office with 3 month history of persistent right ear pain. He tried to take acetaminophen and ibuprofen but it didnt improve. He has no medical issues. He works as a welder and has smoked a pack daily for 40 years and drinks on weekends. Vitals are normal. Right ear exam- normal. Palpation of the temporomandibular joint elicits no tenderness or creptus. Left ear is normal. Oral cavity shows poor dentition but no ulcers. The tonsils are not enlarged and posterioir pharyngeal wall is normal. There is a non tender 2 cm lymph node on the righ side of the neck. What is the next best step? A- Audiogram B- Flexible laryngopharyngoscopy C- MRI imaging of the brain D- Reassurance and symptomatic care E- Tympanometry F- Tympanostoomy tube placement

B- Flexible laryngopharyngoscopy Otalgia in the setting of a normal ear exam- referred pain. MC due to dental disease and temporomandibular joint disorder. But referred otalgia is also a symptom of mucosal head and neck squamous cell carcinoma- especially in elderly with history of smoking, alcohol use, exposure to welding fumes, and cervical lymphadenopathy. Referred pain occurs due to glossopharyngeal nerve which has nerve fibers innervating the tongue- also gives afferent sensory fibers input from the external auditory canal. All these afferent fibers converge in a ganglion just prior to entering the jugular foramen. Similarly the vagus nerve which innervates the larynx and hypopharynx also give sensory to the external auditory canal. As a result referred otalgia can be due to tumor at bas of tongue, larynx, or hypopharynx. So flexible laryngopharyngoscopy is used to identify the lesion. MRI- for vestibular schwannoma, referred otalgia usually never a central cause.

70 year old man comes to ER for severe left ear pain. Pain progressively worsened over the past 2 weeks. It is more severe at night and is exacerbated by chewing, so pt cant sleep or eat. He is unable to wear his hearing aid on the left side- so his hearing has worsened. Medical history- HTN, CAD, DM2 with peripheral neuropathy. Temp 37.8, BP 140/90, and pulse 98. On exam- left external auditory canal is mildly edematous with purulent discharge and granulation tissue on the canal floor. TM is clear. Aside from hearing loss CN exam is normal. CBC is normal and ESR 89. WHat is the best initial treatment for pt? A- IV ampicillin/sulbactam B- IV ciprofloxacin C- Surgical excision D- Topical steroids E- Topical neomycin

B- IV ciprofloxacin Necrotising malignant otitis externa Psuedomonas aeruginosa

A 55 year old man comes to office for follow up due to recurrent episodes of jaw pain. Pt most recent episode was a week ago. Pain that worsened by eating, and a tender mass under the left jaw and fever. All symptoms resolved within a few days with oral antibiotics. This is the third episode in the last year. What os the underlying condition? A- Giant cell arteritis B- Sialolithiasis C- Sjogren syndrome D- Temporomandibular joint disease E- Trigeminal neuralgia

B- Sialolithiasis This pt most likely has recurrent sialadenitis (salivary glan infection). It is caused by salivary stasis that leads to retrograde seeding of bacteria from the oral cavity. Salivery stasis is seen in elderly post op, pt with obstruction to flow. In this pt - no risks- so most likely sialolithiasis- stone obstruction. MC stones are found in submandibular glands because saliva here has a higher mucus content. Stones made of calcium and are visible on CT scan. Sialolithiasis- presents with pain and swelling exacerbated by eating.

A 4 month old boy- noisy breathing. Parents noticed it first as a harsh sound when he cried at age 2 weeks but now its louder (especially when lying on his back). Noise improves when pt is help upright or during "tummy time". No laboured breathing- never turned blue. Pt has occasional small spit ups after feeds but is growing well in the 60th percentile for weight, BOrn full term, uncomplicated pregnancy. On physical exam patient has inspiratory stridor when supine and improves when prone. What would confirm the most likely diagnosis? A- Chest radiography B- CT scan of the neck C- Flexible fiberoptic laryngoscopy D- Fluoroscopic barium swallow E- MR angiography of neck F- plain radiograph of neck

C- Flexible fiberoptic laryngoscopy Pt here has laryngomalacia - collapse of the supraglottic tissue on inspiration. Present as inspiratory stridor that worsen when supine- peak age 4-8months. Dx- my laryngoscopy (omega shaped epiglottis). Management- reassure with close follow up (+- gastroesophageal reflux treatment) or supraglottoplasty for severe symptoms. Retropharyngeal abcesses occur in toddlers and with fever, dysphagia, neck pain and stridor, If u do lateral X ray - thickening of the prevertebral space. Vascular rings- when anomalous branch of the aortic arch or pulmonary artery encircles the trachea and esophagus. They may cause biphasic or expiratory stridor - barium swallow identify indentation (pt presents with feeding difficulty). Then confirm ddx by contrast CT or MR angio.

A 22 year old man comes to ER after being hit in the face with a basket ball. HE had bleeding from both sides of his nose for 10 min that stopped with pressure. He is currently unable to breath through his nose. Medical history - allergic rhinitis treated with antihistamine. Tem 37, BP 110/70, pulse 70, rr 14, oxygen 99% on room air. Exam- bruising across the nose and under eyes. Anterior rhinoscopy reveals no bleeding. There is soft tissue fluctuant swelling of the septum bilaterally. No blood in oropharynx. Whats the next step in management? A- Apply ice packs to the nose and recommend NSAIDs B- Embolize the sphenopalantine artery C- Incise and drain nasal septum D- Insert anterior nasal packing E- Order CBC and coagulation

C- Incise and drain nasal septum Pt has septal hematoma- accumulated blood between perichondrium and the septal cartilage. If not drained- septal abscess can form in infants within 2-3 days. Also avascular necrosis of septal cartilage (since it gets nutrients via diffusion). Can result in septal perforation, saddle nose, internal nasal valve prolapse. A- Apply ice packs to the nose and recommend NSAIDs - after drain you do this B- Embolize the sphenopalantine artery - to control posterior epistaxis. D- Insert anterior nasal packing - after drain u do this E- Order CBC and coagulation - if coagulopathy is suspected, spontaneous epistaxis,

A 28 year old woman- persistent nasal congestion and stuffiness. Pt has constant sensation of dripping in the back of her throat and states that food has tasted bland. A year ago - she was at the ER- severe wheezing after taking naproxen for menstrual cramps. No history of trauma, family history is significant for asthma in her sister. Occasionally smokes weed. Whats the most likely cause for this pt symptoms? A- Allergic rhinitis B- Fungal rhinosinusitis C- Nasal polyposis D- nasopharyngeal angiofibroma E- Perforated nasal septum F- Pyogenic granuloma

C- Nasal polyposis Aspirin exacerbated respiratory disease triad of asthma, bronchospasm or nasal congestion after NSAIDs, and chronic rhinosinusitis with nasal polyposis

A 57 year old man comes to the office for follow up after recent thyroid surgery. A month ago he was found to have a solitary thyroid nodule and a fine needle aspiration biopsy showed a neoplasm arising form parafolllicular cells. He underwent uncomplicated total thyroidectomy and removal of surrounging lymph nodes. HE feels well and is taking levothyroxine as perscribed. Medical history- HTN - controlled. No family history of cancers and germline RET testing was negative. Vitals- normal, Exam- well healing incision on his lower anterior neck with no surrounding erythema or edema. No cervical lymphadenopathy. Blood cell counts and serum- normal. Periodic surveillance with which of the following is most appropriate for the pt? A- Antithyroid peroxidase antibodies B- Dexamethasone suppression testing C- Serum calcitonin D- Serum parathyroid hormone E- Serum thyroglobulin F- Serum thyroxine G- Thyroid scintingraphy

C- Serum calcitonin Pt had a medullary thyroid cancer

A 70 year old man is brought to the office by his wife. She reports that he no longer listens to me - when she talks and she thinks it worsened in the past 2 years. Pt moves his chair closer to the TV. Doesn't go to dinners anymore. The pt says he has trouble understanding his wife, especially in noisy places. He gets tired of asking people to repeat themselves. Medications- hydrochlorothiazide, lisinopril, and aspirin. The pt doesn't smoke. What's the cause

Cochlear hair cell loss Presbycusis

A 40 year old woman comes to the office for evaluation for a sore throat. It began 2 months ago, worsens with swallowing and is making it difficult for her to swallow solid foods. She has noticed worsening breath. Medical history is unremarkable. Never smoked and rarely drinks. Pt in long term monogamous relationship and has had multiple sexual partners in her lifetime. Temp 37, BP 118/76, pulse 82. Ear exam- normal. Nose- normal. Oral cavity- mild dental disease but no mucosal lesions. Oropharyngeal exam- enlarged, firm right tonsil with 2 cm ulceration. Also 2 enlarges firm fixed nontender lymph nodes in the right side of her neck. which of the following is responsible for the pt condition? A- Actinomyces israeli B- EBV C- Fusibacterium necrophorum D- HPV E- S pyogenes F- Treponema pallidum

D- HPV

53 year old woman- post anesthesia care unit following thyroid surgery. She underwent a total thyroidectomy for a retrosternal goiter that was causing dysphagia from esophageal copression. The pt states her neck feels "tight" but no significant pain or difficulty breathing. Temp 37, BP 126/86, pulse 100, oxygen 99% on room air. on exam all normal except at the neck incision- a 4 cm ballotable swelling under the incision. The lungs are clear to auscultation, The neck swelling increases in size during the examination. Whats the next step of management ? A- Compressive dressing application B- CT scan of the neck with contrast C- Fluoroscopic swallowing study D- Immediate wound explorations E- Urgent cricothyrotomy

D- Immediate wound explorations The 4 cm ballotable swelling under the incision is and expanding neck hematoma--> life threatening due to potential airway obstruction due to either airway compression or venous congestion causing laryngeal edema. Must be drained immediately.

A 40 year old man comes to the office due to runny nose, cough and sore throat. He began having rhinorrhea 5 days ago and subsequently developed a cough thats worse at night. The pt has been taking an over the counter cough medication but it is not improving his symptoms. Three days ago he got a sore throat, which he thought was from all the coughing. Now his throat is more painful and he has trouble swallowing liquids. Pt has HTN, and DM2 which he takes medications for. Temp is 37.9, BP 148/90, pulse 110, rr 22. BMI 35, pulse oximetry 99% on room air. Pt winces when swallowing. Exam- pooling of oral secretions. Several dental caries, and posterior oropharynx is mildly erythematous due to postnasal drip. The anterior neck is soft but tender to palpation. Lungs- faint stridor with no crackles or rhonchi, Whats the next best step for dx? A- Chest radiograph B- Diptheria PCR C- Group A step rapid antigen D- Lateral neck radiograph E- Sputum gram stain and culture

D- Lateral neck radiograph Epiglottitis

A 62 year old man comes to the dr for a routine follow up appointment. He has a 20 pack year smoking history and recently began chewing tobacco. He drinks 6-10 beers each weekend. The patients past medical history is significant for type 2 diabetes mellitus and HTN. His last HbA1C was 8.3%. His body mass index is 27.5. On oral exam, a white patch is seen on buccal mucosa. The lesion appears to have a granular texture, is not indurated, and is not removed by scraping with tongue depressor. There is no regional lymphadenopathy. Which of the following is most likely cause of the oral lesion in this pt? A- Apthous stomatitis B- Candidiasis C- HSV infection D- Leukoplakia E- SCC

D- Leukoplakia

3 year old girl is evaluated for hoarseness that has been getting worse over the last 2 months. The pt has had no fever, shortness of breath, or change in activity level. She is eating normally, no pain nothing. Vitals normal. Physical- normal. cranial nerves- normal just hoarseness. Flexible laryngoscopy shows several finger shaped lesions on both vocal cords. What is the cause? A- Anomalous airway development B- IgE- mediated hypersensitivity C- inherited def in C1 inhibitor D- Maternally transmitted viral infection E- Vaccine preventable bacterial infection

D- Maternally transmitted viral infection Pt hoarseness and multiple finger shaped lesions on her true vocal cords- laryngeal papillomas due to recurrent respiratory papillomatosis. Lesions are finger shaped, warty or grape like. Caused by HPV (6 and 11)- most likely acquired via vertical transmission prior to delivery. Tx- surgical debridement.

A 55 year old man comes to office due to left sided facial numbness. Symptoms began a month ago with tingling over his left mid face and have progressively worsened to complete numbness. Pt also had 2 month history of headaches, nasal congestions with intermittent epistaxis, and left ear fullness. He has had no fever, rhinorrhea, or purulent nasal discharge. He tried taking allergy medications- but no relief. He has no other medical issues, doesn't drink or smoke. He is an immigrant from China. Vitals normal. Exam- loss of sensory touch and pain on left side of face. No facial muscle weakness or other neurological findings. Enlarged nontender and mobile cervical lymph nodes are palpable bilaterally. Otoscopy- left ear- retracted TM, and right ear is normal. Nasopharyngoscopy reveals a soft tissue mass in nasopharynx. whats the dx? A- Granulomatosis with polyangiitis B- Mucormycosis C- Nasal polyposis D- Nasopharyngeal carcinoma E- Tertiary syphilis

D- Nasopharyngeal carcinoma

18 month old boy, brought to clinic because he is pulling his ears. 2 weeks ago- pt was at ER for fever and irritable and was found to have acute ottitis media of the right ear. He took the prescribed amoxicillin with resolution of symptoms. But in the past few days he has been pulling his ears. Temp 36. On otoscopic exam- air fluid level visible posterior to both tympanic membranes which appear translucent and gray. Pneumatic insufflation demonstrates reduced mobility of tympanic membranes bilaterally. External canal is clear. WHat is the best next step in management? A- Additional antibiotics B- Glucocorticoids C- Intranasal decongestant D- Observe and follow up E- Tympanostomy tube placement

D- Observation and follow up Pt has ottits media with effusion- middle ear fluid without tympanic membrane inflammation. At ages 6-24 months- predisposed to this cause the eustachian tube is straight. Most effusions develop in setting of a viral infection or post ottitis media. Usually asymp, but can cause discomfort, conductive hearing loss (due to poor TM motility) should resolve within weeks and no need to treat. If u follow up at the pt still has OME (>3months)- chronic OME - it can cause speech delay and long term hearing loss. Now we put a tympanostomy tube.

A 4 year old girl is brought to the office for worsening cough and nasal discharge. 2 weeks ago pt developed nasal congestion and a runny nose which improved over a few days. Now for the past 10 days she has had increasing amounts of thick yellow-green nasal discharge. She stayed home from preschool for the past two days due to worsening daytime cough and has also been waking up at night from the cough. No medical conditions. Fully vaccinated. Temp 37, pulse 90, rr 18, pulse oximetry is 99. Examination - alert child, active, intermittent cough. Thick purulent discharge is present in nares and seen in posterior oropharynx. Nasal turbinates are mildly erythematous and swollen. Bilateral tympanic membranes are translucent and mobile - lungs are clear. What is the next step in management? A- CT scan of sinuses B- Intranasal corticosteroids C- Observation and close follow up D- Oral antibiotics E- Oral antihistamines F- Sinus fluid culture G- X ray of sinuses

D- Oral antibiotics Acute bacterial rhinosinusitis Features- cough, nasal discharge, fever, face pain/ headache. Dx- 1 of 3 a- persistent symptoms >10 days without improvement b- severe onset - fever> 39 for >3 days c- worsening symptoms following initial improvement Tx- amoxicillin +- clavulanate ABRS- clinically diagnosed. If pt gets red flags then do imaging (periorbital edema, vision issue)

A 68 year old woman come to the office due to oral pain. For the last 3 days she has had mild pain in the left lower jaw associated with swelling of the gums. The patient had a loose molar extracted 3 weeks ago and the extraction site never completely healed. MEdical history - osteoporosis treated with calcium, vit D, and zoledronic acid. She never smoked or drank. Vitals are normal. Exam- gingiva; edema and erythema surrounding an area of exposed bone at the left lower jaw. Whats the diagnosis ? A- Apthous ulcer B- Herpetic stomatitis C- Mucorcycosis D- Osteonecrosis E- Periodontal abscess F- Squamous cell carcinoma

D- Osteonecrosis Bisphosphonate related osteonecrosis of the jaw Risks- high dose, parentral bis, dental procedures, concurrent steroids, concurrent or previous malignancies. Clinically- Chronic, indolent symptoms, mild pain and swelling, exposed bone, loosening of teeth, pathologic fractures Treat- oral hygiene, antibacterial rinses, antibiotics and debridement as needed.

27 year old woman, gravida 1 para 0 at 30 weeks of gestation come to office due to increasing difficulty hearing, especially on the right side. She has no pain or discharge. Pt is medically free. Pregnancy uncomplicated except for cystitis 8 weeks ago treated with antibiotics. She takes only multivitamins. Eats balanced diet and doesnt smoke or drink. Vitals are normal. Bilateral TM are normal. Tunking for over the middle of forehead- heard more in right ear. On the right side bone>air conduction. Left side - air> bone. Remainder of exam is normal. What is causing the pt symptoms ? A- Chronic otitis media B- Medication ototoxicity C- Meniere disease D- Otosclerosis E- Presbycusis F- Vestibular shwannoma

D- Otosclerosis SHe has conductive hearing loss, normal otoscopic exam- suspect otosclerosis. Occurs due to an imbalance of bone resorption and deposition that leads to stiffening and ultimately fixed stapes. Tx is hearing amplification or surgical reconstruction of stapes. A- Chronic otitis media - does cause conductive hearing loss- but with ear pain, retracted tympanic membrane or fluid in middle ear. B- Medication ototoxicity - aminoglycoside antibiotics cause sensorineural C- Meniere disease - cause sensorineural with normal exam E- Presbycusis - cause sensorineural with normal exam F- Vestibular shwannoma - cause sensorineural with normal exam

1 hour old boy is evaluated in newborn nursery for feeding difficulty. Pt born at 40 weeks to 22 year old primigravida- spontaneous vaginal delivery. Apgar was 8 and 9 at 1 and 5 min. Boy is placed on mothers chest for skin to skin care and attempting breast feeding. He was able to latch and feed but after one min - his face developed blue tinge. Boy cried and his color improved. Mother tried different positions but he would still turn blue. Temp 37, pulse 150, pulse oximetry- 97. Palate appears intact. Lungs- equal sounds bilaterally. No murmur or gallops. String pulses. Abdomen is soft. Skin pink. Chest xray- normal. What is the best next step to evaluate pt? A- Draw blood cultures B- Measure blood methemoglobin level C- Obtain echo D- Pass catheter through nares E- perform U/S of the head

D- Pass catheter through nares Choanal atresia - due to failure of the posterior nasal passage to canalize during the first trimester clinical findings - Mc is unilateral - chronic nasal discharge, symptomatic during childhood Bilateral - cyanosis that worsen with feeding and improve with cry, noisy breathing (stridor), symptomatic shortly after birth. May be associated with CHARGE syndrome. (coloboma, heart defect, atresia choanae, growth retardation, genital abnormal, ear abnormal) DX- inability to pass catheter past nasopharynx, confirm with CT or nasal endoscopy. Tx- oral airway and surgical repair

2 year old boy, right ear pain. 2 days ago mom saw him put a rock in his ear. She pulled it out and rinsed his ear with soapy water in the bath. Pt had no pain when he went to sleep. But in the morning he wook up crying and pulling on his ear. Very fussy and not slept since. Pt has 2 previous episodes of AOM that resolved iwt antibiotics. Fully immune. Temp 37, BP 90/50, pulse 100. Very anxiois kid, no rhinorrhea, examination- right ear tender, swollen ear canal. TM is mormal. Left ear is normal. What is the best treatment? A- ORal amoxicillin/clavulanic acid B- Oral fluconazole C- Oral trimethoprim sulfamethoxazole D- Topical ciprofloxacin E- Topical clindamycin F- Topical nystatin

D- Topical ciprofloxacin

3 month old girl, flexible fiberoptic laryngoscopy for noisy breathing. 2 weeks - squeaking when lying on her back- and now more persistent. When on her stomach it improves. Pt eats well, gaining well, breast fed, and doesn't look labored to breath- no cyanosis. On flexible fiberoptic laryngoscopy- all normal except intermittent collapse of the arytenoid cartilages into the airway, which worsens when crying. Vocal cords are mobile. Pt most likely makes which sound? A- Biphasic stridor B- Expiratory stridor C- Expiratory wheezing D- Inspiratory rhonchi E- Inspiratory stridor

E- Inspiratory stridor

3 year old, nasal discharge for 2 weeks, Mom says whitish nasal discharge has become progressively thicker and more maloderous. Pt has no fever, cough, or SOB. Eats normally. Medical history - congenitally acquired HIV and pt takes antiretroviral therapy since birth. 2 months ago- CD4 520. He got a ll vaccines. Pt lives with parents, bro and a dog. Father smokes outside. He is in the 40th percentile. On exam- playful and interactive. Purulent discharge from right nostril, and right nasal mucosa and turbinates are Erythematous and swollen. Left is normal. Oropharynx and tonsils normal. No cervical lymphadenopathy. What is the cause? A. Acute bacterial sinusitis B- Adenoid hypertrophy C- Allergic rhinosinusitis D- Frontal sinus agenesis E- Intranasal foreign body F- Mucormycosis

E- Intranasal foreign body Clinically- inorganic substance - asymp, pain/discomfort organic substance- unilateral, foul smelling, purulent discharge Button battery - epistaxis, purulent discharge Tx- positive pressure- exhale with unaffected occluded nares or mechanical extraction

A 30 year old teacher- 3 days history of fever, sore throat, and chills. He complains of difficulty swallowing that started yesterday. Denies any cough, chest pain, or difficulty breathing. Married- no new sexual partners. Temp 39.8, BP 118/76, pulse 102, rr 19. On exam - voice is muffles. Enlarged cervical lymph nodes on the left. Uvula is deviated to the right. Most appropriate treatment? A- Throat swab and oral antibiotics B- Monospot test and oral antibiotics C- Emergency laryngoscopy D- Cricothyroidotomy E- Needle peritonisllar aspiration

E- Needle peritonisllar aspiration Peritonisllar abscess is a complication of tonsilitis - do drainage + IV antibiotics

A 34 year old man comes to the office due to intermittent dizziness over the last 3 months. The patient has had episodes of a sudden spinning sensation, accompanied by nausea, that resolves spontaneously after approximately a minute. Symptoms occur when he is lifting heavy objects, riding an elevator, or after sneezing. No headache, no ear pain, but has trouble hearing out of right ear. The patient had a concussion after a bicycle collision 4 months ago but has no other medical conditions and no recent URTI. Vitals- normal. Physical- shows normal ears. No sensory or motor weakness. No nystagmus at rest but valsalva elicits nystagmus. What is the most likely dx? A- BEnign paroxysmal positional vertigo B- Eustachian tude dysfunction C- Meniere disease D- Orthostatic hypotension E- Perilymphatic fistula F- Postconcussive syndrome

E- Perilymphatic fistula Perilymphatic fistula --> are rare but debilitating complication of head injury/ barotrauma. They cause leakage of the endolymph from the semicircular canals and cochlea into surrounding tissues, resulting in characteristic findings : 1- progressive sensorineural hearing loss- caused by damage to cochlear hair cells from loss of endolymph. 2- Episodic vertigo with nystagmus - triggered by pressure changes in the inner ear (valsalva, elevator, lifting) due to acutely increased endolymph leakage. You can demonstrate this clinically by a loud clap- u see nystagmus (Tullio phenomenon) A- BEnign paroxysmal positional vertigo - caused by debris (otoliths) that temporarily alter endolymph flow through the semicircular canals. Therefore patients typically have sudden brief episodes of vertigo triggered by head movement. F- Postconcussive syndrome - headache, confusion, difficulty concentrating, mood alteration and sleep issues. No nystagmus or vertigo.

A 56 year old man - enlarging painless mass above the right angle of the jaw. HE recently had right sided facial weakness. When he was 20- pt had Hodgkin disease that was treated with radiation to the neck. Family history - thyroid cancer in his mother. Pt doesnt smoke, drink or use drugs. He had several male and female sexual partners in his 30s but now has been with on person for the last 15 years. Vitals normal. Exam- firm nontender mass in right parotid and weakness on the entire right side of the face. Which is concerning for malignancy is this pt? A- Exposure ot oncogenic virus B- Family history of malignancies C- Lack of salivary gland pain D- Origin from parotid gland E- Presence of facial droop

E- Presence of facial droop Pt has a parotid neoplasm- most are benign but since he had radiation- there is a high risk of malignancy. The presence of facial droop or numbness is concerning for neural invasion due to malignancy

30 year old woman comes to the office due to hearing loss in her right ear. A week ago the pt had symptoms of nasal congestion, cough, and rhinorrhea. 3 days ago - she travelled from new york to london. On her return flight, pt developed hearing loss and severe pain in her right ear and noticed a drop of blood on her finger when she scratched her ear canal. All symp have resolved except hearing loss in the ear. Whats the next step? A. Aural irrigation B. MRI of the internal auditory canal C. Oral glucocorticoids D- Oxymetazoline E- Reassurance and follow up F- Tympanoplasty

E- Reassurance and follow up Pt with severe pain ear pain in a flight with persistent hearing loss --> barotrauma of the ear--> complicated by TM rupture.--> minor bleed Follow up because most patients TM will heal spontaneously

A 35 year old women comes to the office due to persistent rhinorrhea. The pt has clear drainage from the right side of the nose that increases when she has a bowel movement or bends to pick something off the the floor. On exam- external nose appears normal and turbinate- pink and septum is straight. There is a small amount of clear fluid from her right nostril. The remainder of the exam is normal. What is important in history? A- Family history B- Illicit drug use C- Occupation D- Prior seasonal allergies E- Recent head trauma F- Use of decongestant spray

E- Recent head trauma Cerebrospinal fluid rhinorrhea Etiology- Accidental trauma, surgical trauma, non traumatic (increased ICP)- cirbriform plate or temporal bone fracture Complications- meningitis Evaluate- test for CSF proteins, imaging, endoscopy Manage- bed rest, head of bed elevation, avoid straining Lumbar drain placement Surgical repair

55 year old man come to the office for follow up. 6 months ago he was diagnosed with papillary thyroid cancer and underwent total thyroidectomy. Followed by radioactive iodine treatment. Since then he has been on levothyroxine and has had no issues. No smoke, alcohol or drugs. Vitals are normal. Exam- well healed surgical incision with no palpable neck mass or enlarged cervical lymph nodes. Lab findings- increased thyroglobulin concentration compared with levels 6 months ago. What explains this finding? A- Adverse effect of radioactive iodine treatment B- Antibody formation against tumor neoantigens C- Enhanced negative feedback to the pituitary D- Excessive thyroid hormone replacement E- Recurrence of the thyroid malignancy

E- Recurrence of the thyroid malignancy

7 year old boy at clinic for rhinorrhea. 3 days ago pt developed rhinorrhea and cough that was worse at night. For the past day- had intermittent, mild pain around upper cheeks, particularly when leaning forward. He had a fever on day one but has been afebrile for the past 48hrs. No medical illness of medications. Immunized pt. Temp 37.6, pulse 100, rr 20. Pt looks well and comfortable on exam. TM are clear. Nasal discharge is profuse and yellow green. Posterior oropharynx is erythematous. Palpation over the upper cheeks bilaterally causes discomfort. cardio-pul exam is normal. Abdomen soft no organomagaly. What is the next step in management? A- Antihistamine therapy B- Inhaled bronchodilator therapy C- Oral antibiotics D- Oral glucocorticoids E- Supportive care

E- Supportive care Acute rhinosinusitis in children present- nasal congestion and or purulent discharge facial pressure/pain fever, cough, headache, loss of smell, ear pain Etiology Viral No fever- or early resolution of it mild symptoms (well appearing child, mild face pain) Improvement and resolution 5-10 days Bacterial Fever >3 days or NEw recurrent fever after initial improvement Persistant symptoms >10 days treat- supportive - intranasal saline, saline irrigation, NSAIDS if bacterial - antibiotics given Antihistamine- for allergic rhinitis Bronchodilator and steroids- if asthma exacerbations

5 year old boy- clinic for persistent ear discharge. Pt has purulent right ear discharge a month ago for which he tool topical antibiotics and oral antibiotics but symptoms didnt improve. no fever, no ear pain, no tinnitus, not dizzy. Pt born with cleft palate - was repaired. Due to bilateral middle ear effusion- tymanostomy placed and were removed three years ago. After the removal- audiometry was normal. Temp 37,. Scant yellow malodorous discharge in the right ear canal. The right TM is immobile with insufflation and appears intact. There is retraction of superior portion of TM and appears pearly white. Left T< normal. Audiometry- conductive hearing loss on right side. Gait normal. What is the cause? A- Acute middle ear effusion with concurrent TM inflammation B- Chronic foreign body impaction with external ear canal abrasion C- External ear canal epithelium maceration and inflammation D- Schwannoma formation with cochlear nerve damage E- TM epithelium and keratin debris accumulation

E- TM epithelium and keratin debris accumulation Cholesteatoma- benign growth of the squamous epithelium and accumulation of keratin debris within the middle ear. MC is acquired and unilateral. Risks- recurrent AOM, chronic middle ear effusion, and tympanostomy tube placement. Pt with cleft palate are at an increased risk due to the increased risk of middle ear disease. tx- surgical excision

A 32 year old man comes to the office due to right ear pain for the past month. The pain often awakens the pt and increases i severity when he chews food. He has no ear discharge, dizziness, sinus tenderness, or rash. Medical history is significant for generalized anxiety disorder, for which she take sertraline. The patient does not use tobacco or alcohol. Vitals are normal. On exam- the ears are normal with a small amount of wax. Mobility of the TM is normal, and results of the Weber and Rinne tests are normal. There are no lesions in the oral cavity, the tonsils are normal, and the teeth appear worn and smooth with no evidence of dental cavities or periodontal disease. Which of the following is the most likely ddx? A- Eustachian tube dysfunction B- Giant cell arteritis C- Glossopharyngeal neuralgia D- Occult malginancy E- Temporomandibular joint disorder

E- Temporomandibular joint disorder Risks- Joint trauma, psychiatric illness, Clinical features; facial pain, ear pain, tinnitus, headache, jaw dysfunction Diagnosis: clinical, no need to image, tenderness of mastication muscles, tooth wear, crepitus or clicking with TMJ motion Management: eduction, dental splints, NSAIDS. Most common causes of referred otalgia - are dental disease and TMD

74 year old woman - several days of right ear pain. This morning she had 2 episodes of dizziness and almost fell. The pt takes trimethoprim sulfamethoxazole for uncomplicated UTI. Ne fever, vision loss or headache. Temp 37, BP 116/78, and pulse 100. Ear exam- several Erythematous vesicles in the right external auditory canal with no drainage. TM seen and is intact. There is mild right sided facial droop. Whats causing this? A- Borrelia burgdori B- HSV type 1 C- Pseudomonas aeruginosa D- Stevens-Johnson syndrome E- Varicella zoster virus

E- Varicella zoster virus Ramsy hunt syndrome Reactivation of varicella from the geniculate ganglion - causes CN 7 palsy and CN 8 to have a painful Erythematous vesicular rash on the auditory canal or auricle.

A 40 year old man comes to the office for evaluation of hoarseness. The patient first noticed the symptoms 4 months ago. Since then he has gotten progressively more "raspy". He has no fever, throat pain, SOB, or trouble swallowing. Medical history- asthma, gerd. Medications- inhaled budesonide, albuterol, and omeprazole. The patient smokes 3-4 cigs a day. Vitals normal. Flexible laryngoscopy shows irregular, exophytic growths in clusters on the surface of the vocal cords. Pathology shows no malignant features. Which of the following is the most likely cause for the pt lesions? A- Cigarette smoking B- Environmental allergens C- Fungal infection D- GERD E- Viral infection F- Vocal abuse

E- Viral infection Recurrent respiratory papillomatosis This patioent has laryngeal papillomas due to recurrent resp papillomatosis. They are caused by HPV 6 and 11. Ether due to vertical transmission - reactivation as adults or exposure through sexual. contact.

A 5 year old boy brought ti the ER due to sudden onset difficult breathing. Pt developed a mild cough and sore throat yesterday- parents gave acetominophen- improved throat pain. This morning- difficult breathing and leaning forward refusing to lie down. No medications or allergies. Never taken vaccine. Temp 39, BP 100/65, Pulse 130 and resp 46/min. Oxygen- 92 on room air. Pt anxiuos, drooling, with stridor. Uvula is midline, no oropharyngeal or tonsillar erythema. Lungs- transmitted upper airway noises with no wheezing or crackles. Whats the dx? A- Bronchiolitis B- Croup C- Diphtheria D- Epiglottitis E- Foreign body aspiration F- PEritonosillar abcess

Epiglottitis pt was not vaccinated. pt is leaning forward and hyperextend the neck to maximize airway diameter (tripod position).

3 year old boy- ER for sore throat. Boy woke up this morning and won't eat. Mom gave acetaminophen but pain didn't go. Temp 38.7, resp 28, pt sitting still on moms lap and looks scared. He has hoarse voice, rhinorrhea, and mild stridor. TM are normal. Posterior pharynx shows no erythema or tonsillar exudate. Anterior neck is tender to palpation. Lungs transmit upper airway sounds but are equal and no wheeze or crackles. Lateral X ray given. What is the dx? A. Bacterial tracheitis B- croup C- Epiglottitis D- Foreign body aspiration E- Peritonisllar abscess F- Retropharyngeal abscess

Epiglottitis Xray - shows us supraglottic swelling with enlarged epiglottis- thumb sign B- croup- subglottic narrowing , barky cough F- Retropharyngeal abscess - presents with fever, dysphagia, drooling, stridor, and stiff neck. Yiu will have a swelling of the posterior pharyngeal wall, and X ray shows widened retropharyngeal space.

16 year old boy - ER with sore throat and fever. He started having a sour throat after coming back from summer camp a week ago- it has worsened in the last 2 days. The pt has right neck pain and ear ahce bit no cough or shortness of breath. He does not use tobaco, no sex, no alcohol. Temp 38.8, bp 118/74 and pulse 104. Enlarged and tender cervicallymph nodes are present. Pt is not able to fully open mouth but ear exam normal. A rapid test for S pyogenes- negative. Whats the diagnosis A- Acute epiglottitis B- Acute tonsilitis C- Adenoidal hypertrophy D- Herpangina E- Infectoius mononucleosis F- Peritonisllar abscess

F- Peritonisllar abscess clinical- fever, sore throat, difficult swallow, trimus, hot potato voice, uvula deviated away from abscess, pooling of saliva. Tx- needle aspiration and drainage + antibiotics

A 62 year old man - complains of hoarseness. He says he always had a deep voice but over the past 4 months--> rough and scratchy and the hoarseness is constant. Medical history- COPD and GERD. Pt smokes a pack a day for 40 years. Drinks 12 beers weekly. Vitals normal. Nasal mucosa- dry and oral cavity examination - poor dentition with mild thrush seen on lateral surface of the tongue bilaterally. No cervical lymphadenopathy. Flexible laryngoscopy - clear nasal cavity and nasopharynx. BAs of tongue and tonsils- normal. Vocal cords mobile bilaterally. Fungating irregular mass on the left vocal cord that appears white in some areas and red in others- some crusting blood. Biopsy would show what? A- Adenocarcinoma B- Apthous ulcer C- Laryngeal candidiasis D- Pemphigus vulgaris E- Reflux laryngitis F- SCC G- squamous papilloma H- Vocal cord polyp

F- SCC Fungating mass and persistent hoarseness - laryngeal squamous cell carcinoma. Most important risk are smoking and drinking which this pt does have. A- Adenocarcinoma - unlikely in larynx B- Apthous ulcer - painful ulcer - resolve in less than 2 weeks and usually in oral cavity C- Laryngeal candidiasis - opportunistic infection with oral thrush if pt on corticosteroid inhaler. White patches and plaques would be seen but not a large laryngeal mass. E- Reflux laryngitis - cause hoarseness and dysphagia but no mass G- squamous papilloma - RRP- HPV H- Vocal cord polyp - due to excessive voice us- hoarseness- polyps seen and they dont invade or ulcerate

A 66 year old man comes to the office due to sore throat over the last 3 months. The pain in the throat is worsening when he swallows. HE thought the pain was related to tonsil stones and tried picking them out with tooth picks and gargling with salt water after meals- but the pain wasn't relieved. Pt noticed an ulcer on the right tonsil that bleeds when he touches it. Medical history- COPD- on multiple inhalers. Also pt smoked 2 packs for 50 years. Vitals- normal, Ear exam normal. Nasal mucosa is dry, oral cavity- poor dentition with no lesions. Oropharyngeal - enlarged, firm right tonsil with 1cm ulceration with surrounding fibrinous debris. The left tonsil has several small tonsil stones without surrounding inflammation. No cervical adenopathy. Biopsy- will show what? A- Adenocarcinoma B- Apthous ulcer C- Non-Hodgkin lymphoma D- Pemphigus vulgaris E- Small cell carcinoma F- Squamous cell carcinoma

F- Squamous cell carcinoma Ulcerated tonsil + history of smoking --> suspected SCC. Presents as a sore throat and odynophagia, can ulcerate and bleed to touch. Can present with referred otalgia. Risks- age above 40, tobacco use, alcohol, immunocompromised, HPV.

A 36 year old woman comes to ER due to persistent spinning associated with nausea and vomiting. Since the onset of symptoms 2 days ago, the patient has stayed in bed most of the time due to feeling unsteady when walking. She has had no headache, hearing loss, speech disturbance, or muscle weakness. 2 weeks ago, she had an URTI with sore throat, right ear fullness, and a feeling of muffled hearing. Medical history- childhood asthma, and her only medication is a combined OCP. The pt history is most consistent with consistent with which of the following diagnoses? A- Acute mastoiditis B- BPPV C- Meniere disease D- Perilymphatic fistula E- Vestibular migraine F- Vestibular neuritis

F- Vestibular neuritis : acute single episode that can last days, often follows viral syndrome, abnormal head thrust test

52 year old man comes into the office for hearing loss in the left ear. Pt works in sales and is frequently on the phone. Over the past several months he has had difficulty hearing phone conversations in the left ear and needs to use his right ear. No pain, or vertigo but sometimes feels off balance when walking at night and holds onto walls. Vitals are normal. Exam- normal TM on both sides. Tuning fork on forehead best heard in the right ear. Air conduction is greater than bone conduction bilaterally. There is decreased sensation to touch on the left side of the face. Bilateral upper and lower extremity strength, deep tendon reflexes, and sensation are normal. Which of the following is the most likely cause of the patients symp? A- Cholesteatoma B- Eustachian tube dysfunction C- Herpes zoster oticus D- Meniere disease E- Verterbrobasilar insufficiency F- Vestibular schwannoma

F- Vestibular schwannoma AKA acoustic neuroma Epidemiology - 50 years old, usually unilateral (if bilateral - NF type 2) Clinical- sensorineural hearing loss and imbalance (CN 8 schwann cell tumor) +- facial numbness and or paralysis (due to growth of tumor into the cerebellopontine angle) Dx- Audiogram and MRI with contrast of internal auditory canal Management- observation (if small tumor, minimal symp, older pt) surgery, radiation therapy C- Herpes zoster oticus - can cause hearing loss and imbalance, but pt will have severe pain and a vesicular rash. Also facial paralysis rather than numbness. E- Verterbrobasilar insufficiency - can cause imbalance, but usually with diplopia, perioral numbness, dysarthria and ataxia

A 10 year old girl, right ear pain that began yesterday. Ear feels itchy and gives the sensation of something stuck inside. She recently came from visiting her grandparents at their beach house where a few cousins were recovering from a respiratory infection. The pt had recurrent AOM complicated by persistent effusion and required tympanostomy tube placement at age 2 years old. They fell off and had no ear infection since she was 3 years old. She is not up to date with vaccine, no medical issues. Parents dont smoke in the house. Temp 37, bp 102/58, pulse 94. Examination - tenderness to movement of the pinna during otoscopy, canal red and swollen. TM seen- normal. Left ear normal. Which of the following risk factors most likely contributed to pt condition? A- immunization status B- multiple sick contacts C- recurrent AOM D- tobacco exposure E- Tympanostomy tube placement F- water exposure

F- water exposure

14 year old boy- right ear pain, pruritus, and discharge over the past week. HE has no cold symp, hearing loss, dizziness, or tinitus. Pt returned yesterday from a two week vacation at a lake house where he swam and ate fish. Temp 37, BP 110/70, pulse 75/min. Manipulation of the right ear during otoscopy causes pain. Prominent swelling and erythema of the ear canal with purulent and crusty debris. TM normal. Left ear normal. Nasal and oropharyngeal mucosa are also normal, no rash, no skin lesion. What is the causative organism? A- Aspergillus Fumigatus B- Candida Albicans C- H. Influenza type B D- M. Catarrhalis E- Mucor Circinelloides F- Non typeable H. Influenzae G- Pseudomonas aeruginosa H- S. Pneumoniae

G- Pseudomonas aeruginosa OE- Risks- water exposure, trauma, foreign material, derma issues. microbiology -(MC) Pseudomonas aeruginosa and S. aureus tx- topical antibiotics (fluoroquinolone) +- glucocorticoids consider wick placement to facilitate medication delivery

A 3 year old brought to office by mom due to "inattentiveness". Medical history- significant for preterm birth at 35 weeks,4 ear infections in the past year and mild eczema. Vaccinations are up to date and hearing screening was done 8 months ago and it was normal. Family his- asthma, anxiety and ADHD. When she asks him to do tasks he ignores her. He has become withdrawn lately and often sits in the corner alone playing with rockets instead of with his bro. Poor attention span has worsened over the last couple of months and mom wonders if its related to anxiety about starting preschool. Apart from the inattention- he is affectionate, active little boy who loves ti run around and loves pets. Examination - small 2-3 word phrases, similar to 6 months ago. Neuro exam is normal. Growth curves just under the 50th percentile. Whats the best management? A- Administer an autism spectrum screening questionnaire B- Obtain metabolic testing C- Obtain parent and teacher ADHD rating scales D- Obtain speech and language assessment E- Perform EEG F- Refer to genetic testing G- Repeat audiometry testing

G- Repeat audiometry testing Screening is indicated due to several ear infections in the last year. Hearing tests to be conducted first for all children presenting with social or language deficit.

4 month old boy, noisy breathing. A month ago mom first noticed a squeaky sound when he was crying or lying in his crib. The noise is becoming louder and persistent. Mom thought he got a virus form day care but it wouldn't resolve. No episode of diff breathing or turning blue during feeding but he spits up after feeds. He is vaccinated, full term, uncomplicated preg. He is in the 60th percentile. On PE- pt well and smiles. When supine - inspiratory stridor is heard- resolves when prone. What is the dx? A- airway foreign body B- allergic rhinitis C- choanal atresia D- Food allergy E- Larygnomalacia F- Laryngotracheobronchitis

Larygnomalacia

A 21 month old giri is brought to the ER for difficulty swallowing. She first became ill 3 days ago with runny nose, cough, and low grade fever. Over the last 4 hrs she became extremely fussy at home and would drink or eat. The patient previously has been well and has received all her immunizations. Temp is 38.5, pulse is 180, and resp 40. The patient is agitated, drooling, and has suprasternal and intercostal retractions. She has audible stridor. Lung exam - diminished breath sounds. Due to impending resp failure-pt gets endotracheal intubation- during this- epiglottis is seen as erythematous and oedematous. WHich of the following is the best empiric antibiotics for this pt? a. Ampicillin and gentamicin b. Azithromycin c. Ceftriaxone and vanco d. Clindamycin e. Metronidazile f. Piperacillin-tazobactam and tobramycin

c. Ceftriaxone and vanco This is a case of epiglottitis. It is usually due to H influenza type B, but since we vaccinate all kids that cause is unlikely. Now we have other strains- s pneumoniae, S pygones, S aureus - to worry about. Ceftriaxone - targets the H influenza and strep species. WHile vanco targets staph arues and MRSA.

A 25 year old man comes to the office for evaluation of a painless mass in his mouth. This pt has had mass for many years and it hasn't grown or changed in any way. He has had occasional sinus infections and was in a motor vehicle accident several years ago where he got a concussion but otherwise healthy. Pt smokes a pack a day and drinks on the weekend. Vital normal. The mass is immobile, non tender, and hard in consistency. The maxillary and frontal sinuses are non tender, there is no cervical lymphadenopathy. Whats the cause of the mass? A- congenital anomaly B- Infectious sequelae C- Malignant transformation D- Palatal fracture E- Vascular malformation

congenital anomaly Pt had a chronic mass in his palate - torus palatinus - a benign growth located in midline of the hard palate. It can be congenital or develop later in life. Usually treat only if - symptoms, interfere with speech or eating, or cause issue with fitting dentures later in life.

A 28 year man comes to the office asking for antibiotics to treat a sinus infection. He reports recurrent episodes of nasal congestion, rhinorrhea, and dry cough. The pt has used over the counter allergy medicines with some relief but continues to feel uncomfortable and has difficulty concentrating at work. HE doesn't have SOB, chest pain, or ocular symptoms. The pt has no history of asthma, or allergies but did have eczema as a child. Doesn't smoke or drink. Vitals normal. Exam- transverse nasal crease, swollen pale nasal turbinates, and clear nasal discharge. No maxillary sinus tenderness. Posterior wall has a cobblestone appearance. Breath sound are normal. Whats the most effective management? a- Inhaled beta blockers b- intranasal decongestants c- intranasal glucocorticoids d- oral antibiotics E- oral leukotriene modifiers

c- intranasal glucocorticoids Allergic rhinitis