PANCE Exam: Eyes, Ears, Nose, Throat (EENT) Review Questions & Answers

EYE

Question: What are cotton wool spots?
Cotton wool spots are white patches on the retina that are observed upon funduscopic examination. These patches are due to the ischemia of the superficial nerve layer of the retina. They are most commonly associated with hypertension but also occur in patients with diabetes, anemia, collagen vascular disease, leukemia, endocarditis, and AIDS.

Question: Do visual changes in chronic open-angle glaucoma patients begin centrally or peripherally?
Peripherally. Patients with chronic glaucoma experience a gradual and painless loss of vision. Those with acute- or subacute-angle closure glaucoma will have either dull or severe pain, blurry vision, lacrimation, and even nausea and vomiting. The pain may be more severe in the dark.

Question: Which is more common, chronic open-angle glaucoma or acute closed-angle glaucoma?
Chronic open-angle glaucoma (90%). Four percent of the population older than 40 years have glaucoma.

Question: What is the most common cause of chronic open-angle glaucoma?
Outflow obstruction through the trabecular meshwork. Other causes are obstruction of Schlemm canal and excess secretion of aqueous fluid.

Question: What is the normal range of intraocular pressure?
10 to 23 mm Hg. Patients with acute angle-closure glaucoma generally have pressures elevated to 40 to 80 mm Hg.

Question: In what cases are topical steroids for the eyes absolutely contraindicated?
If the patient has a herpetic infection. Herpetic lesions of the cornea are noted to have dendritic patterns of fluorescein uptake upon slit lamp examination.

Question: What is the most common finding upon funduscopic examination of a patient with AIDS?
Cotton wool spots due to microvascular disease. Other findings are hemorrhage, exudate, or retinal necrosis.

A patient presents with an itching, tearing, in both eyes. Upon examination, large cobblestone papillae are found under the upper lid. What is the probable diagnosis?
Allergic conjunctivitis.

Question: A patient is seen with herpetic lesions on the tip of the nose. Why is this a problem?
The tip of the nose and the cornea are both supplied by the nasociliary nerve. Thus, the cornea may also be involved. This is an ophthalmological emergency.

Question: A patient presents with conjunctiva and lid margin inflammation. Slit lamp examination reveals a “greasy” appearance of the lid margins with scaling, especially around the base of the lashes. What is the diagnosis?
Blepharitis. This is often caused by a staphylococcal infection of the oil glands and skin next to the lash follicles. Treatment includes scrubbing with baby shampoo and, after consultation with an ophthalmologist, use of sulfacetamide drops and steroids.

Question: A patient presents with a painful red eye. Slit lamp examination reveals a localized, white, flocculent infiltrate in the anterior chamber. What is this?
Hypopyon. This is an accumulation of white inflammatory exudate in the anterior chamber.

Question: A welder presents with severe eye pain. What is the expected finding upon slit lamp examination?
Diffuse punctate keratopathy (welder’s flash), which presents as a multiple pinpoint area of fluorescein uptake representing ruptured corneal epithelial cells.

Question: A patient presents with a painful pustular vesicle at the lid margin. What is the diagnosis and treatment?
A hordeolum (sty) is a painful, red, swelling occurring on the upper or lower eyelids. An internal hordeolum is an abscess of the meibomian gland and “points” toward the conjunctival side of the eyelid. An external hordeolum is a painful swelling at the eyelid margin and “points” outward.

Question: A patient presents with a chronic, nontender, uninflamed nodule of the upper lid. What is the diagnosis?
Chalazion. For persistent chalazion, surgical removal may be indicated.

Question: A patient presents with the sensation of a foreign body in the eye. Slit lamp examination reveals a dendritic (branchlike) lesion on the cornea. What is the treatment?
Antiviral agents and cycloplegics. This is most probably a herpes simplex keratitis. Steroids are contraindicated because they allow for viral replication. Emergent ophthalmology consultation is indicated.

Question: A patient presents with sudden onset of vision loss in one eye that quickly returns. This should be diagnosed as what?
Amaurosis fugax. This is usually caused by central retinal artery emboli from extracranial atherosclerosis.

Question: A patient presents with painless vision loss in one eye and describes it as a curtain slowly appearing in the visual field. What finding do you expect upon examination?
A gray, detached retina. The patient may also complain of flashing lights in the peripheral visual field or spider webs in the visual field. Treatment consists of surgical repair.

A patient was hit in the eye during a fight. He presents 8 hours after the incident, with proptosis and visual loss. Examination reveals an intact globe and an afferent pupillary defect. What is the problem?
Retro-orbital hematoma with ischemia of the optic nerve or retina. The pressure in the orbit exceeds the perfusion pressure of the optic nerve and ocular globe, resulting in a lack of blood flow and loss of function. Treatment is to release the pressure by lateral canthotomy. A similar situation can occur with orbital emphysema.

Question: What are the complications of a hyphema?
The 4 Ss:

1. Staining of the cornea due to hemosiderin deposits.

2. Synechiae, which interfere with iris function.

3. Secondary rebleeds, which usually occur between the second and fifth day after the injury (since this is the time of clot retraction) and tend to be worse than the initial bleed.

4. Significantly increased intraocular pressure, which can lead to acute glaucoma, chronic late glaucoma, and optic atrophy.

Question: Why do patients with sickle cell anemia and a hyphema require special consideration when presenting with ophthalmologic concerns?
Increased intraocular pressure can occur if the cells sickle in the trabecular network, preventing aqueous humor from leaving the anterior chamber. Some medications, such as hyperosmotics and Diamox, increase the likelihood of sickling.

Question: A patient presents with a history of trauma to the orbit and dull ocular pain, decreased visual acuity, and photophobia. The examination reveals a constricted pupil and ciliary flush. What will be found on a slit lamp examination?
Cells and flare in the anterior chamber are likely present with a traumatic iritis.

Question: What are the causes of a subluxed or dislocated lens?
Trauma, Marfan syndrome, homocystinuria, and Weill-Marchesani syndrome.

Question: Physiologically, what causes flare?
Flare is caused by inflammatory proteins resulting in the “dust in the movie projector lights” or “fog in the headlights” phenomena during slit lamp examination.

Question: Which is worse, acid or alkaline burns of the cornea?
Alkaline burns, because these cause deeper penetration compared to acid burns. A barrier is formed from precipitated proteins with acid burns. The exceptions are hydrofluoric acid and heavy metal containing acids, which can penetrate the cornea.

Question: When do preexisting conditions contraindicate pharmacologic papillary dilation?
Narrow-angle glaucoma and with an iris-supported intraocular lens.

Question: Why shouldn’t topical ophthalmologic anesthetics be prescribed?
These anesthetics inhibit healing and decrease a patient’s ability to protect the affected eyes because of the loss of sensation.

What is the most common organism in contact lens–associated corneal ulcers?
Pseudomonas.

Question: How can Krazy-Glue (cyanoacrylate) be removed if a patient has stuck the eyelids together?
Begin copious irrigation immediately and then apply mineral oil. Acetone and ethanol are unacceptable in the eyes. Surgical separation must be done with extreme care to prevent laceration of the lids or globe. Often the patient will have a corneal abrasion, which should be treated in the usual manner.

Question: Three hours ago, a patient experienced sudden, painless visual loss in her right eye. Central retinal artery occlusion (CRAO) is suspected. What findings are expected upon eye examination? What is the prognosis?
Afferent pupillary defect, pale gray retina, and a small cherry red dot near the fovea. This dot is the choroidal vasculature seen at the macula where the retina is the thinnest. After 2 hours the prognosis is extremely poor for visual recovery. Digital massage or anterior chamber paracentesis may dislodge the clot. Immediate ophthalmic consultation is necessary.

Question: What conditions have been associated with central retinal vein occlusion?
Hyperviscosity syndromes, diabetes, and hypertension. Funduscopic examination shows a chaotically streaked retina with congested dilated veins. There are superficial and deep retinal hemorrhages, cotton wool spots, and macular edema.

Question: A patient presents with a traumatic pain behind the left eye, an afferent papillary defect, central visual loss, and papilledema. What is the diagnosis? What are the potential etiologies?
Optic neuritis. This may be idiopathic or may be associated with multiple sclerosis, Lyme disease, neurosyphilis, lupus, sarcoid, alcoholism, toxins, or drug abuse.

Question: A patient developed eye pain, nausea, vomiting, blurred vision, and sees halos around lights. Why would this patient be given mannitol, pilocarpine, and acetazolamide?
This patient has acute angle closure glaucoma. The goal of treatment is to decrease intraocular pressure.
- Decrease the production of aqueous humor with carbonic anhydrase inhibitor.
- Decrease intraocular volume by making the plasma hypertonic to the aqueous humor with glycerol or mannitol.
- Constrict the pupil with pilocarpine, allowing increased flow of the aqueous humor out through the previously blocked canals of Schlemm.

Question: A patient presents with multiple vertical linear corneal abrasions. What should be suspected?
A foreign body under the upper lid. This pattern is sometimes called an “ice rink” sign.

Question: What technique can be used to identify and narrow anterior chamber?
Tangential light (from a penlight) is shone perpendicular to the line of vision across the anterior chamber. If the entire iris is in the light, then the chamber is most likely a normal depth. If part of the iris is in a shadow, then the chamber is narrow. This can occur with angle closure glaucoma and with perforating corneal injuries.

Question: What is the difference between a sympathomimetic and a cycloplegic medication when dilating the eye?
A sympathomimetic simulates the iris’s dilator muscle. The cycloplegic inhibits the parasympathetic stimulation, which constricts the iris and inhibits the ciliary muscle. Thus, cycloplegics will cause blurred near vision.

While mowing the lawn, a patient felt something fly into his eye. On examination, there is a brown foreign body on the cornea and a tear drop iris pointing toward the foreign body. What is the diagnosis?
Perforated cornea with extruded iris. A similar foreign body may appear black on the sclera with scleral perforation.

Question: A patient’s cornea fluoresces prior to instillation of fluorescein. What should be considered?
Pseudomonal infection. Several species are fluorescent.

Question: Which anesthetic is faster acting: proparacaine or tetracaine?
Proparacaine has a rapid onset and a duration of 20 minutes. Tetracaine has a delayed onset and a duration of 1 hour.

Question: Place the following mydriatic-cycloplegic medications in the order of duration of activity: tropicamide, homatropine, atropine, and cyclopentolate:
- Tropicamide (onset 15–20 minutes, brief duration)
- Cyclopentolate (onset 30–60 minutes, duration <24 hours)
- Homatropine (long lasting, 2–3 days)
- Atropine (very long lasting, 2 weeks)

Question: What organisms are typically responsible for causing bacterial conjunctivitis?
Staphylococcus aureus, Streptococcus pneumoniae, and Hemophilus influenzae.

Question: A patient presents with a painful eye, blurred vision, and conjunctivitis. Upon slit lamp examination, you detect a dendritic ulcer. What is the most likely cause of this patient’s symptoms?
Herpes simplex keratitis. Treat with topical antivirals. Immediate ophthalmology consult is warranted. Corticosteroids are not to be used unless under direction of an ophthalmologist. If the eye has a bacterial superinfection, prescribe topical antibiotics.

Question: What are the most common causes of periorbital and orbital infections?
Staphylococcus aureus, Streptococcus pneumonia, and Hemophilus influenzae.

Question: What condition should be suspected in a patient with vision loss and a pale fundus?
Central retinal artery occlusion (CRAO). Vision loss is usually acute and painless.

Question: Describe the symptoms of optic neuritis:
Variable loss of central visual acuity with a central scotoma and change in color perception. The disk margins are blurred from hemorrhage, the blind spot is increased, and the eye is painful, especially with movement.

Question: Describe a patient with acute angle-closure glaucoma:
Symptoms include nausea, vomiting, and abdominal pain. Visual acuity is markedly diminished. The pupil is semidilated and nonreactive. There is usually a glassy haze over the cornea, and the eye is red and very painful. Intraocular pressure may be as high as 50 to 60 mm Hg.

Describe the treatment of acute angle-closure glaucoma:
Intravenous acetazolamide (a carbonic anhydrase inhibitor to minimize aqueous humor production), miotics (such as pilocarpine) to open the angle, topical beta-blocker, alpha-adrenergic receptor agonist, and, if necessary, intravenous hyperosmotic agent such as mannitol to reduce intraocular pressure. After the ocular pressure is stabilized, an iridectomy is eventually performed to provide aqueous outflow.

Question: What is the appropriate treatment of hyphema?
Rest, elevation of the head, and topical steroids. Avoid aspirin and NSAIDS. Re-bleeding can occur in up to 20% at 3 days. Complications include glaucoma and corneal staining.

Question: What is the differential diagnosis of a red eye with decreased visual acuity?
Conjunctivitis, keratitis, iritis, glaucoma, and central corneal lesions.

Question: What disease is associated with retrobulbar optic neuritis?
Multiple sclerosis.

Question: Define strabismus, esotropia, and exotropia:
- Strabismus: Lack of parallelism of the visual axis of vision.
- Esotropia: Medial deviation of the axis of vision.
- Exotropia: Lateral deviation of the axis of vision.

Question: An elderly patient presents with the complaint of seeing halos around lights. What diagnosis is suspected?
Glaucoma. Another presenting complaint of glaucoma is blurred vision. Also, consider digitalis toxicity.

Question: What diseases are commonly associated with central retinal vein occlusion?
Hypertension and glaucoma.

Question: What are the common eye findings in patients with AIDS?
Cotton wool spots and hemorrhages are most commonly caused by cytomegalovirus (CMV) retinitis.

Question: What is a hordeolum?
A Meibomian gland infection, usually of the upper lid.

Question: What is a pinguecula?
It is a yellowish nodule, particularly on the nasal portion of the bulbar conjunctiva near the palpebral fissure. In some cases, they can also be located laterally.

Question: What is a pterygium?
It is a chronic growth more commonly over the medial aspect of the conjunctive and part of the cornea approaching the pupil. It is often caused by chronic exposure to wind and dust.

On funduscopic examination, microaneurysms and soft exudates are typical of what?
Hypertension.

Question: On funduscopic examination, macular microaneurysms and hard exudates are typical of what?
Diabetes.

Question: What medications are likely to exacerbate angle-closure glaucoma?
Anticholinergics, antihistamines, antidepressants, benzodiazepine, carbonic anhydrase inhibitors, CNS stimulants, phenothiazine, sympathomimetics, theophylline, and vasodilators.

Question: An elderly patient presents with bilateral eye irritation and states that this persists despite using eye-lubricating drops. On physical examination, you notice that lower eyelid margins are rolled in and eyelashes appear to be rubbing against the conjunctiva and cornea. What is this condition called?
Entropion. This is an inward turning of the eyelid margin from a degeneration of the eyelid fascia. For cases that involve continual irritation of the cornea from the eyelashes, surgery is indicated. Ectropion also occurs at an advanced age, and creates an outward turning or drooping of the lower eyelid. Complications from this are excessive tearing, exposure keratitis, and bad cosmetic appearance.

Question: What is the clinical history and physical examination findings of a central retinal vein occlusion?
Sudden painless vision loss. Physical findings can range from a few hemorrhages and cotton wool spots to a massive superficial and deep hemorrhage with vitreous involvement. Diffuse hemorrhages in a quadrants of the fundus referred to as a “blood and thunder fundus.”

Question: A patient presents with a painful reddened area over the tear duct at the nasal side of the right eye. A small amount of pus is draining from the tear duct. What is this condition called?
Dacryocystitis. The most common pathogens for acute dacryocystitis are S. aureus, and beta-hemolytic streptococci. In chronic dacryocystitis, Candida albicans, anaerobic streptococci, and Staphylococcus epidermidis can be the causative pathogens. Treatment is with systemic antibiotics.

Question: An elderly patient complains of decreasing central vision clarity. He has long smoking history. Upon physical examination, you notice Drusen formations, and on direct ophthalmoscopic examination you see retinal atrophy. What condition is likely?
Age-related macular degeneration.


EAR

Question: What is the most common type of hearing loss in the elderly?
Presbycusis. This is an idiopathic, insidious, symmetrical decline in hearing that is associated with aging.

Question: What systemic sexually transmitted disease is associated with sensorineural hearing loss?
Syphilis. Seven percent of patients with idiopathic hearing loss test positive for treponemal antibodies.

Acute tinnitus is associated with toxicity of what medications?
Salicylates, loop diuretics, and aminoglycosides. Other causes of tinnitus are vascular abnormalities, mechanical abnormalities, and damaged cochlear hair cells. Unilateral tinnitus is associated with chronic suppurative otitis, Meniere disease, and trauma.

Question: A patient experiences vertigo and disequilibrium after a Valsalva maneuver, coughing, or sneezing. What is the most likely diagnosis?
Perilymphatic fistula.

Question: A patient presents with ear pain and fluid-filled blisters on the tympanic membrane. What is the diagnosis?
Bullous myringitis, which is commonly caused by mycoplasma or a virus. Treat with erythromycin or azithromycin.

Question: A 16-year-old boxer presents with a hematoma of the external right ear after receiving a blow to the ear. What is the treatment?
The hematoma should be aseptically drained by incision or aspiration and a mastoid conforming dressing should be applied. ENT follow-up is mandatory. If the ear is not treated appropriately, a cauliflower deformity may result.

Question: A patient presents with a swollen, tender, red left auricle. What is the diagnosis?
Perichondritis. This is most often caused by Pseudomonas.

Question: What is the most common cause of hearing loss?
Cerumen impaction.

Question: Describe the physical finding of unilateral sensorineural hearing loss:
The patient will have air conduction greater than bone conduction (i.e., normal Rinne test) indicating no conductive loss. The Weber test will lateralize to the normal ear.

Question: Which medications should be suspected in a patient with bilateral sensorineural hearing loss?
Ototoxins such as aminoglycosides, loop diuretics, antineoplastics, or salicylates.

Question: What is the most common neuropathy associated with acoustic neuroma?
The corneal reflex may be lost due to trigeminal nucleus involvement.

Question: Name some causes of tympanic membrane perforation:
Air or water blast injuries, foreign bodies in the ear (particularly cotton tip swabs), lightning strikes, otitis media, and associated temporal bone fractures.

Question: A young man who was involved in a barroom brawl complains of ear pain, significantly decreased hearing, and vertigo. A tympanic membrane rupture is determined by examination. What is the concern?
Injury to the ossicles, temporal bone, or labyrinth. An urgent ENT consult is necessary.

A diver on vacation decided to go scuba diving despite having an upper respiratory infection. While descending, she had acute ear pain followed by vertiginous symptoms and vomiting. What happened?
Middle ear squeeze (barotitis media). Pressure from the middle ear could not be equalized because of abnormal eustachian tube function resulting from the illness. The middle ear volume decreased until the tympanic membrane retracted to the point of rupture. The inrush of cold water caused vestibular stimulation. This is the most common form of barotrauma in amateur scuba divers. Similar problems may occur while flying on aircraft.

Question: What organism usually causes pediatric acute otitis media?
Streptococcus pneumoniae, followed by Haemophilus influenzae and Moraxella catarrhalis.

Question: Why are preschool children more susceptible to acute otitis media?
Children have shorter, more horizontal eustachian tubes, which may prevent adequate drainage and allow aspiration of nasopharyngeal bacteria into the middle ear, particularly with URIs.

Question: What is the most common cause of sialadenitis?
Stasis of the flow of saliva. The most common bacterial pathogens are S. aureus, S. pneumonia, E. coli, H. influenzae, and viruses. Signs and symptoms include fever, pain, swelling of the salivary glands, which may include the parotid gland.

Question: A patient presents with trismus, fever, and an erythematous, tender parotid gland. Pus is expressed from Stensen duct. What conditions predispose the patient to bacterial parotitis?
Any situation that decreases salivary flow, including irradiation, phenothiazines, antihistamines, parasympathetic inhibitors, dehydration, and debilitation. Up to 30% of cases occur postoperatively.

Question: What are the incidences of salivary gland malignancies?
Parotid 40%, submandibular 10%, and sublingual 1%.

Question: A 44-year-old man has lost sensorineural hearing in his left ear. What ear will the Weber test lateralize to?
The right or normal ear. The damaged ear is less prone to detect sound waves via vibration.

Question: What is the most common complication of acute otitis media?
Tympanic membrane perforation. Other complications include mastoiditis, cholesteatoma, and intracranial infections.

Question: A patient presents with hearing loss, nystagmus, facial weakness, and diplopia. Vertigo is provoked with sudden movement. A lumbar puncture reveals elevated CNS protein. What diagnosis is suspected?
Acoustic neuroma.

Question: What is the most common causative organism of otitis externa?
Pseudomonas species.

Question: Which medications put patients at risk for hearing loss?
Aminoglycoside, antineoplastic agents, loop diuretics, and salicylates.

A 17-year-old female patient presents with a history of ear discharge and pain, fever and swelling, and redness over the mastoid bone. She was treated for an otitis media 2 weeks ago. What is your clinical suspicion?
Mastoiditis is a complication of otitis media and is caused by bacterial invasion into the mastoid air cells. The most common causative pathogens are S. pneumonia, H. influenzae, and S. aureus. If a subperiosteal abscess develops, surgical drainage is indicated.

Question: Describe the clinical presentation and treatment for Meniere disease:
A patient will complain of aural pressure, episodic vertigo that lasts for hours, tinnitus, and hearing loss. The treatment includes a sodium-restricted diet, limiting caffeine and alcohol, and prescribing diuretics like hydrochlorothiazide. Acute episodes can be managed with vestibular suppressant benzodiazepines and antiemetics.

Question: Describe the signs and symptoms in a patient with vestibular neuronitis (labyrinthitis):
The patient will have a rapid onset of severe vertigo (but some may have a gradual prodromal period) accompanied by nausea, vomiting, and imbalance. This is usually preceded by an upper respiratory infection. Rapid phase nystagmus and the feeling of body motion is toward the opposite ear with falling and past pointing toward the affected ear.

Question: What is a vestibular schwannoma?
An acoustic neuroma or a tumor of the eighth cranial nerve. In addition to hearing loss and vertigo, patients also present with tinnitus. Surgical removal is the treatment of choice because this tumor may spread to the cerebellum and the brainstem.

Question: What are the most common initial symptoms of an acoustic neuroma?
Tinnitus, hearing loss, and unsteadiness.

Question: Describe the signs and symptoms of acoustic neuroma:
Unilateral high tone sensorineural hearing loss and tinnitus. Decreased corneal sensitivity, diplopia, headache, facial weakness, and positive radiographic findings may also be displayed. Vertigo usually appears late, is more often exhibited as a progressive feeling of imbalance, and can be provoked by changes in head movement. Nystagmus is frequently present and is usually spontaneous. The CSF may have elevated protein.

Question: A child with blurry vision has an abnormal pupillary reflex and a white reflex upon funduscopic examination. What is the likely diagnosis?
Retinoblastoma. These can grow to other sites in the brain or body. Surgical removal is indicated. This condition is inheritable and thus the parents should be counseled about the risks.

Question: The Weber test is performed on a patient complaining of hearing loss. The patient hears sounds more loudly in his right ear. Which types of hearing loss may this patient have?
Conductive hearing loss on the right or sensory neural hearing loss on the left.

Question: Describe Rinne test and explain the normal findings:
Rinne test is performed by placing the tip of the tuning fork on the mastoid process until the patient can no longer hear the tone. The fork is then relocated to just in front of the pinna until the patient can no longer hear the tone. In normal patients, the air conduction to bone conduction ratio is 2:1.

A 35-year-old woman with a history of flulike symptoms (URI) 1 week ago presents with vertigo, nausea, and vomiting. No auditory impairment or focal deficits are noted. What is the likely diagnosis?
Labyrinthitis or vestibular neuronitis.

Question: Describe the key features of Meniere disease, also known as endolymphatic hydrops:
Vertigo, hearing loss, and tinnitus. Meniere disease typically presents with the rapid onset of vertigo, nausea, and vomiting that lasts for hours to 1 day. Nystagmus may be spontaneous during the critical stage. Tinnitus may be present and is louder during attacks, and sensorineural hearing loss may occur. There also may be an aura with a sensation of fullness in the ear during an attack. Symptoms are unilateral in more than 90% of patients and recurring attacks are typical.

Question: What are the distinguishing characteristics of benign positional vertigo?
Positional vertigo is usually provoked by certain head positions or movement. Nystagmus is always positional, of brief duration, and with fatigability.

Question: What are the key features of viral labyrinthitis or vestibular neuritis?
Severe vertigo (usually lasting 3–5 days), with nausea and vomiting. Symptoms generally regress over 3 to 6 weeks. Nystagmus may be spontaneous during the severe stage.

Question: A 50-year-old female patient with acute vertigo, nausea, and vomiting reports similar episodes over the last 20 years that are sometimes associated with hearing change, hearing loss, and tinnitus. She has permanent right > left sensorineural hearing loss. What is the diagnosis?
Meniere disease.

Question: For the following clinical presentations, identify which are associated with peripheral vertigo or with central vertigo:

1. Intense spinning, nausea, hearing loss, diaphoresis.

2. Swaying or impulsion, worse with movement, tinnitus, acute onset.

3. Unidirectional nystagmus inhibited by ocular fixation, fatigable.

4. Mild vertigo, diplopia, and ataxia.

5. Multidirectional nystagmus not inhibited by ocular fixation, nonfatigable.
Peripheral vertigo: (1), (2), and (3); central vertigo: (4) and (5).

Question: What are the common features of central vertigo?
Symptoms are gradual and continuous. They include focal signs, nausea, and vomiting. Hearing loss is rare.

Question: What are the signs and symptoms of peripheral vertigo?
Symptoms are usually acute and intermittent. Hearing loss is common; nausea and vomiting are severe.

Question: What is the significance of bilateral nystagmus with cold caloric testing?
It signifies that an intact cortex, midbrain, and brainstem are present.

What is a mnemonic for remembering the drugs that cause nystagmus?
MALES TIP:
Methanol
Alcohol
Lithium
Ethylene glycol
Sedative hypnotics and Solvents
Thiamine depletion and Tegretol (carbamazepine)
Isopropanol
PCP and phenytoin


NOSE/SINUS

Question: A 3-year-old child presents with a unilateral purulent rhinorrhea. What is the probable diagnosis?
Nasal foreign body.

Question: What potential complications of nasal fracture should always be considered on physical examination?
Septal hematoma and cribriform plate fractures. A septal hematoma appears as a bluish mass on the nasal septum. If not drained, aseptic necrosis of the septal cartilage and septal abnormalities may occur. A cribriform plate fracture should be considered in a patient who has a clear rhinorrhea after trauma.

Question: What four physical examination findings would make posterior epistaxis more likely than anterior epistaxis?

1. Inability to see the site of bleeding. Anterior nosebleeds usually originate at Kiesselbach plexus and are easily visualized on the nasal septum.
2. Blood from both sides of the nose. In a posterior nosebleed, the blood can more easily pass to the other side because of the proximity of the choanae.
3. Blood trickling down the oropharynx.
4. Inability to control bleeding by direct pressure.

Question: Where is the most common site of bleeding in posterior nosebleeds?
The sphenopalatine artery’s lateral nasal branch.

Question: A patient returns to the emergency department with fever, nausea, vomiting, and hypotension 2 days after having nasal packing placed for an anterior nosebleed. What potential complication of nasal packing should be considered?
Toxic shock syndrome. This syndrome is caused by toxin-releasing Staphylococcus aureus.

Question: A child with a sinus infection presents with proptosis, a red, swollen eyelid, and an inferolaterally displaced globe. What is the diagnosis?
Orbital cellulitis and abscess associated with ethmoid sinusitis.

Question: A patient with frontal sinusitis presents with a large forehead abscess. What is the diagnosis?
Pott puffy tumor. This is a complication of frontal sinusitis in which the anterior table of the skull is destroyed, allowing the formation of the abscess.

An ill-appearing patient presents with a fever of 103°F, bilateral chemosis, extra ocular motion palsy, with a history of untreated sinusitis. What is the diagnosis?
Cavernous sinus thrombosis. This life-threatening complication occurs from direct extension through the valveless veins. Complications of sinusitis may be local (osteomyelitis), orbital (cellulitis), or within the central nervous system (meningitis or brain abscess).

Question: Symptoms of itchy eyes, nasal congestion, sneezing, rhinorrhea with physical findings of bluish inflamed turbinates, and mucoid nasal discharge are consistent with what condition?
Allergic rhinitis.

Question: What is the differential diagnosis for persistent nasal congestion?
Allergic rhinitis, infection, perennial nonallergic rhinitis (vasomotor rhinitis), pollutants and irritants, medication-induced topical rhinitis (rhinitis medicamentosa), anatomic deformities like nasal polyps or deviated septum, and tumors and foreign bodies.

Question: What are the classifications of allergic rhinitis?

Seasonal allergic rhinitis occurs when symptoms predictably appear seasonally in response to plant and tree pollination. Symptoms are exacerbated during windy periods.
Perennial allergic rhinitis occurs all year long but can vary in intensity. Allergens responsible for this condition are usually indoor irritants like dust mites, smoke, chemicals, cockroaches, and animal dander.

Question: What are the two common pathogens in adult acute sinusitis?
Streptococcus pneumoniae and Haemophilus influenzae.

Question: What is a frequent complication of ethmoid sinusitis?
Orbital cellulitis.


MOUTH/THROAT

Question: Hairy leukoplakia is characteristic of which two viruses?
HIV and Epstein-Barr virus. Hairy leukoplakia is usually found on the lateral aspect of the tongue. Oral thrush may also be associated with HIV infection.

Question: How can Ellis class II and III dental fractures be differentiated?
Class II fractures involve the dentin and enamel. The exposed dentin will be pinkish. Class III fractures involve the enamel, dentin, and pulp. A drop of blood is frequently noted in the center of the pink dentin.

Question: A patient presents 3 days after tooth extraction with severe pain and a foul mouth odor and taste. What is the appropriate diagnosis and treatment?
Alveolar osteitis (dry socket) results from loss of the blood clot and local osteomyelitis. Treat by irrigation of the socket and application of a medicated dental packing or iodoform gauze moistened with Campho-Phenique or eugenol.

What is the most common oral manifestation of AIDS?
Oropharyngeal thrush. Other AIDS-related oropharyngeal diseases are Kaposi sarcoma, hairy leukoplakia, and non-Hodgkin lymphoma. Thrush can be differentiated from leukoplakia if it can be scraped from the mucosa with a tongue blade. Hairy leukoplakia cannot be removed.

Question: Retropharyngeal abscesses are most common in what age group? Why?
Retropharyngeal abscesses occur from 6 months to 3 years of age. Retropharyngeal lymph nodes regress in size after age 3.

Question: Describe the overall appearance of a child with a retropharyngeal abscess:
These children are often ill-appearing, febrile, stridorous, drooling, and in an opisthotonic position. They may complain of difficulty swallowing or may refuse to eat.

Question: What radiographic sign indicates a retropharyngeal abscess?
Widening of the retropharyngeal space, which is normally 3 to 4 mm or less than half the width of the vertebral bodies. False widening may occur if the X-ray is not taken during inspiration and with the patient’s neck extended. Occasionally, an air–fluid level may be noted in the retropharyngeal space.

Question: Retropharyngeal abscesses are most commonly caused by which organisms?
β-Hemolytic streptococci and Staphylococcus aureus.

Question: What is the most common type of laryngeal cancer?
Squamous cell carcinoma accounts for greater than 90% and is linked to tobacco and excessive alcohol use.

Question: A 48-year-old male patient presents with high fever, trismus, dysphagia, and swelling inferior to the mandible in the lateral neck. What is the diagnosis?
Parapharyngeal abscess.

Question: Where is the most common origin of “Ludwig angina”?
The lower second and third molar. Ludwig angina is a swelling in the region of the submandibular, sublingual, and submental spaces, which may cause upward and posterior displacement of the tongue. It is most commonly caused by hemolytic streptococci, staphylococci, and mixed anaerobic/aerobic bacteria.

Question: Herpangina is caused by what virus?
Coxsackie virus group A. Sore throat, fever, malaise, and vesicular lesions on the posterior pharynx or the soft palate are prevalent with this disease.

Question: What is the IM treatment for adult streptococcal pharyngitis?

1.2 million units of benzathine penicillin G. Use 0.6 million units of benzathine penicillin G for children weighing less than 27 kg.

What viral agent most commonly induces laryngotracheitis?
Parainfluenza virus type I, II, & III are most common, but can be Influenza A & B or RSV(respiratory syncytial virus). Staphylococcus aureus and Streptococcus pneumoniae are the most common bacterial pathogens.

Question: What is the initial antibiotic treatment for a child with epiglottitis?
Treat with a second- or third-generation cephalosporin. The most likely cause of this condition is H. influenzae type b. This pathogen is seen in patients who lack Hib vaccination or have had vaccination failure. Other pathogens are group A streptococci and Streptococcus pneumonia.

Question: What are the signs and symptoms of a peritonsillar abscess?
Sore throat, dysarthria (“hot potato” voice), odynophagia, ipsilateral otalgia, low-grade fever, trismus, and uvular displacement.

Question: What is the presentation of a patient with diphtheria?
Sore throat, dysphagia, fever, and tachycardia. A dirty, tough gray fibrinous membrane so firmly adherent that removal causes bleeding may be present in the oropharynx. Corynebacterium diphtheriae exotoxin acts directly on cardiac, renal, and nervous systems. It can cause ocular bulbar paralysis that may suggest botulism or myasthenia gravis. The exotoxin may also cause flaccid limb weakness. Such weakness may also include decreased or absent DTRs—a finding suggestive of Guillain-Barré or tick paralysis.

Question: How does a patient present with a retropharyngeal abscess?
Retropharyngeal abscesses are common among those younger than 3 years of age. On examination, the uvula and tonsil are displaced away from the abscess. The neck is held in hyperextension. Soft tissue swelling and forward displacement of the larynx are present. Soft tissue X-ray films of the neck may show the retropharyngeal space to be wider that the vertebral body of C4.

Question: How does an adult with epiglottitis present?
Sore throat and severe dysphagia, drooling, muffled voice are prominent symptoms. Adults have an indolent course preceded by a viral URI. Pain is out of proportion to objective findings.

Question: Name the most likely pathogens to cause acute parotitis:
The most likely causes of acute parotitis are paramyxovirus (mumps), influenza A virus, Coxsackievirus group A, cytomegalovirus, and echovirus.

Question: List the criteria that would be helpful to diagnose group A hemolytic streptococci:
Tonsillar exudate, tender anterior cervical adenopathy, absence of cough, and a history of fever.

Question: What is the first-line drug of choice for treating streptococcus pyogenes?
The first-line treatment for group A beta-hemolytic streptococci is penicillin. Clindamycin or erythromycin is recommended for patients with a penicillin allergy.

Question: A patient presents with a history of sore throat, fever, hot potato voice, and difficulty swallowing. What must you be clinically suspicious of?
Peritonsillar abscess.

A patient presents with a history of sudden pain and swelling over the submandibular gland. He states this occurred while eating lunch. What is your diagnosis?
Sialolithiasis. Eighty percent of the time, salivary duct stones develop in the submandibular gland, with 10% to 20% occurring in the parotid gland. If the stone doesn’t pass spontaneously, ENT referral for endoscopic extraction is indicated.

Question: A patient presents to you with a dental abscess. What antibiotic is indicated for this condition?
Clindamycin or amoxicillin and clavulanic acid will provide good coverage for the oral flora and anaerobes such as Bacteroides fragilis.

Question: A patient presents with a painful cluster of vesicles on the lower lip. What is your diagnosis?
Herpes simplex type 1 causes lesions to develop on the lips and mouth. HSV-1 can also cause genital lesions transmitted by oral–genital contact. Herpes simplex type 2 causes genital herpes. Approximately 25% of the population has serologic evidence of HSV-2.

Question: What anatomic abnormalities exist when a patient presents with stridor?
Swelling or obstruction in the larynx or trachea. Inspiratory stridor indicates obstruction at glottis or supraglottis. Expiratory stridor is created in the trachea. Biphasic stridor is created at the subglottis.

Question: What are the incidences of salivary gland malignancies?
Parotid 40%, submandibular 10%, and sublingual 1%.