ENT 2 Examples + Tx

Question 1

A pt comes in complaining of ipsilateral facial paralysis and ear pain. Upon examination you note otalgia (pain out of proportion to PE findings), & vesicles in EAC or on auricle.

What condition is this characteristic of? What other symptoms may they have?

Answer 1

Ramsay Hunt syndrome (herpes zoster oticus)

-Ipsilateral altered taste perception & tongue lesions, hearing abnormalities, lacrimation, & vertigo

Question 2

Ramsay hunt syndrome Tx

Answer 2

Treatment (within 3 days):
-Antiviral (valacyclovir) x 7-10 days
-Steroid (prednisone) x 5 days (no taper)
-IV therapy for severe cases (vertigo, tinnitus, or hearing loss)

Question 3

John, age 1, who was previously diagnosed with AOM, presents with a prominent auricle, retro-auricular swelling, and tenderness over the mastoid process with a fever. His parent notes poor feeding since the onset of Sx.

Upon otoscopy you note edematous EAC, bulging or perforated TM, middle ear effusion.

What is his Dx? What other Sx may he have?

Answer 3

Mastoiditis

Otalgia, lethargy, malaise, irritability, diarrhea

Question 4

Mastoiditis Tx

Answer 4

-Obtain specimens: middle ear, abscess fluid, CSF, or blood cultures
-IV antibiotics, surgery
-Refer to otolaryngologist early
-Uncomplicated: IV antibiotics & middle ear drainage with myringotomy (+ T-tube placement)
-Complicated: aggressive surgery with mastoidectomy

Question 5

Jane, age 30, has experienced 2 episodes of episodic vertigo lasting 6 hours, unilateral tinnitus, & sensorineural hearing loss.

Audiometry shows low- to mid-frequency SNHL in affected ear. No edema or otorrhea on PE.

What is her Dx? Does her Dx always present this way?

Answer 5

Meniere’s disease; can also be bilateral, vertigo can last anywhere from 20 mins to 12 hours.

Question 6

Meniere’s disease Tx

Answer 6

(Improve quality of life/symptomatic):
1) Diet & lifestyle adjustment: Low-salt diet
-Avoid/limit triggers (caffeine, alcohol, nicotine, stress, MSG)
2) Medications (daily vasodilators or diuretics with as-needed vestibular suppressants & antiemetics)
3) Vestibular rehabilitation (for residual disequilibrium between attacks)

Question 7

A pt with a Dx of presbycusis complains of ringing in their ears. Why should you perform a PE?

Answer 7

To check for cerumen impaction or effusion as alternate causes

Question 8

A pt complains of non-pulsatile tinnitus. What test should you perform? Why?

Answer 8

Audiometry to exclude HL

Question 9

A pt complains of unilateral tinnitus with HL. What test do you order? Why?

Answer 9

MRI; exclude retro-cochlear lesion such as vestibular Schwannoma

Question 10

A pt experiences pulsatile tinnitus. What tests do you need to order and why?

Answer 10

MRA/MRV & temporal bone CT; exclude vascular lesion or sigmoid sinus abnormality

Question 11

How do you treat tinnitus?

Answer 11

Goal: decrease awareness & impact on quality of life
1) Address associated conditions than can exacerbate symptoms (i.e., depression, insomnia, vascular abnormalities, presbycusis)
2) Avoidance of exposure to excessive noise, ototoxic agents & other factors possibly damaging cochlea
3) Masking with music or amplification of normal sounds (hearing aids)
4) Oral antidepressants most effective (nortriptyline 50 mg PO qhs)

Question 12

If a pt has cerumen impaction or transient ETD, what type of HL are they most likely to have? Is it correctable?

Answer 12

CHL; usually correctable

Question 13

MRI or CT should be ordered in what HL scenario?

Answer 13

If your pt has progressive or sudden asymmetric SNHL

Question 14

Gerald, age 75, complains that over time, he’s lost his ability to hear his wife’s voice, but he notes that he can still hear his brother’s voice just fine. Upon examination, you verify that his HL is bilateral. What is his Dx?

Answer 14

Presbycusis; age-related hearing loss (ARHL)

Question 15

Should hearing amplification be the first thing you recommend to all patients with HL?

Answer 15

No; indicated for patients with HL not correctable by medical therapy

Question 16

A pt diagnosed with otitis externa is still experiencing worsening symptoms despite treatment. What should you suspect?

Answer 16

Squamous cell carcinoma (SCC)

Question 17

A pt has a neoplasm on the EAC.
1) Based on statistics alone, what is it most likely to be?
2) What else could it be?

Answer 17

1) Squamous cell carcinoma (SCC)
2) Adenomatous tumors from ceruminous glands

Question 18

A patient complains of pulsatile tinnitus, hearing loss, unilateral facial muscle abnormalities, and is unable to shrug their shoulder. You visualize a mass behind an intact TM.

1) You realize they have a rare condition; what is it?
2) What test should you order and why?

Answer 18

1) Primary middle ear tumor (possible glomus tumor)
2) MRA & MRV to rule out vascular mass

Question 19

How would you treat a pt with acoustic neuroma (Vestibular Schwannoma)?

Answer 19

Observation, surgical excision, and/or radiation therapy

Question 20

A child presents with epistaxis. What is the most likely cause?

Answer 20

Digital trauma; predominately anterior

Question 21

A pt who is on anticoagulation or antiplatelet medication is experiencing epistaxis. Do you tell them their medication is the cause?

Answer 21

No; these meds may cause frequency and reoccurrence of epistaxis to increase, but they don’t cause it

Question 22

A pt has epistaxis. What is its most likely location?

Answer 22

Anterior septum (Kiesselbach’s plexus)

Question 23

What are some things that may increase a pts predisposition to epistaxis?

Answer 23

Tumors, coagulation disorders, recent trauma or surgery, medications, & other conditions (cirrhosis, HIV, cocaine use

Question 24

How would you examine a pt with epistaxis who is stable?

Answer 24

1) Pre-treat/anesthetize nasal cavity: cotton swabs soaked in anesthetic & vasoconstrictive agents (i.e., lidocaine with epinephrine)
2) Localize source: visualization with nasal speculum, headlamp, & suction (use eye protection), perform head & neck exam

Question 25

Describe how to treat a stable epistaxis pt

Answer 25

1) Initial tamponade (anterior): Pt blows nose to remove blood & clots, clnician sprays nares with oxymetazoline, pt pinches mid-nose tightly for 10-15 minutes
2) Cauterization (if source visualized): silver nitrate, diathermy, or electrocautery
3) Packing: Anesthetic-vasoconstrictor solution pleglets - 4% lidocaine & topical epinephrine (1:10,000), petrolatum gauze packing, compressed sponge (Merocel), tampons, balloons (Rapid Rhino), absorbable Materials (Surgicel, Gelfoam

Question 26

How would you treat a pt with posterior epistaxis?

Answer 26

1) Insert posterior nasal packing: posterior (+ anterior) balloon or Foley catheter (usually performed by otolaryngologist)
2) Urgent ENT consultation & hospitalization (may require surgical cauterization)
3) Hematology consultation for bleeding disorders & coagulopathies

Question 27

A pt presents with allergic rhinitis, asthma, atopic dermatitis. What is this an example of?

Answer 27

The allergic triad

Question 28

Pale or violaceous/bluish turbinate mucosa and clear rhinorrhea upon otoscopic examination are indicative of what condition?

Answer 28

Allergic rhinitis

Question 29

Cobblestoning of posterior pharynx and darkening of the skin under the eyes are likely due to what?

Answer 29

Allergic rhinitis

Question 30

Allergic rhinitis Tx

Answer 30

1) Environmental control measures & allergen avoidance
2) Nasal saline sprays & irrigation
3) Pharmacotherapy
-Intranasal corticosteroids (mainstay of therapy) (i.e., fluticasone)

Question 31

A pregnant pt presents with allergic rhinitis. How would you treat them?

Answer 31

1) Intranasal cromolyn sodium (1st line of defense)
2) Intranasal corticosteroids: TOC for moderate-to-severe disease

Question 32

Antihistamine nasal sprays, oral and nasal decongestants, and initiating immunotherapy should all be avoided for what kind of patient?

Answer 32

Pregnant pts

Question 33

If a pt presents with only nasal congestion, can you diagnose them with non-allergic rhinitis?

Answer 33

Yes (but tends to occcur w later age of onset (usually > 20 y/o))

Question 34

A 35 year old woman presents with post-nasal drainage and rhinorrhea. She reports that it doesn’t seem to be related to illness, and often occurs when the weather changes. What does she likely have?

Answer 34

Non-allergic rhinitis [due to weather]

Question 35

How do you treat a pt with non-allergic rhinitis?

Answer 35

1) Topical intranasal glucocorticoids (i.e., budesonide)
2) Topical antihistamine (i.e., azelastine)
3) Combination glucocorticoid & antihistamine more effective (i.e., fluticasone/azelastine)
4) Nasal saline irrigation

Question 36

If a pt says their PCP diagnosed them with “rebound nasal congestion”, you know that this means what?

Answer 36

Rhinitis medicamentosa

Question 37

A pt who uses oxymetazoline or phenylephrine (they can’t remember) daily reports severe nasal congestion.

What do they have? How do you treat them?

Answer 37

Rhinitis medicamentosa; counseling

Question 38

1) Symptomatic inflammation of nasal cavity & paranasal sinuses that lasts less than 4 weeks is called what?
2) What abt if it lasts more than 12 weeks?

Answer 38

1) Acute rhinosinusitis
2) Chronic rhinosinusitis

Question 39

If a pt has acute rhinosinusitis, what type are they most likely to have?

Answer 39

Acute viral rhinosinusitis (common cold)

Question 40

If a pt has acute rhinosinusitis, but you’ve ruled out a viral cause, what may they be infected with?

Answer 40

ABRS because of Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis

Question 41

A 75 year old pilot with a Hx of allergies presents with purulent nasal discharge and facial pain or pressure that is worse when bending to pick up their suitcase. Upon palpation of the sinuses the pt experiences pain.

What do they most likely have? Do you need to do a test to Dx them with this?

Answer 41

Acute rhinosinusitis; no, diagnostic imaging is NOT required

Question 42

You order a CT scan for a pt who appears to be presenting with severe acute rhinosinusitis. What should you expect to see? Are these specific to this condition?

Answer 42

Air-fluid levels, mucosal edema, & air bubbles within the sinuses; nonspecific.

Question 43

How should you treat a pt with acute viral rhinosinusitis?

Answer 43

1) OTC analgesics & antipyretics: NSAIDs & acetaminophen
2) Saline irrigation: buffered, physiologic, or hypertonic saline
3) Intranasal glucocorticoids: short-term
4) Others: intranasal saline spray, intranasal ipratropium bromide, oral decongestants, intranasal decongestants, antihistamines, mucolytics, & steam inhalation (tenting)

Question 44

A pt presents with pre-septal and orbital cellulitis. You know that these two things could be complications of what?

Answer 44

Acute rhinosinusitis

Question 45

A pt diagnosed with ABRS (acute bacterial rhinosinusitis) comes back to your office and presents with neck stiffness, papilledema upon examination, and obvious proptosis. What should you do?

Answer 45

Refer them to a specialist immediately