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A 28-year-old 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
patient has used over-the-counter allergy medicines with some relief but continues to feel
uncomfortable and has difficulty concentrating at work. He does not have shortness of
breath, chest pain, or ocular symptoms. The patient has no prior history of allergies or
asthma but had eczema during childhood. He does not use tobacco, alcohol, or illicit
drugs. His temperature is 37 C (98.6 F), blood pressure is 120/78 mm Hg, and pulse is
76/min. Physical examination shows a transverse nasal crease, swollen and pale nasal
turbinates, and a clear nasal discharge. There is no maxillary sinus tenderness. The
posterior pharyngeal wall has a "cobblestone" appearance. Breath sounds are normal
with no added sounds. Which of the following is the most effective therapy for this
patient's condition?

0 A. Inhaled beta agonist


0 B. Intranasal decongestant
0 C. Intranasal glucocorticoid
o D. Oral antibiotics
0 E. Oralleukotriene modifier

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A 28-year-old 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
patient has used over-the-counter allergy medicines with some relief but continues to feel
uncomfortable and has difficulty concentrating at work. He does not have shortness of
breath, chest pain, or ocular symptoms. The patient has no prior history of allergies or
asthma but had eczema during childhood. He does not use tobacco, alcohol, or illicit
drugs. His temperature is 37 C (98.6 F), blood pressure is 120/78 mm Hg, and pulse is
76/min. Physical examination shows a transverse nasal crease, swollen and pale nasal
turbinates, and a clear nasal discharge. Ther.e is no maxillary sinus tenderness. The
posterior pharyngeal wall has a "cobblestone" appearance. Breath sounds are normal
with no added sounds. Which of the following is the most effective therapy for this
patient's condition?

A. Inhaled beta agonist [2%)


B. Intranasal decongestant [20%)
C. Intranasal glucocorticoid [68%)
D. Oral antibiotics [2%)
E. Oralleukotriene modifier [8%)

Proceed to Next Item

Explanation: User

Allergic rhinitis

• Rhinorrhea, nasal congestion, sneezing, nasal itching


Symptoms • Cough secondary to postnasal drip
• Fatigue, irritability
• Ocular itching & tearing

• "Allergic shiners" (infraorbital edema & darkening)


• Dennie-Morgan lines (prominent lines on lower eyelids)
Physical • "Allergic salute" (transverse nasal crease)
examination • Pale, bluish, enlarged turbinates
• Pharyngeal cobblestoning
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Explanation: User

Allergic rhinitis

• Rhinorrh ea, nasal congestion, sneezing, nasal itching


Symptoms • Cough secondary to postnasal drip
• Fatigue, irritability
• Ocular itching & tearing

• "Allergic shiners" (infraorbital edema & darkening)


• Dennie-Morgan lines (prominent lines on lower eyelids)
Physical • "Allergic salute" (transverse nasal crease)
examination • Pale, bluish, enlarged turbinates
• Pharyngeal cobblestoning
• "Allergic facies" (high-arch ed palate, open-mouth breathing)

Treatment • Intranasal corticosteroid


• Allergen avoidance
@UWorid

This patient has typical features of allergic rhinitis including nasal congestion, clear
rhinorrhea, and pale, edematous nasal mucosa. Patients may also have nasal creases,
pharyngeal cobblestoning, conjunctival edema, or thick, green nasal discharge. During
peak allergy seasons, patients can experience systemic (eg, fever) or neuropsychiatric
(eg, fatigue, irritability) symptoms. Atopic disorders (eg, allergic rhinitis, "hay fever,"
asthma, eczema) frequently cluster in families, but individual patients usually experience
only a subset of these manifestations.

Allergen avoidance can mitigate the symptoms of allergic rhinitis but is not always
possible, and even low-level exposure can trigger bothersome symptoms.
Glucocorticoid nasal sprays (eg, fluticasone, mometasone) are the most effective
single agents. An initial response can be seen within several hours of administration, but
maximal benefits may require continuous treatment for several days or weeks.
Nonsedating oral antihistamines (eg, loratadine, cetirizine), antihistamine (eg, azelastine)
or cromolyn nasal sprays, and leukotriene modifiers (eg, montelukast) are less effective
but can be considered based on the patient's symptoms and drug tolerances (Choice E).

(Choice A) Inhaled beta agonists are indicated for patients with asthma. Patients with
wheezing should be evaluated for possible asthma, but a dry cough alone is a
Treatment
• Allergen avoidance

This patient has typical features of allergic rhinitis including nasal congestion, clear
rhinorrhea, and pale, edematous nasal mucosa. Patients may also have nasal creases,
pharyngeal cobblestoning, conjunctival edema, or thick, green nasal discharge. During
peak allergy seasons, patients can experience systemic (eg, fever) or neuropsychiatric
(eg, fatigue, irritability) symptoms. Atopic disorders (eg, allergic rhinitis, "hay fever,"
asthma, eczema) frequently cluster in families, but individual patients usually experience
only a subset of these manifestations.

Allergen avoidance can mitigate the symptoms of allergic rhinitis but is not always
possible, and even low-level exposure can trigger bothersome symptoms.
Glucocorticoid nasal sprays (eg, fluticasone, mometasone) are the most effective
single agents. An initial response can be seen within several hours of administration, but
maximal benefits may require continuous treatment for several days or weeks.
Nonsedating oral antihistamines (eg, loratadine, cetirizine), antihistamine (eg, azelastine)
or cromolyn nasal sprays, and leukotriene modifiers (eg, montelukast) are less effective
but can be considered based on the patient's symptoms and drug tolerances (Choice E).
(Choice A) Inhaled beta agonists are indicated for patients with asthma. Patients with
wheezing should be evaluated for possible asthma, but a dry cough alone is a
nonspecific symptom.
(Choice B) Nasal decongestant sprays can reduce mucosal edema but are less
effective overall than glucocorticoids and can cause rebound congestion (rhinitis
medicamentosa).
(Choice 0 ) This patient has no fever or sinus tenderness to suggest bacterial sinusitis.
Educational objective:
Glucocorticoid nasal sprays are the most effective single agent for allergic rhinitis,
although maximal benefits may require continuous treatment for several days or weeks.
Oral antihistamines, antihistamine or cromolyn nasal sprays, and leukotriene modifiers
can be considered based on the patient's symptoms and drug tolerances.

References:
1. Mechanisms and clinical implications of glucocorticosteroids in the
treatment of allergic rhinitis.

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Crease

- AIIergic rhinitis -- • Q
1-1- Ear, Nose & Throat (ENT)
------------- -
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A 25-year-old man comes to the physician because of a mass in his mouth. He has had
the lump for many years. He denies weight loss. He was in a motor vehicle accident
several years ago and sustained a concussion of the brain. He does not use tobacco.
alcohol, or illicit drugs. Physical examination shows a nontender 2 x 2-cm mass located
on the hard palate of the mouth that is immobile and has a bony hard consistency.
Which of the following is the most likely cause of this patient's oral finding?

0 A Congenital
o B. Infectious
0 C. Neoplastic
o D. Traumatic
o E. Vascular

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A 25-year-old man comes to the physician because of a mass in his mouth. He has had
the lump for many years. He denies weight loss. He was in a motor vehicle accident
several years ago and sustained a concussion of the brain. He does not use tobacco.
alcohol, or illicit drugs. Physical examination shows a nontender 2 x 2-cm mass located
on the hard palate of the mouth that is immobile and has a bony hard consistency.
Which of the following is the most likely cause of this patient's oral finding?

A Congenital [54%)

B. Infectious [1%)

C. Neoplastic [1 0%)

D. Traumatic [31%]
E. Vascular [4%]

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Explanation: User
This patient presents with a chronic growth on his hard palate consistent with likely torus
palatinus (TP). which is a benign bony growth (i.e.. exostosis) located on the midline
suture of the hard palate. It is thought to be due to both genetic and environmental
factors and is more common in younger patients. women. and Asians. Preceding trauma
does not appear to be associated with TP (Choice 0). Although a TP is usually <2 em in
size. it can increase in size throughout a person's life.
Patients with TP usually say that the lesion has been present for some time and deny
tenderness. The thin epithelium overlying the bony growth tends to ulcerate with normal
trauma of the oral cavity and heal slowly due to a poor vascular supply. Surgery is
indicated for patients in whom the mass becomes symptomatic, interferes with speech or
eating. or causes problems with fitting of dentures later in life.
(Choice B) Infections can occur in the oral cavity but typically do not present as a hard
mass. They also tend to be tender. with surrounding erythema. exudates. discharge. or
drainage.
E. Vascular [4%)

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Explanation: User
This patient presents with a chronic growth on his hard palate consistent with likely torus
palatinus (TP), which is a benign bony growth (i.e., exostosis) located on the midline
suture of the hard palate. It is thought to be due to both genetic and environmental
factors and is more common in younger patients, women, and Asians. Preceding trauma
does not appear to be associated with TP (Choice 0). Although a TP is usually <2 em in
size, it can increase in size throughout a person's life.
Patients with TP usually say that the lesion has been present for some time and deny
tenderness. The thin epithelium overlying the bony growth tends to ulcerate with normal
trauma of the oral cavity and heal slowly due to a poor vascular supply. Surgery is
indicated for patients in whom the mass becomes symptomatic, interferes with speech or
eating, or causes problems with fitting of dentures later in life.
(Choice S) Infections can occur in the oral cavity but typically do not present as a hard
mass. They also tend to be tender, with surrounding erythema, exudates, discharge, or
drainage.
(Choice C) Neoplasms of the oral cavity can be nontender and immobile but are usually
associated with a history of tobacco or chronic alcohol use. Neoplasms usually tend to
grow in size, without getting smaller, and can cause symptoms with eating or breathing.
This is less likely in this younger patient.

(Choice E) Vascular lesions tend to be mobile and sometimes pulsatile but are not
usually hard and fixed (as seen in this patient).
Educational objective:
In a young individual who presents with a fleshy immobile mass on the midline hard
palate, the most likely diagnosis is torus palatinus. No medical or surgical therapy is
required unless the growth becomes symptomatic or interferes with speech or eating.

References:
1. Current status of the torus palatinus and mandibularis

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A 12-year-old girl comes to the office complaining of a small amount of left-sided ear
discharge that has persisted for the last three weeks. She has completed two courses of
antibiotics that were prescribed during her previous visits. She also complains of hearing
loss on the left side. On examination, she is afebrile. Otoscopy reveals an intact left
tympanic membrane with peripheral granulation and some skin debris. The patient
should be evaluated for which of the following?

o A. Meniere's disease
o B. Craniopharyngioma
o C. Otosclerosis
o D. Cholesteatoma
o E. Middle ear osteoma

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A 12-year-old girl comes to the office complaining of a small amount of left-sided ear
discharge that has persisted for the last three weeks. She has completed two courses of
antibiotics that were prescribed during her previous visits. She also complains of hearing
loss on the left side. On examination, she is afebrile. Otoscopy reveals an intact left
tympanic membrane with peripheral granulation and some skin debris. The patient
should be evaluated for which of the following?

A. Meniere's disease [4%)

B. Craniopharyngioma [2%)

C. Otosclerosis [20%)

D. Cholesteatoma [65%)

E. Middle ear osteoma [1 0%)

Proceed to Nexlltem

Expl<mation: User
This patient should undergo further evaluation for a possible
cholesteatoma. Cholesteatomas in children can either be congenital or acquired, with
congenital lesions typically found in younger patients around the age of five. Acquired
cholesteatomas usually occur secondary to chronic middle ear disease. The diagnosis
should be suspected in any patient with continued ear drainage for several weeks
despite appropriate antibiotic therapy. Chronic middle ear disease leads to the formation
of a retraction pocket in the tympanic membrane, which can fill with granulation tissue
and skin debris, as seen in this patient. Complications of cholesteatomas include hearing
loss (which this patient appears to already be experiencing), cranial nerve palsies,
vertigo, and potentially life-threatening infections such as brain abscesses or
meningitis. This patient should be referred to an otolaryngologist for a dedicated otologic
exam, possibly accompanied by a CT and/or surgical visualization to confirm the
diagnosis.
(Choice A) Meniere's disease is a condition associated with an accumulation of fluid in

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E. Middle ear osteoma [1 0%)

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Explanation: User
This patient should undergo further evaluation for a possible
cholesteatoma. Cholesteatomas in children can either be congenital or acquired, with
congenital lesions typically found in younger patients around the age of five. Acquired
cholesteatomas usually occur secondary to chronic middle ear disease. The diagnosis
should be suspected in any patient with continued ear drainage for several weeks
despite appropriate antibiotic therapy. Chronic middle ear disease leads to the formation
of a retraction pocket in the tympanic membrane, which can fill with granulation tissue
and skin debris, as seen in this patient. Complications of cholesteatomas include hearing
loss (which this patient appears to already be experiencing), cranial nerve palsies,
vertigo, and potentially life-threatening infections such as brain abscesses or
meningitis. This patient should be referred to an otolaryngologist for a dedicated otologic
exam, possibly accompanied by a CT and/or surgical visualization to confirm the
diagnosis.
(Choice A) Meniere's disease is a condition associated with an accumulation of fluid in
the inner ear that leads to hearing loss, vertigo, and tinnitus. The presence of ear
drainage and the lack of vertigo make Meniere's disease unlikely in this case.

(Choice B) Craniopharyngioma is a tumor that can occur in children. However, it is


derived from Rathke's pouch, which is located in the suprasellar space.

(Choice C) Otosclerosis is a condition in which there is bony overgrowth of the stapes


footplate that results in conductive hearing loss. Ear drainage would not be present.
(Choice E) An osteoma is a benign, solitary area of bony overgrowth that can form in the
outer ear and lead to hearing loss. However, the findings present on this patient's
tympanic membrane are more typical for cholesteatoma.
Educational objective:
Cholesteatomas in children can either be congenital or acquired secondary to chronic
middle ear disease. New-onset hearing loss or chronic ear drainage despite antibiotic
therapy are typical presenting symptoms of cholesteatomas, and granulation tissue and
skin debris may be seen within retraction pockets of the tympanic membrane on otoscopy.

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A 23-year-old woman comes to the physician because of a 4-week history of a whistling


noise during respiration. She underwent a difficult rhinoplasty a few months ago. The
noise is getting louder and is annoying. Which of the following is the most likely
diagnosis?

o A. Nasal septal perforation


o B. Nasal polyp
o C. Nasal foreign body
o D. Allergic rhinitis
o E. Nasal furunculosis

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A 23-year-old woman comes to the physician because of a 4-week history of a whistling


noise during respiration. She underwent a difficult rhinoplasty a few months ago. The
noise is getting louder and is annoying. Which of the following is the most likely
diagnosis?

A. Nasal septal perforation [74%)


B. Nasal polyp [1 2%)
C. Nasal foreign body [6%)
D. Allergic rhinitis [1%)
E. Nasal furunculosis [7%)

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Explanation : User
Complications are common following rhinoplasty, and up to one in four rhinoplasties may
need revision. Common complications include patient dissatisfaction, nasal obstruction
and epistaxis. Those that involve the nasal septum are less common but more serious.
The septum is made up of cartilage and has poor blood supply contrasting sharply with
the rich anastomosing blood supply of the nasal sidewall. The underlying cartilage relies
completely on the overlying mucosa for nourishment by diffusion. Because of the poor
regenerating capacity of the septal cartilage, trauma or surgery on the septum may result
in septal perforation. The typical postoperative presentation is a whistling noise heard
during respiration. Following nasal surgery, septal perforation is typically the result of a
septal hematoma though a septal abscess may also be the cause. Additional conditions
that can cause septal perforation are self-inflicted trauma (nose picking), syphilis,
tuberculosis, intranasal cocaine use, sarcoidosis and granulomatosis with polyangiitis
(Wegener's).
(Choice B) Nasal polyps are usually seen in patients with asthma and allergic disorders
but may also occur in patients with other inflammatory conditions of the nasal mucosa.
They may cause chronic nasal obstruction and should be surgically removed in
symptomatic patients.
(Choice C) Foreign bodies are common in children. On presentation, patients will have
nasal obstruction and may have a foul odor, halitosis and nasal bleeding. Following
surgery, a retained foreign body such as nasal packing most classically would cause
toxic shock syndrome.

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Explanation: User

Complications are common following rhinoplasty, and up to one in four rhinoplasties may
need revision. Common complications include patient dissatisfaction, nasal obstruction
and epistaxis. Those that involve the nasal septum are less common but more serious.
The septum is made up of cartilage and has poor blood supply contrasting sharply with
the rich anastomosing blood supply of the nasal sidewall. The underlying cartilage relies
completely on the overlying mucosa for nourishment by diffusion. Because of the poor
regenerating capacity of the septal cartilage, trauma or surgery on the septum may result
in septal perforation. The typical postoperative presentation is a whistling noise heard
during respiration. Following nasal surgery, septal perforation is typically the result of a
septal hematoma though a septal abscess may also be the cause. Additional conditions
that can cause septal perforation are self-inflicted trauma (nose picking), syphilis,
tuberculosis, intranasal cocaine use, sarcoidosis and granulomatosis with polyangiitis
(Wegener's).

(Choice B) Nasal polyps are usually seen in patients with asthma and allergic disorders
but may also occur in patients with other inflammatory conditions of the nasal mucosa.
They may cause chronic nasal obstruction and should be surgically removed in
symptomatic patients.
(Choice C) Foreign bodies are common in children. On presentation, patients will have
nasal obstruction and may have a foul odor, halitosis and nasal bleeding. Following
surgery, a retained foreign body such as nasal packing most classically would cause
toxic shock syndrome.
(Choice 0) Allergic rhinitis commonly presents with rhinorrhea, nasal pruritus, cough and
occasionally dyspnea. On examination, the nasal mucosa is edematous and pale, and
polyps may be present.
(Choice E) Nasal furunculosis results from staphylococcal folliculitis following nose
picking or nasal hair plucking. It is potentially life threatening as it can spread to the
cavernous sinus. Patients complain of pain, tenderness and erythema in the nasal
vestibule.
Educational objective:
If a patient develops a whistling noise during respiration following rhinoplasty, one should
suspect nasal septal perforation likely resulting from a septal hematoma.

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A 5-year-old boy is brought to the emergency department by his parents due to


sudden-onset difficulty breathing overnight. He had mild rhinorrhea earlier in the day but
no cough or fever. He takes no medications and has no known allergies, although his
younger brother was recently diagnosed with a severe peanut allergy. Temperature is
39.1 C (1 02.4 F), blood pressure is 100/65 mm Hg, pulse is 130/min, and respirations are
46/min. His oxygen saturation is 92% on room air. The patient appears anxious and is
drooling with inspiratory stridor. He app_ears most comfortable when sitting upright with
his neck extended. Which of the following is the most likely diagnosis in this patient?

o A Anaphylaxis
o B. Bronchiolitis
o C. Diphtheria
o D. Epiglottitis
o E. Foreign body aspiration
o F. Laryngotracheitis
o G. Peritonsillar abscess

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A 5-year-old boy is brought to the emergency department by his parents due to


sudden-onset difficulty breathing overnight. He had mild rhinorrhea earlier in the day but
no cough or fever. He takes no medications and has no known allergies, although his
younger brother was recently diagnosed with a severe peanut allergy. Temperature is
39.1 C (102.4 F), blood pressure is 100/65 mm Hg, pulse is 130/min, and respirations are
46/min. His oxygen saturation is 92% on room air. The patient appears anxious and is
drooling with inspiratory stridor. He appears most comfortable when sitting upright with
his neck extended. Which of the following is the most likely diagnosis in this patient?

A. Anaphylaxis [1%]
B. Bronchiolitis [1 %]
C. Diphtheria [1%]
D. Epiglottitis [80%]
E. Foreign body aspiration [4%]
F. Laryngotracheitis [9%]
G. Peritonsillar abscess [5%]

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Explanation : User

Epiglottitis

Microbiology • Haemophilus influenzae type b

• Distress ("tripod" positioning, stridor)


Clinical • Dysphagia
features • Drooling
• "Thumbprint sign" (enlarged epiglottis) on x-ray

• Endotracheal intubation
Management
• Antibiotics
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@UWorld

Epiglottitis is an uncommon but potentially fatal infection that presents with acute onset
of fever with dysphagia, drooling, and respiratory distress. Symptoms often develop
over several hours without a significant prodrome (eg, cough, congestion, rhinorrhea).
Signs of impending airway obstruction include restlessness, anxiety, worsening stridor,
and a muffled "hot potato" voice. Patients may hyperextend the neck and maintain a
tripod position to maximize airway diameter when significant airway swelling is present.
Although the incidence of epiglottitis has been drastically reduced due to widespread
Haemophilus influenzae type b (Hib) vaccination, Hib remains the most common cause,
even in immunized children. Acute management focuses on securing the airway (eg,
intubation) and antibiotic therapy.
(Choice A) Anaphylaxis is also a potentially life-threatening condition that can present
with acute onset of respiratory distress. This patient has fever and no history of allergies
or any other signs of an allergic reaction (eg, hives, swelling, vomiting, diarrhea,
hypotension).
(Choice B) Bronchiolitis presents in children age <2 with fever, cough, retractions, and
crackles/wheezing. These patients do not have stridor as bronchiolitis results from viral
infection of the lower respiratory tract.
(Choice C) Diphtheria presents with a gradual onset of sore throat, low-grade fever, and
a laryngeal pseudomembrane that can lead to severe respiratory distress and stridor.
These patients may also have significant neck edema.

(Choice E) Foreign body aspiration most commonly presents in infants/toddlers with


acute onset of wheezing, stridor, and/or respiratory distress without fever.
(Choice F) Laryngotracheitis (croup) presents with a "barky" cough, stridor, and fever.
Drooling is uncommon, and patients are typically less ill-appearing than those with
epiglottitis.
(Choice G) Peritonsillar abscesses are most common in older children and adolescents
and present with gradual onset of fever, muffled voice , and unilateral tonsillar swelling
with uvular deviation. This patient's age and acute onset of symptoms make this
diagnosis less likely.
Educational objective:
Epiglottitis presents with abrupt onset of fever, dysphagia, drooling, and respiratory
distress. Signs of impending airway obstruction include anxiety and tripod positioning
(upright/forward positioning with neck hyperextension).
and a muffled "hot potato" voice. Patients may hyperextend the neck and maintain a
tripod position to maximize airway diameter when significant airway swelling is present.

Although the incidence of epiglottitis has been drastically reduced due to widespread
Haemophilus influenzae type b (Hib) vaccination, Hib remains the most common cause,
even in immunized children. Acute management focuses on securing the airway (eg,
intubation) and antibiotic therapy.

(Choice A) Anaphylaxis is also a potentially life-threatening condition that can present


with acute onset of respiratory distress. This patient has fever and no history of allergies
or any other signs of an allergic reaction (eg, hives, swelling, vomiting, diarrhea,
hypotension).
(Choice B) Bronchiolitis presents in children age <2 with fever, cough, retractions, and
crackles/wheezing. These patients do not have stridor as bronchiolitis results from viral
infection of the lower respiratory tract.
(Choice C) Diphtheria presents with a gradual onset of sore throat, low-grade fever, and
a laryngeal pseudomembrane that can lead to severe respiratory distress and stridor.
These patients may also have significant neck edema.
(Choice E) Foreign body aspiration most commonly presents in infants/toddlers with
acute onset of wheezing, stridor, and/or respiratory distress without fever.
(Choice F) Laryngotracheitis (croup) presents with a "barky" cough, stridor, and fever.
Drooling is uncommon, and patients are typically less ill-appearing than those with
epiglottitis.
(Choice G) Peritonsillar abscesses are most common in older children and adolescents
and present with gradual onset of fever, muffled voice, and unilateral tonsillar swelling
with uvular deviation. This patient's age and acute onset of symptoms make this
diagnosis less likely.

Educational objective:
Epiglottitis presents with abrupt onset of fever, dysphagia, drooling, and respiratory
distress. Signs of impending airway obstruction include anxiety and tripod positioning
(upright/forward positioning with neck hyperextension).

References:
1. Symptoms and signs differentiating croup and epiglottitis.

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)Ositioning

Tripod position & epiglottitis

Trunk
leaning forwa1rd

Neck & chin


extended

Air
flow
Swollen ---4
epiglottis
obstructs
airway

Esophagus

@UWorld

--eplgtottitiS - • 0
1-1 -Ear, Nose & Throat (ENT)
------------ -
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Fe_e_d_b_a_ck_ _ End Block
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A 70-year-old man comes to your office with complaints of difficulty hearing. His wife
says that he has been raising the television volume much louder recently. The patient
claims that he can hear well when he talks to his family members at home, but he has
significant difficulty hearing in restaurants or during other family gatherings, which is why
he prefers to stay at home most of the time. He worked in a shipbuilding yard for 30
years, and retired five years ago. He has no history of significant noise exposure. What
is the most likely diagnosis?

o A. Otosclerosis
o B. Presbycusis
0 C. Middle ear effusion
o D. Meniere's disease
0 E. Acoustic neuroma
o F. Depression

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A 70-year-old man comes to your office with complaints of difficulty hearing. His wife
says that he has been raising the television volume much louder recently. The patient
claims that he can hear well when he talks to his family members at home, but he has
significant difficulty hearing in restaurants or during other family gatherings, which is why
he prefers to stay at home most of the time. He worked in a shipbuilding yard for 30
years, and retired five years ago. He has no history of significant noise exposure. What
is the most likely diagnosis?

A. Otosclerosis [1 9%]

B. Presbycusis [76%]

C. Middle ear effusion [1%]

D. Meniere's disease [1%]


E. Acoustic neuroma [2%]
F. Depression [1%]

Proceed to Next Item

Explanation: User
This patient's hearing difficulties are most likely caused by presbycusis, defined as
sensorineural hearing loss that occurs with aging. The hearing loss associated with
presbycusis is typically first noticed in the sixth decade of life, and characteristically
begins with symmetrical, high-frequency hearing impairment. Patients often complain of
difficulty hearing in crowded or noisy environments, similar to what this patient
describes. In addition, affected patients usually have trouble hearing high-pitched noises
or voices. Although presbycusis is a disease of aging, multiple factors have been shown
to influence the rate of hearing loss, including medications, genetics, a history of
infection, and exposure to loud noise.
(Choice A) Otosclerosis is a type of chronic conductive hearing loss associated with
bony overgrowth of the stapes. It typically begins with low-frequency hearing loss and is
often found in middle-aged individuals.

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-----------------
E. Acoustic neuroma [2%]
F. Depression [1%]

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Explanation: User
This patient's hearing difficulties are most likely caused by presbycusis, defined as
sensorineural hearing loss that occurs with aging. The hearing loss associated with
presbycusis is typically first noticed in the sixth decade of life, and characteristically
begins with symmetrical, high-frequency hearing impairment. Patients often complain of
difficulty hearing in crowded or noisy environments, similar to what this patient
describes. In addition, affected patients usually have trouble hearing high-pitched noises
or voices. Although presbycusis is a disease of aging, multiple factors have been shown
to influence the rate of hearing loss, including medications, genetics, a history of
infection, and exposure to loud noise.
(Choice A) Otosclerosis is a type of chronic conductive hearing loss associated with
bony overgrowth of the stapes. It typically begins with low-frequency hearing loss and is
often found in middle-aged individuals.
(Choice C) A middle ear effusion, as is seen in patients with serous otitis media, often
produces tinnitus and a sensation of pressure in addition to conductive hearing loss.
(Choice 0) Patients with Meniere's disease present with episodes of tinnitus, vertigo,
and sensorineural hearing loss. This patient does not complain of vertigo or tinnitus.
(Choice E) The most common tumor that causes sensorineural hearing loss is an
acoustic neuroma. It is associated with unilateral hearing loss as opposed to the bilateral
hearing loss of presbycusis.
(Choice F) Although presbycusis can contribute to the development of low self esteem
and depression, this patient's complaints are not indicative of depression.
Educational objective:
Sensorineural hearing loss that occurs with aging is referred to as presbycusis. It is
usually first noticed in the sixth decade of life, and presents with high-frequency, bilateral
hearing loss. Patients with presbycusis often have difficulty hearing in noisy, crowded
environments.

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A 60-year-old man comes to your office complaining of difficulty hearing for the past few
weeks. He has type 2 diabetes mellitus, which is well-controlled by diet alone. His past
medical history is also significant for essential hypertension, congestive heart failure
secondary to diastolic dysfunction, and chronic renal failure. Medications include aspirin,
diuretics, an ACE inhibitor, and a beta-blocker. His pulse is 82/min, blood pressure is
140/90 mmHg, and respirations are 14/min. Examination reveals hearing loss in both
ears. Which of the following medication is a potential cause of this patient's hearing
problems?

0 A. Lisinopril
o B. Aspirin
o C. Metoprolol
o D. Furosemide
o E. Hydrochlorothiazide

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A 60-year-old man comes to your office complaining of difficulty hearing for the past few
weeks. He has type 2 diabetes mellitus, which is well-controlled by diet alone. His past
medical history is also significant for essential hypertension, congestive heart failure
secondary to diastolic dysfunction, and chronic renal failure. Medications include aspirin,
diuretics, an ACE inhibitor, and a beta-blocker. His pulse is 82/min, blood pressure is
140/90 mmHg, and respirations are 14/min. Examination reveals hearing loss in both
ears. Which of the following medication is a potential cause of this patient's hearing
problems?

A Lisinopril [5%)

B. Aspirin [1 6%)

C. Metoprolol [1%)
D. Furosemide [65%)
E. Hydrochlorothiazide [1 2%)

. . . '

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Explanation: User ld
This patient's complaints of new-onset, bilateral hearing loss raises concern for
medication-induced ototoxicity. There are a large number of ototoxic medications that
can cause sensorineural hearing loss, including aminoglycoside antibiotics,
chemotherapeutic agents, aspirin, and loop diuretics. With this patient's history of
congestive heart failure, one of the diuretics he may be taking is the loop diuretic
furosemide, which is well-known to potentially cause ototoxicity. Loop diuretics are
associated with reversible or permanent hearing impairment, reversible deafness, and/or
tinnitus. The risk of ototoxicity is greater in patients taking high doses of furosemide, but
patients who have coexistent renal failure, as is the case in this vignette, may experience
hearing loss or deafness at lower doses.
(Choice A) Lisinopril is an ACE inhibitor that is classically associated with the side
effects of cough, hyperkalemia, and angioedema. It does not cause ototoxicity.
(Choice B) Aspirin usually causes tinnitus; but in very higher doses it can cause (6 to 8
grams/day) hearing loss. This patient's hearing loss is more likely to be associated with

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.; D. Furosemide [65%)
E. Hydrochlorothiazide [1 2%)

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Explanation: User

This patient's complaints of new-onset, bilateral hearing loss raises concern for
medication-induced ototoxicity. There are a large number of ototoxic medications that
can cause sensorineural hearing loss, including aminoglycoside antibiotics,
chemotherapeutic agents, aspirin, and loop diuretics. With this patient's history of
congestive heart failure, one of the diuretics he may be taking is the loop diuretic
furosemide, which is well-known to potentially cause ototoxicity. Loop diuretics are
associated with reversible or permanent hearing impairment, reversible deafness, and/or
tinnitus. The risk of ototoxicity is greater in patients taking high doses of furosemide, but
patients who have coexistent renal failure, as is the case in this vignette, may experience
hearing loss or deafness at lower doses.
(Choice A) Lisinopril is an ACE inhibitor that is classically associated with the side
effects of cough, hyperkalemia, and angioedema. It does not cause ototoxicity.
(Choice B) Aspirin usually causes tinnitus; but in very higher doses it can cause (6 to 8
grams/day) hearing loss. This patient's hearing loss is more likely to be associated with
loop diuretics.

(Choice C) Beta-blockers, such as metoprolol, are associated with many significant side
effects, including increased airway resistance, bradycardia, fatigue, and depression
among many others. Hearing loss, however, is not a common side effect of
beta-blockers.
(Choice E) Hydrochlorothiazide is a thiazide diuretic that can cause orthostatic
hypotension, photosensitivity, hypercalcemia, or other potential side effects. Hearing
loss, however, is not associated with hydrochlorothiazide.
Educational objective:
Loop diuretics can cause reversible or permanent hearing loss and/or tinnitus. These
ototoxic effects typically occur in patients taking high doses of loop diuretics, those with
coexistent renal failure, or in patients who are also being treated with other known
ototoxic medications, such as aminoglycosides.

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A 6-year-old boy is brought to the physician by his mother because of "inattentiveness."


His mother reports that when asked to perform tasks at home, he ignores her and
continues to do whatever he is engaged in. She has had difficulty disciplining him at
home because of this, but reports that he is otherwise a happy and affectionate child.
His school teacher frequently complains about him, stating that he "has trouble following
directions and just does not listen." He rarely completes his classroom assignments on
time. He has limited language skills compared to his peers and usually prefers to play
alone. Which of the following is the most likely diagnosis in this case?

A. Selective mutism
0

B. Attention deficit hyperactivity disorder


0

C. Undetected hearing impairment


0

0 D. Autism
E. Oppositional defiant disorder
0

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A 6-year-old boy is brought to the physician by his mother because of "inattentiveness."


His mother reports that when asked to perform tasks at home, he ignores her and
continues to do whatever he is engaged in. She has had difficulty disciplining him at
home because of this, but reports that he is otherwise a happy and affectionate child.
His school teacher frequently complains about him, stating that he "has trouble following
directions and just does not listen." He rarely completes his classroom assignments on
time. He has limited language skills compared to his peers and usually prefers to play
alone. Which of the following is the most likely diagnosis in this case?

A. Selective mutism [1%)


B. Attention deficit hyperactivity disorder [1 0%)
C. Und.etected hearing impairment [68%)
D. Autism [20%)
'-' E. Oppositional defiant disorder [2%)

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Explanation: User
Hearing impairment in children can be due to a variety of causes, both hereditary and
acquired. The most common cause is conductive hearing loss due to repeated ear
infections. Undetected hearing impairment can lead to poo.r language development and
social skills. Often, these children suffer from poo.r self-esteem and isolate themselves
as a result. This patient's apparent inattentiveness, difficulty following directions, and
refusal to listen are a result of his undetected hearing impairment. A thorough evaluation
is required to make a definitive diagnosis.

(Choice A) Selective mutism is characterized by failure to speak in one or more specific


social situations. These children, however, have normal language skills and speak
normally in other situations or at home.

(Choice B) Children with hearing impairments often appear inattentive and impulsive
and may be incorrectly diagnosed with attention deficit hyperactivity disorder (ADHD).
However, poor language development and social isolation are not features of ADHD, and
a hearing impairment should be ruled out before a diagnosis of ADHD is considered.
(Choice 0) This child does not have any of the repetitive behaviors that are
characteristic of autism and is affectionate towards his mother, making autism less likely.
Hearing impairment in children can be due to a variety of causes, both hereditary and
acquired. The most common cause is conductive hearing loss due to repeated ear
infections. Undetected hearing impairment can lead to poor language development and
social skills. Often, these children suffer from poor self-esteem and isolate themselves
as a result. This patient's apparent inattentiveness, difficulty following directions, and
refusal to listen are a result of his undetected hearing impairment. A thorough evaluation
is required to make a definitive diagnosis.

(Choice A) Selective mutism is characterized by failure to speak in one or more specific


social situations. These children, however, have normal language skills and speak
normally in other situations or at home.

(Choice B) Children with hearing impairments often appear inattentive and impulsive
and may be incorrectly diagnosed with attention deficit hyperactivity disorder (ADHD).
However, poor language development and social isolation are not features of ADHD, and
a hearing impairment should be ruled out before a diagnosis of ADHD is considered.
(Choice 0 ) This child does not have any of the repetitive behaviors that are
characteristic of autism and is affectionate towards his mother, making autism less likely.
While hearing impairment may be mistaken for autism, repetitive behaviors, poor eye
contact, and impaired social interactions are not seen in hearing impairment. In addition,
features of autism generally appear before age three and social isolation is more
prominent than in hearing impairment.
(Choice E) Oppositional defiant disorder is characterized by a pattern of disobedient,
defiant, and hostile behavior. Children with oppositional defiant disorder frequently lose
their tempers, disobey and defy their elders, and deliberately annoy others. These
children do not present with the poor language skills and inattentiveness seen in this
patient.
Educational objective:
Undetected hearing impairment can easily be confused with certain pervasive and
behavioral disorders of childhood. Therefore, hearing tests should be routinely
conducted in all children with any behavioral concerns.

References:
1. Hearing assessment in infants and children: recommendations beyond
neonatal screening

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A 4-month-old boy is brought to the office for "noisy breathing." His parents first noticed
a harsh sound with inspiration at age 2 weeks but report that it has gotten louder in the
past 4 weeks, especially when he is lying on his back. The noise seems to improve
when the patient is held upright or during "tummy time." The infant has occasional, small
spit-ups after feeds but is growing well along the 60th percentile for weight. He was born
full term without complications during pregnancy or labor and delivery. On examination,
the infant is noted to have inspiratory stridor while supine that improves when he is
prone. The remainder of the examination is normal. Which of the following diagnostic
studies can confirm the most likely diagnosis for this patient?

0 A. Barium swallow
0 B. Chest radiograph
o C. CT scan of the neck
o D. Direct laryngoscopy
o E. MRI with angiography of the neck
o F. Neck radiograph

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A 4-month-old boy is brought to the office for "noisy breathing." His parents first noticed
a harsh sound with inspiration at age 2 weeks but report that it has gotten louder in the
past 4 weeks, especially when he is lying on his back. The noise seems to improve
when the patient is held upright or during "tummy time." The infant has occasion al, small
spit-ups after feeds but is growing well along the 60th percentile for weight. He was born
full term without complications during pregnancy or labor and delivery. On examination,
the infant is noted to have inspiratory stridor while supine that improves when he is
prone. The remainder of the examination is normal. Which of the following diagnostic
studies can confirm the most likely diagnosis for this patient?

A. Barium swallow [6%)


B. Che.st radiograph [5%)
C. CT scan of the neck [7%)
D. Direct laryngoscopy [58%)
E. MRI with angiography of the neck [6%)
-· F. Neck radiograph [1 8%)

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Explanation : User

Laryngomalacia

Pathophysiology • Increased laxity of supraglottic structures

Clinical • Inspiratory stridor worsens when supine


presentation • Peaks at age 4-8 months

• Usually clinical
Diagnosis • Confirmation by flexible laryngoscopy for
moderate/severe cases

• Reassurance for most cases


Management
• Supraglottoplasty for severe symptoms

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Explanation: User ld

Laryngomalacia

Pathophysiology • Increased laxity of supraglottic structures

Clinical • Inspiratory stridor worsens when supine


presentation • Peaks at age 4-8 months

• Usually clinical
Diagnosis • Confirmation by flexible laryngoscopy for
moderate/severe cases

• Reassurance for most cases


Management
• Supraglottoplasty for severe symptoms
@UWortd

Laryngomalacia, which causes chronic stridor in infants, is caused by "floppy"


supraglottic structures that collapse during inspiration. Stridor from laryngomalacia
usually begins in the neonatal period and is loudest at age 4-8 months. Presentation
includes inspiratory stridor worse in the supine position and exacerbated by feeding
or upper respiratory illnesses; prone positioning improves symptoms. The diagnosis is
made clinically but can be confirmed with visualization of the larynx by direct or flexible
fiber-optic laryngoscopy. Findings include an omega-shaped (Q) epiglottis and collapse
of the supraglottic structures during inspiration.

Most infants with laryngomalacia will feed, grow, and ventilate normally with
spontaneous resolution of stridor by age 18 months. However, the majority of patients
will have symptoms of gastroesophageal reflux (eg, vomiting, arching of the back with
feeds, poor weight gain) and should be treated accordingly (eg, upright positioning after
feeds, acid reducers).
(Choices A and E) Vascular rings occur when an anomalous branch of the aortic arch
encircles the trachea and esophagus. Infants present with biphasic stridor due to
tracheal compression and feeding difficulties secondary to esophageal compression. A
barium swallow can identify indentations of these structures, and the diagnosis can be

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----------------- -------------------------------
includes inspiratory stridor worse in the supine position and exacerbated by feeding
or upper respiratory illnesses; prone positioning improves symptoms. The diagno.s is is
made clinically but can be confirmed with visualization of the larynx by direct or flexible
fiber-optic laryngoscopy. Findings include an omega-shaped (Q) epiglottis and collapse
of the supraglottic structures during inspiration.
Most infants with laryngomalacia will feed, grow, and ventilate normally with
spontaneous resolution of stridor by age 18 months. However, the majority of patients
will have symptoms of gastroesophageal reflux (eg, vomiting, arching of the back.with
feeds, poor weight gain) and should be treated accordingly (eg, upright positioning after
feeds, acid reducers).
(Choices A and E) Vascular rings occur when an anomalous branch of the aortic arch
encircles the trachea and esophagus. Infants present with biphasic stridor due to
tracheal compression and feeding difficulties secondary to esophageal compression. A
barium swallow can identify indentations of these structures, and the diagnosis can be
confirmed by MRI with angiography.

(Choice B) Chest radiographs can identify anterior mediastinal masses and radiopaque
foreign bodies, both of which can cause stridor. Mediastinal masses (eg, lymphoma) also
present with systemic symptoms (eg, fever, weight loss, lymphadenopathy), and airway
foreign bodies present with more acute symptom onset; none of these are present in this
patient.
(Choices 'C and F) Retropharyngeal abscesses occur in toddlers and present with
fever, dysphagia, neck pain, and stridor. Lateral neck radiographs can demonstrate
thickening of the prevertebral space. CT scan of the neck can better define extension of
the abscess to nearby structures. This patient does not have symptoms suggestive of
infection.
Educational objective:
Laryngomalacia presents in infants with inspiratory stridor that worsens in the supine
position and improves in the prone position. Direct laryngoscopy shows collapse of the
supraglottic structures during inspiration. Laryngomalacia usually resolves
spontaneously by age 18 months.

References:
1. Laryngomalacia: disease presentation, spectrum, and management.
2. Laryngomalacia.

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A 62-year-old man comes to the physician 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 patient's past medical history is significant for type 2 diabetes
mellitus and hypertension. His last hemoglobin A,. was 8.3%. His body mass index is
27.5 kg/m2 • On oral examination, a white patch is seen on the buccal mucosa. The
lesion appears to have a granular texture, is not indurated, and is not removed by
scraping with a tongue depressor. There is no regional lymphadenopathy. Which of the
following is the most likely cause of the oral lesion in this patient?

o A. Aphthous stomatitis
o B. Candidiasis
o C. Herpes simplex virus infection
o D. Leukoplakia
0 E. Squamous cell carcinoma

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l of 1

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A 62-year-old man comes to the physician 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 patient's past medical history is significant for type 2 diabetes
mellitus and hypertension. His last hemoglobin A,. was 8.3%. His body mass index is
27.5 kg/m2 • On oral examination, a white patch is seen on the buccal mucosa. The
lesion appears to have a granular texture, is not indurated, and is not removed by
scraping with a tongue depressor. There is no regional lymphadenopathy. Which of the
following is the most likely cause of the oral lesion in this patient?

A. Aphthous stomatitis [6%)


B. Candidiasis [3%)
C. Herpes simplex virus infection [0%)
D. Leukoplakia [70%)
E. Squamous cell carcinoma [21%)
. . . '

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Explanation: User ld
The clinical description of the lesion, with the presence of a white granular patch or
plaque over the buccal mucosa in a patient with a history of alcohol and tobacco use, is
most consistent with oral leukoplakia. Leukoplakia is a reactive precancerous lesion
that represents hyperplasia of the squamous epithelium.
The risk factors for development of leukoplakia are similar to those for squamous cell
carcinoma, with smokeless tobacco and alcohol use accounting for the majority of
cases. The natural history of oral leukoplakia depends on the degree of dysplasia, with
1%-20% of lesions progressing to squamous carcinoma within 10 years. Fortunately,
most lesions resolve within a few weeks after cessation of tobacco use. The
development of areas with induration and/or ulceration should prompt biopsy to rule out
malignant transformation of the lesion.
(Choice A) Aphthous stomatitis refers to localized, shallow, painful ulcers with a gray
base. Recurrent aphthous stomatitis is the most common cause of oral ulcers.
(Choice B) Oral candidiasis, or thrush, occurs in patients with diabetes,
immunodeficiency states, and use of antibiotics or inhaled glucocorticoids. The lesions
of candidiasis typically consist of white plaques on the oral mucosa, tongue, or
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Explanation: User
The clinical description of the lesion, with the presence of a white granular patch or
plaque over the buccal mucosa in a patient with a history of alcohol and tobacco use, is
most consistent with oral leukoplakia. Leukoplakia is a reactive precancerous lesion
that represents hyperplasia of the squamous epithelium.
The risk factors for development of leukoplakia are similar to those for squamous cell
carcinoma, with smokeless tobacco and alcohol use accounting· for the majority of
cases. The natural history of oral leukoplakia depends on the degree of dysplasia, with
1%-20% of lesions progressing to squamous carcinoma within 10 years. Fortunately,
most lesions resolve within a few weeks after cessation of tobacco use. The
development of areas with induration and/or ulceration should prompt biopsy to rule out
malignant transformation of the lesion.

(Choice A) Aphthous stomatitis refers to localized, shallow, painful ulcers with a gray
base. Recurrent aphthous stomatitis is the most common cause of oral ulcers.
(Choice B) Oral candidiasis, or thrush, occurs in patients with diabetes,
immunodeficiency states, and use of antibiotics or inhaled glucocorticoids. The lesions
of candidiasis typically consist of white plaques on the oral mucosa, tongue, or
oropharynx with underlying erythema. In contrast to leukoplakia, the plaques of
candidiasis can usually be scraped off with a tongue depressor.
(Choice C) Herpes simplex virus type 1 can cause gingivostomatitis. It can present
with multiple vesicular lesions with an erythematous and inflammatory base and
erythematous border within the oral cavity and perioral area. Herpes simplex virus type 1
does not cause the white plaque seen in this patient.
(Choice E) This patient has several risk factors for squamous cell carcinoma of the oral
cavity, including extensive use of tobacco and alcohol. Squamous cell carcinoma usually
presents as persistent nodular, erosive, or ulcerative lesions with surrounding erythema
or induration. Regional lymphadenopathy can be present as well. The white granular
lesions in this patient are more consistent with oral leukoplakia.
Educational objective:
Oral leukoplakia presents as white patches or plaques over the oral mucosa that usually
cannot be scraped off. The risk factors for development of leukoplakia are similar to
those for squamous cell carcinoma (tobacco and alcohol use). Development of areas
with induration and/or ulceration should prompt biopsy to rule out malignant
transformation of the lesion.

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us ulceration

Q
ll
~koplakia, erythroplakia -- •
Ear, Nose & Throat (ENT) _________________________F
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1didiasis

Q
ll
~koplakia, erythroplakia -- •
Ear, Nose & Throat (ENT) _________________________F
_e_e_d_b_a_ck
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al herpes simplex
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A 33-year-old woman comes to the office with intermittent dizziness. The patient
describes a sensation of severe spinning accompanied by intense nausea that lasts 1-2
hours. She feels unsteady during these episodes and has to lie down with her eyes
closed for relief. The patient has had several similar episodes during the past 2 years
and has not noted any particular factors that precipitate the symptoms. She also reports
hearing a "mechanical humming" sound in her right ear during these episodes, causing
distortion of speech. The patient has no associated headaches, ear pain, or ear
discharge. Her temperature is 36.6 C (98 F), blood pressure is 130/84 mm Hg, and pulse
is 86/min. On examination, air conduction is greater than bone conduction in both ears.
When the base of a tuning fork is placed against her forehead, the sound is heard more
prominently in the left ear. Which of the following is the most likely cause of this patient's
condition?

0 A Benign tumor compressing a cranial nerve


0 B. Central nervous system demyelination
0 C. Elevated endolymphatic pressure
0 D. Inflammation of the membranous labyrinth
0 E. Loose calcium debris in the semicircular canal
0 F. Reduced mobility of the ossicles

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A 33-year-old woman comes to the office with intermittent dizziness. The patient
describes a sensation of severe spinning accompanied by intense nausea that lasts 1-2
hours. She feels unsteady during these episodes and has to lie down with her eyes
closed for relief. The patient has had several similar episodes during the past 2 years
and has not noted any particular factors that precipitate the symptoms. She also r.eports
hearing a "mechanical humming" sound in her right ear during these episodes, causing
distortion of speech. The patient has no associated headaches, ear pain, or ear
discharge. Her temperature is 36.6 C (98 F), blood pressure is 130/84 mm Hg, and pulse
is 86/min. On examination, air conduction is greater than bone conduction in both ears.
When the base of a tuning fork is placed against her forehead, the sound is heard more
prominently in the left ear. Which of the following is the most likely cause of this patient's
condition?

A. Benign tumor compressing a cranial nerve [1 7%)


B. Central nervous system demyelination [5%)
C. Elevated endolymphatic pressure [49%)
D. Inflammation of the membranous labyrinth [11%)
E. Loose calcium debris in the semicircular canal [1 4%)
F. Reduced mobility of the ossicles [4%)

Proceed to Next Item

Explanation : User

Common causes of vertigo

• Recurrent episodes
Meniere
• Unilateral hearing loss & tinnitus
d isease
• Feeling of fullness in the ear

• Brief episodes triggered by head movement


BPPV
• Dix-Hallpike maneuver causes nystagmus

• Acute, single episode that can last days


. -
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Explanation: User

Common causes of vertigo

• Recurrent episodes
Meniere
disease • Unilateral hearing loss & tinnitus
• Feeling of fullness in the ear

• Brief episodes triggered by head movement


BPPV
• Dix-Hallpike maneuver causes nystagmus

• Acute, single episode that can last days


Vestibular
neuritis • Often follows viral syndrome
• Abnormal head thrust test

• Vertigo associated with headache or other


Migraine migrainous phenomenon (eg, visual aura)
• Symptoms resolve completely between episodes

Brainstem/ • Sudden-onset, persistent vertigo


cerebellar
stroke • Usually other neurologic symptoms

BPPV = benign paroxysmal positional vertigo.


©UWor1d

This patient has Meniere disease, a disorder of the inner ear characterized by
increased volume and pressure of endolymph (endolymphatic hydrops), likely due to
defective resorption of endolymph. The resulting distension of the endolymphatic system
causes damage to the vestibular and cochlear components of the inner ear. Meniere
disease is characterized by the following triad:
• Low-frequency tinnitus in the affected ear, often accompanied by a feeling of
fullness
• Episodic vertigo, commonly associated with lightheadedness, nausea, and
vomiting
• Sensorineural hearing loss, variable in severity but usually worsening over time

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BPPV = benign paroxysmal positional vertigo.
© UWor1d

This patient has MeniE~re disease, a disorder of the inner ear characterized by
increased volume and pressure of endolymph (endolymphatic hydrops), likely due to
defective resorption of endolymph. The resulting distension of the endolymphatic system
causes damage to the vestibular and cochlear components of the inner ear. Meniere
disease is characterized by the following triad:
• Low-frequency tinnitus in the affected ear, often accompanied by a feeling of
fullness
• Episodic vertigo, commonly associated with lightheadedness, nausea, and
vomiting
• Sensorineural hearing loss, variable in severity but usually worsening over time

The diagnosis of Meniere disease is based primarily on clinical findings, although


audiometry is helpful to fully characterize hearing loss and follow its course over time.
Initial management includes restriction of sodium, caffeine, nicotine, and alcohol.
Benzodiazepines, antihistamines, and antiemetics can relieve acute symptoms. Diuretics
can be considered for long-term management.
(Choice A) Vestibular schwannoma can cause unilateral sensorineural hearing loss,
sometimes with imbalance and tinnitus. However, symptoms are usually persistent and
progr.essive rather than episodic, and true vertigo is not typical.
(Choice B) Multiple sclerosis can cause episodic vertigo and sensorineural hearing
loss. However, most patients have manifestations in multiple systems (eg, paresthesias,
weakness, visual disturbances, urinary incontinence).
(Choice 0) Like Meniere disease, labyrinthitis (vestibular neuritis) can cause vertigo,
hearing loss, and tinnitus. However, symptoms are typically acute and resolve within
several weeks.
(Choice E) Benign paroxysmal positional vertigo causes brief, often intense episodes of
vertigo triggered by changes in head position. Patients can have headaches or a feeling
of ear fullness, but tinnitus and hearing loss are not typical.
(Choice F) Otosclerosis is characterized by progressive conductive rather than
sensorineural hearing loss. Some patients may experience tinnitus, but vertigo is not
reported.
Educational objective:
Meniere disease is a disorder of the inner ear characterized by increased volume and

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-----------------
increased volume and pressure of endolymph (endolymphatic hydrops), likely due to
defective resorption of endolymph. The resulting distension of the endolymphatic system
causes damage to the vestibular and cochlear components of the inner ear. Meniere
disease is characterized by the following triad:
• Low-frequency tinnitus in the affected ear, often accompanied by a feeling of
fullness
• Episodic vertigo, commonly associated with lightheadedness, nausea, and
vomiting
• Sensorineural hearing loss, variable in severity but usually worsening over time

The diagnosis of Meniere disease is based primarily on clinical findings, although


audiometry is helpful to fully characterize hearing loss and follow its course over time.
Initial management includes restriction of sodium, caffeine, nicotine, and alcohol.
Benzodiazepines, antihistamines, and antiemetics can relieve acute symptoms. Diuretics
can be considered for long-term management.
(Choice A) Vestibular schwannoma can cause unilateral sensorineural hearing loss,
sometimes with imbalance and tinnitus. However, symptoms are usually persistent and
progressive rather than episodic, and true vertigo is not typical.
(Choice B) Multiple sclerosis can cause episodic vertigo and sensorineural hearing
loss. However, most patients have manifestations in multiple systems (eg, paresthesias,
weakness, visual disturbances, urinary incontinence).
(Choice 0) Like Meniere disease, labyrinthitis (vestibular neuritis) can cause vertigo,
hearing loss, and tinnitus. However, symptoms are typically acute and resolve within
several weeks.
(Choice E) Benign paroxysmal positional vertigo causes brief, often intense episodes of
vertigo triggered by changes in head position. Patients can have headaches or a feeling
of ear fullness, but tinnitus and hearing loss are not typical.
(Choice F) Otosclerosis is characterized by progressive conductive rather than
sensorineural hearing loss. Some patients may experience tinnitus, but vertigo is not
reported.
Educational objective:
Meniere disease is a disorder of the inner ear characterized by increased volume and
pressure of endolymph (endolymphatic hydrops). Clinical features include tinnitus,
episodic vertigo, and sensorineural hearing loss.

Time Spent: 2 seconds Copyright © UWorld Last updated: [08/01/2016)

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A 28-year-old African American female complains of recurrent nasal discharge and


increasing nasal congestion. She has a constant sensation of dripping in the back of her
throat, and states that food has tasted bland to her recently. She is known to have sickle
cell trait. She came to the emergency department for severe wheezing after taking
naproxen for menstrual cramping one year ago.. She has no history of head trauma. She
does not smoke cigarettes, but she admits to smoking marijuana occasionally. Which of
the following is the most likely diagnosis?

0 A Angiofibroma
o B. Inverted papilloma
o C. Nasal polyp
0 D. Perforated nasal septum
0 E. Pyogenic granuloma

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A 28-year-old African American female complains of recurrent nasal discharge and


increasing nasal congestion. She has a constant sensation of dripping in the back of her
throat, and states that food has tasted bland to her recently. She is known to have sickle
cell trait. She came to the emergency department for severe wheezing after taking
naproxen for menstrual cramping one year ago. She has no history of head trauma. She
do.es not smoke cigarettes, but she admits to smoking marijuana occasionally. Which of
the following is the most likely diagnosis?

A. Angiofibroma [9%)
B. Inverted papilloma [3%)
C . Nasal polyp [75%)
D. Perforated nasal septum [6%)
_. E. Pyogenic granuloma [7%)

Explanation: User

This patient's history of wheezing following the ingestion of naproxen as well as her
symptoms of rhinitis and post-nasal drainage are highly suggestive of aspirin
exacerbated respiratory disease (AERO), a condition commonly associated with the
development of nasal polyps. AERO consists of the following features: asthma, chronic
rhinosinusitis with nasal polyposis, and bronchospasm or nasal congestion following the
ingestion of aspirin or non-steroidal anti-inflammatory drugs (NSAIDS). The diagnosis of
AERO can often be made clinically when all three of these conditions are present. This
patient's current symptoms of bland tasting food (secondary to anosmia) and recurrent
nasal discharge/congestion are typical in patients with nasal polyps, and examination
should reveal the presence of bilateral, grey, glistening mucoid masses in her nasal
cavities. Although surgery can often provide temporary relief, the polyps tend to recur
and ultimate treatment should be geared toward medical management of the underlying
etiology.

(Choice A) Juvenile nasal angiofibroma is a rare, benign tumor of the nasopharynx that
can cause nasal obstruction and nasal drainage, but also usually results in epistaxis. In
addition, it occurs almost exclusively in teenage males.

(Choice B) An inverted papilloma is a tumor of unknown etiology that clinically presents


with signs of unilateral nasal obstruction and/or epistaxis. It is not associated with AERO.

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E. Pyogenic granuloma [7%)

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Explanation: User
This patient's history of wheezing following the ingestion of naproxen as well as her
symptoms of rhinitis and post-nasal drainage are highly suggestive of aspirin
exacerbated respiratory disease (AERO), a condition commonly associated with the
development of nasal polyps. AERO consists of the following features: asthma, chronic
rhinosinusitis with nasal polyposis, and bronchospasm or nasal congestion following the
ingestion of aspirin or non-steroidal anti-inflammatory drugs (NSAIOS). The diagnosis of
AERO can often be made clinically when all three of these conditions are present. This
patient's current symptoms of bland tasting food (secondary to anosmia) and recurrent
nasal discharge/congestion are typical in patients with nasal polyps, and examination
should reveal the presence of bilateral, grey, glistening mucoid masses in her nasal
cavities. Although surgery can often provide temporary relief, the polyps tend to recur
and ultimate treatment should be geared toward medical management of the underlying
etiology.
(Choice A) Juvenile nasal angiofibroma is a rare, benign tumor of the nasopharynx that
can cause nasal obstruction and nasal drainage, but also usually results in epistaxis. In
addition, it occurs almost exclusively in teenage males.
(Choice B) An inverted papilloma is a tumor of unknown etiology that clinically presents
with signs of unilateral nasal obstruction and/or epistaxis. It is not associated with AERO.
(Choice 0) Patients with a perforated nasal septum often complain of nasal discomfort
and obstruction with excess crusting and bleeding. It is often seen in patients who use
intranasal cocaine.
(Choice E) Pregnant women have an increased incidence of pyogenic granulomas on
the anterior nasal septum. These highly vascular lesions are frequent sources of nose
bleeds during pregnancy.
Educational objective:
Nasal polyps are often associated with chronic rhinosinusitis, asthma, and aspirin- or
NSAIO-induced bronchospasm in a condition known as aspirin-exacerbated respiratory
disease. They frequently cause symptoms of bilateral nasal obstruction, nasal
discharge, and anosmia.

Time Spent 1 seconds Copyright © UWorld Last updated: [08/1 5/2016)

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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 has also had persistent
nasal congestion, frequent epistaxis, and headaches. The patient 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 have not
provided relief. He has no other medical problems. The patient takes daily multivitamins
and occasionally uses nonsteroidal anti-inflammatory medications for aches and pains.
He immigrated to the United States from China 15 years ago. Vital signs are within
normal limits. Several enlarged and hard cervical lymph nodes are present.
Nasopharyngoscopy reveals a mass in the posterior nasal cavity, and biopsy
demonstrates poorly differentiated carcinoma. Which of the following is most strongly
associated with this patient's current condition?

o A. Aflatoxin B , exposure
0 B. Epstein-Barr virus infection
0 C. Excessive use of nonsteroidal anti-inflammatory drugs
o D. Recurrent bacterial sinusitis
o E. Vitamin A supplements

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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 has also had persistent
nasal congestion, frequent epistaxis, and headaches. The patient 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 have not
provided relief. He has no other medical problems. The patient takes daily multivitamins
and occasionally uses nonsteroidal anti-inflammatory medications for aches and pains.
He immigrated to the United States from China 15 years ago. Vital signs are within
normal limits. Several enlarged and hard cervical lymph nodes are present.
Nasopharyngoscopy reveals a mass in the posterior nasal cavity, and biopsy
demonstrates poorly differentiated carcinoma. Which of the following is most strongly
associated with this patient's current condition?

A. Aflatoxin B , exposure [0%)


B. Epstein-Barr virus infection [100%)
C. Excessive use of nonsteroidal anti-inflammatory drugs [0%)
D. Recurrent bacterial sinusitis [0%)
E. Vitamin A supplements [0%)

' ...
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Explanation: User

Anatomy of lateral wall


of nasal cavity and nasal pharynx

Superior concha bone•

Superior nasal meatus


Sphenoidal sinus

t:..--- Middle concha bone•


~:..---_. Middle nasal meatus
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Explanation: User

Anatomy of lateral wall


of nasal cavity and nasal pharynx

Superior concha bone•

Superior nasal meatus


Sphenoidal sinus

L--- Middle concha bone•

~:.......---- Middle nasal meatus

-r- -- Eustacian (auditory)


tube orifice
Inferior concha bone•
Inferior nasal meatus

©UWorld • Also known as turbinate.

This patient has nasopharyngeal carcinoma (NPC), which is associated with the
reactivation of Epstein-Barr virus (EBV). Tumors typically express EBV DNA, and EBV
assays are often used to monitor treatment response and disease relapse. NPC is rare
in the United States but is endemic to southern China (and parts of Africa and the
Middle East). Risk is thought to be higher in these locations dl!e to diet (salt-cured food,
early exposure to salted fish) and genetic predisposition.

NPC tumors obstruct the nasopharynx and invade adjacent tissues, often resulting in
nasal congestion with epistaxis, headache, cranial nerve palsies (eg, facial
numbness), and/or serous otitis media (eustachian tube obstruction). Early metastatic
spread to the cervical lymph nodes may cause a nontender neck mass (as in this
patient).
Inferior concha bone•
Inferior nasal meatus

©UWorld •A lso known a s turbinate.

This patient has nasopharyngeal carcinoma (NPC), which is associated with the
reactivation of Epstein-Barr virus (EBV). Tumors typically exp.ress EBV DNA, and EBV
assays are often used to monitor treatment response and disease relapse. NPC is rare
in the United States but is endemic to southern China (and parts of Africa and the
Middle East). Risk is thought to be higher in these locations due to diet (salt-cured food,
early exposure to salted fish) and genetic predisposition.
NPC tumors obstruct the nasopharynx and invade adjacent tissues, often resulting in
nasal congestion with epistaxis, headache, cranial nerve palsies (eg, facial
numbness), and/or serous otitis media (eustachian tube obstruction). Early metastatic
spread to the cervical lymph nodes may cause a nontender neck mass (as in this
patient).

(Choice A) Aflatoxin B, is a mycotoxin that often contaminates agricultural products and


is associated with an increased risk of hepatocellular carcinoma, not NPC.
(Choice C) Nonsteroidal anti-inflammatory drugs (NSAIDs) are often associated with
bleeding (gastrointestinal) and renal injury. Although NSAIDs may increase the risk of
epistaxis, they are not a cause of NPC.

(Choice 0) Recurrent bacterial sinusitis may result in nasal polyposis. This may
manifest with nasal congestion and thick rhinorrhea. Recurrent sinusitis is not typically
associated with NPC.
(Choice E) Some forms of vitamin A (eg, beta carotene) in excess may increase the risk
of lung cancer in smokers, but there is no association with NPC.
Educational objective:
Nasopharyngeal carcinoma is associated with the reactivation of Epstein-Barr virus and
occurs most commonly in those from Asia (particularly southern China) and parts of Africa
and the Middle East. Manifestations include nasal congestion with epistaxis, headaches,
cranial nerve palsies, and otitis media. Early spread to the cervical lymph nodes is
common.

Time Spent: 2 seconds Copyright © UWorld Last updated: [1 2/05/2016)

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A 65-year-old female complains of difficulty eating over the last two days. She states that
food drops out of her mouth. She has also been having some discharge in her left ear
recently. She denies any sore throat, nasal discharge, chest pain, cough, or difficulty
breathing. Her past medical history is significant for type 2 diabetes mellitus,
hypertension, and hyperlipidemia. She has been poorly compliant with follow-up
appointments. Her temperature is 38.8° C (1 01. 7o F), pulse is 96/min, blood pressure is
140/90 mmHg, and respirations are 18/min. Examination of the left ear canal shows
granulations. There is facial asymmetry, and the angle of the mouth on the left is
deviated downward. Which of the following is the most likely causative organism for this
patient's condition?

0 A. Rhizopus species
0 B. Pseudomonas aeruginosa
0 C. Staphylococcus aureus
o D. Aspergillus niger
o E. Herpes zoster

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A 65-year-old female complains of difficulty eating over the last two days. She states that
food drops out of her mouth. She has also been having some discharge in her left ear
recently. She denies any sore throat, nasal discharge, chest pain, cough, or difficulty
breathing. Her past medical history is significant for type 2 diabetes mellitus,
hypertension, and hyperlipidemia. She has been poorly compliant with follow-up
appointments. Her temperature is 38.8° C (101 .7o F), pulse is 96/min, blood pressure is
140/90 mmHg, and respirations are 18/min. Examination of the left ear canal shows
granulations. There is facial asymmetry, and the angle of the mouth on the left is
deviated downward. Which of the following is the most likely causative organism for this
patient's condition?

A. Rhizopus species [25%]

B. Pseudomonas aeruginosa [55%]

C. Staphylococcus aureus [4%]


D. Aspergillus niger [3%]
E. Herpes zoster [1 3%]

Proceed to Next lteni '

Explanation: User

This patient's presentation is most consistent with malignant otitis externa (MOE), which
is a severe infection typically seen in elderly diabetic patients that is most commonly
caused by Pseudomonas aeruginosa. Patients typically present with ear pain and ear
drainage that is not responsive to topical medications. The granulation tissue seen
within the ear canal in this patient is a characteristic manifestation of MOE, and her
history of poorly controlled diabetes is also a diagnostic clue. Progression of the
infection can lead to osteomyelitis of the skull base and cranial nerve damage. This
patient's facial drooping, which is likely causing food to drop out of her mouth, is a result
of damage to the left facial nerve. CT or MRI can be used to confirm the diagnosis.
Treatment consists of systemic antibiotics that are effective against Pseudomonas
aeruginosa , such as ciprofloxacin. Topical antibiotics are ineffective.

(Choice A) Patients with poorly controlled diabetes are susceptible to Rhizopus


infections, but these infections typically begin in the paranasal sinuses and extend into

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C. Staphylococcus aureus [4%]


D. Aspergillus niger [3%]
E. Herpes zoster [1 3%]

. . . '

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Explanation: User ld
This patient's presentation is most consistent with malignant otitis externa (MOE), which
is a severe infection typically seen in elderly diabetic patients that is most commonly
caused by Pseudomonas aeruginosa. Patients typically present with ear pain and ear
drainage that is not responsive to topical medications. The granulation tissue seen
within the ear canal in this patient is a characteristic manifestation of MOE, and her
history of poorly controlled diabetes is also a diagnostic clue. Progression of the
infection can lead to osteomyelitis of the skull base and cranial nerve damage. This
patient's facial drooping, which is likely causing food to drop out of her mouth, is a result
of damage to the left facial nerve. CT or MRI can be used to confirm the diagnosis.
Treatment consists of systemic antibiotics that are effective against Pseudomonas
aeruginosa , such as ciprofloxacin. Topical antibiotics are ineffective.

(Choice A) Patients with poorly controlled diabetes are susceptible to Rhizopus


infections, but these infections typically begin in the paranasal sinuses and extend into
the orbit and brain.
(Choice C) Staphylococcus aureus is a rare cause of malignant otitis externa.
(Choice 0) Overall, Aspergillus species rarely cause malignant otitis externa. They are,
however, the most common fungal cause.

(Choice E) The most typical manifestation of herpes zoster infection in the ear is
Ramsay Hunt syndrome, which presents with facial nerve palsy and vesicles in the
auditory canal and auricle.
Educational objective:
Malignant otitis externa (MOE) is a serious infection of the ear seen in elderly patients
with poorly controlled diabetes, and is most commonly caused by Pseudomonas
aeruginosa. The characteristic presentation consists of ear pain and ear drainage, and
granulation tissue may be seen within the ear canal on examination. Progression of the
infection can lead to osteomyelitis of the skull base and destruction of the facial nerve.

Time Spent: 6 seconds Copyright © UWorld Last updated: [06/09/2016)

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A 78-year-old woman comes to the physician with a week-long history of worsening


left-sided ear pain and drainage. The pain is unrelenting, but it is especially severe at
night and is exacerbated by chewing. She reports a sense of fullness in the ear and mild
hearing loss on the left side. The patient's past medical history is significant for
hypertension, type 2 diabetes mellitus, and hyperlipidemia. Current medications include
lisinopril, a statin, and metformin. She has missed her last 2 appointments with her
primary care physician. Her temperature is 38.3 C (101 F), blood pressure is 140/90 mm
Hg, and pulse is 98/min. On examination, the left external auditory canal is edematous
with purulent discharge and granulation tissue in the floor. The tympanic membrane is
clear. Her erythrocyte sedimentation rate is 89 mm/h. An ear swab is obtained. Which
of the following is the best initial treatment for this patient?

o A. Intravenous ampicillin/sulbactam
0 B. Intravenous ciprofloxacin
o C. Surgical excision
o D. Topical corticosteroids
o E. Topical neomycin

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A 78-year-old woman comes to the physician with a week-long history of worsening


left-sided ear pain and drainage. The pain is unrelenting, but it is especially severe at
night and is exacerbated by chewing. She reports a sense of fullness in the ear and mild
hearing loss on the left side. The patient's past medical history is significant for
hypertension, type 2 diabetes mellitus, and hyperlipidemia. Current medications include
lisinopril, a statin, and metformin. She has missed her last 2 appointments with her
primary care physician. Her temperature is 38.3 C (1 01 F), blood pressure is 140/90 mm
Hg, and pulse is 98/min. On examination, the left external auditory canal is edematous
with purulent discharge and granulation tissue in the floor. The tympanic membrane is
clear. Her erythrocyte sedimentation rate is 89 mm/h. An ear swab is obtained. Which
of the following is the best initial treatment for this patient?

A Intravenous ampicillin/sulbactam [31%)


B. Intravenous ciprofloxacin [44%)
C. Surgical excision [9%)
D. Topical corticosteroids [4%)
_. E. Topical neomycin [1 2%)

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Explanation: User
This patient's presentation is concerning for malignant (necrotizing) otitis externa
(MOE), a severe infection of the external auditory canal and base of the skull usually
caused by Pseudomonas aeruginosa. Most patients with MOE are elderly and often
have poorly controlled diabetes or are otherwise immunosuppressed. The most common
symptoms are severe, unrelenting ear pain (especially prominent at night); purulent
drainage with a sense of fullness; and conductive hearing loss on the affected side.
Otoscopy shows granulation tissue and an edematous external auditory canal, although
the remainder of the examination may be proportional with the severity of the pain. As
the infection spreads beyond the external auditory canal, osteomyelitis of the skull base
or temporomandibular joint can develop and present with pain exacerbated by chewing.
Cranial nerve involvement is sometimes seen.
Given the severity of MOE, systemic therapy with an anti-pseudomonal antibiotic is
recommended. In adults, intravenous ciprofloxacin remains the drug of choice; in
patients with fluoroquinolone-resistant P aeruginosa, alternate therapies include
anti-pseudomonal penicillins or cephalosporins such as piperacillin and ceftazidime.

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Explanation: User ld
This patient's presentation is concerning for malignant (necrotizing) otitis externa
(MOE), a severe infection of the external auditory canal and base of the skull usually
caused by Pseudomonas aeruginosa. Most patients with MOE are elderly and often
have poorly controlled diabetes or are otherwise immunosuppressed. The most common
symptoms are severe, unrelenting ear pain (especially prominent at night); purulent
drainage with a sense of fullness; and conductive hearing Joss on the affected side.
Otoscopy shows granulation tissue and an edematous external auditory canal, although
the remainder of the examination may be proportional with the severity of the pain. As
the infection spreads beyond the external auditory canal, osteomyelitis of the skull base
or temporomandibular joint can develop and present with pain exacerbated by chewing.
Cranial nerve involvement is sometimes seen.
Given the severity of MOE, systemic therapy with an anti-pseudomonal antibiotic is
recommended. In adults, intravenous ciprofloxacin remains the drug of choice; in
patients with fluoroquinolone-resistant P aeruginosa , alternate therapies include
anti-pseudomonal penicillins or cephalosporins such as piperacillin and ceftazidime.
Ampicillin/sulbactam is not effective (Choice A). Surgical debridement (of necrotic bone)
and biopsy (to exclude cancer) can be performed if a patient fails to respond to
antibiotics. Surgical excision, commonly used before the advent of anti-pseudomonal
antibiotics, is no longer a component of MOE management (Choice C). Cholesteatoma,
a keratinized epithelial growth in the middle ear, can present with hearing Joss and
discharge and requires surgical management. However, MOE is a much more likely
diagnosis in this patient given the sever.e pain, fever, and elevated erythrocyte
sedimentation rate.

(Choices 0 and E) Topical antibiotics and corticosteroids are appropriate for otitis
externa (OE), but they are not recommended in the treatment of MO'E. The severity of
the pain, the presence of granulation tissue, and the elevated erythrocyte sedimentation
rate are all clues that distinguish OE from MOE.
Educational objective:
Malignant (necrotizing) otitis externa is a severe infection of the external auditory canal
and skull base usually caused by Pseudomonas aeruginosa. It is seen most frequently
in elderly patients with diabetes or immunosuppression. Intravenous ciprofloxacin is
empiric treatment.

References:

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caused by Pseudomonas aeruginosa. Most patients with MOE are elderly and often
have poorly controlled diabetes or are otherwise immunosuppressed. The most common
symptoms are severe, unrelenting ear pain (especially prominent at night); purulent
drainage with a sense of fullness; and conductive hearing loss on the affected side.
Otoscopy shows granulation tissue and an edematous external auditory canal, although
the remainder of the examination may be proportional with the severity of the pain. As
the infection spreads beyond the external auditory canal, osteomyelitis of the skull base
or temporomandibular joint can develop and present with pain exac.erbated by chewing.
Cranial nerve involvement is sometimes seen.

Given the severity of MOE, systemic therapy with an anti-pseudomonal antibiotic is


recommended. In adults, intravenous ciprofloxacin remains the drug of choice; in
patients with fluoroquinolone-resistant P aeruginosa, alternate therapies include
anti-pseudomonal penicillins or cephalosporins such as piperacillin and ceftazidime.
Ampicillin/sulbactam is not effective (Choice A). Surgical debridement (of necrotic bone)
and biopsy (to exclude cancer) can be performed if a patient fails to respond to
antibiotics. Surgical excision, commonly used before the advent of anti-pseudomonal
antibiotics, is no longer a component of MOE management (Choice C). Cholesteatoma,
a keratinized epithelial growth in the middle ear, can present with hearing loss and
discharge and requires surgical management. However, MOE is a much more likely
diagnosis in this patient given the severe pain, fever, and elevated erythrocyte
sedimentation rate.

(Choices 0 and E) Topical antibiotics and corticosteroids are appropriate for otitis
externa (OE), but they are not recommended in the treatment of MOE. The severity of
the pain, the presence of granulation tissue, and the elevated erythrocyte sedimentation
rate are all clues that distinguish OE from MOE.
Educational objective:
Malignant (necrotizing) otitis externa is a severe infection of the external auditory canal
and skull base usually caused by Pseudomonas aeruginosa. It is seen most frequently
in elderly patients with diabetes or immunosuppression. Intravenous ciprofloxacin is
empiric treatment.

References:
1. Initial management of necrotizing external otitis: errors to avoid.
2. Malignant otitis externa.
3. Malignant otitis externa.

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Q. ld : 4282 = Previous Next lab Values Notes Calculator Reverse Color Text Zoom
Media Exhibit

tics effective against Pseudomonas aerugino

Antibiotics effective against


Pseudomonas aeruginosa

Class Drugs

Anti-pseudomonal • Ticarcillin
penicillins • Piperacillin

• Ceftazidime (3rd generation)


Cephalosporins
• Cefepime (4th generation)

• Amikacin
Aminoglycosides • Gentamicin
• Tobramycin

• Ciprofloxacin
Fluoroquinolones
• Levofloxacin

Monobactams • Aztreonam

• lmipenem
Carbapenems
• Meropenem
© UWOIId

-c)titis externa - • Q
1 Ear, Nose & Throat (ENT)
1- - - - - - - - - - - - - -
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _F_e_e_d b_ a_c_k _ End Block
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A 16-year-old boy comes to the office due to right ear pain, pruritus, and discharge for
the past week. He has had no cold symptoms, hearing loss, or tinnitus. The patient
returned yesterday from a 2-week vacation at a Florida beach, where he swam and
surfed almost daily. Temperature is 37.1 C (98.8 F). Manipulation of the right ear during
otoscopy elicits pain. There is prominent swelling and erythema of the ear canal with
purulent and crusty debris. The tympanic membrane appears normal and has normal
mobility. The left ear is normal. Nasal and oropharyngeal mucosa are normal, and no
rashes or skin lesions are noted. Which of the following is the most likely causative
organism of this patient's current condition?

0 A. Actinomyces israe/ii
0 B. Aspergillus fumigatus
0 C. Candida albicans
0 D. Haemophilus influenzae
0 E. Klebsiella oxytoca
0 F. Moraxella catarrhalis
0 G. Proteus mirabilis
0 H. Pseudomonas aeruginosa
0 I. Streptococcus pneumoniae

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A 16-year-old boy comes to the office due to right ear pain, pruritus, and discharge for
the past week. He has had no cold symptoms, hearing loss, or tinnitus. The patient
returned yesterday from a 2-week vacation at a Florida beach, where he swam and
surfed almost daily. Temperature is 37.1 C (98.8 F). Manipulation of the right ear during
otoscopy elicits pain. There is prominent swelling and erythema of the ear canal with
purulent and crusty debris. The tympanic membrane appears normal and has normal
mobility. The left ear is normal. Nasal and oropharyngeal mucosa are normal, and no
rashes or skin lesions are noted. Which of the following is the most likely causative
organism of this patient's current condition?

A. Actinomyces israe/ii [2%]


B. Aspergillus fumigatus [1%]
C. Candida albicans [1%]
D. Haemophilus influenzae [3%]
E. Klebsiella oxytoca [1%]
F. Moraxella catarrhalis [4%]
G. Proteus mirabi/is [2%]
H. Pseudomonas aeruginosa [77%]
I. Streptococcus pneumoniae [1 0%]

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Explanation: User

Otitis externa
I I
• Trauma/foreign material (eg, cotton swab, hearing
aid)
Risk factors • Exposure to outdoor water sources (eg, swimming)
• Skin disruption (eg, psoriasis, eczema, contact
dermatitis)

• Pruritus, pain & discharge, hearing loss


• Tenderness with tragal pressure/auricle
Clinical
. . manipulation
m amfestatlons - .. - .. . -- -· - - -· .
~

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Explanation: User

Otitis externa
I I
!ITrauma/foreign material (eg, cotton swab, hearing
aid)
Risk f;:~ctors • Exposure to outdoor water sources (eg, swimming)
• Skin disruption (eg, psoriasis, eczema, contact
dermatitis)

• Pruritus, pain & discharge, hearing loss


!I Tenderness with tragal pressure/auricle
Clinical
manipulation
manifestations
• Ear canal with erythema, edema &
cerumen/purulent debris

• Remove debris from canal (eg, wire loop)


• Ototopical corticosteroid (inflammation) plus
Management
antibiotic (infection)
• Culture of exudate in recalcitrant cases

This patient has otitis externa ("swimmers ear"), characterized by otic pain, erythema,
edema, and purulent discharge. Otitis externa can occur in adults but is more common in
children and adolescents. It frequently occurs after swimming in outdoor water
sources due to maceration of the skin and introduction of gram-negative organisms into
the ear canal. Cerumen is acidic and has antibacterial properties; loss of cerumen due to
swimming or excessive ear cleaning can increase the risk of otitis. Conditions that
disrupt the skin barrier (eg, eczema, psoriasis) or retain foreign material and water in the
canal (eg, headphones, hearing aids, diving caps) also increase the risk.
The ear canal is colonized by a variety of organisms. However, by far the most common
pathogenic organism in otitis externa is Pseudomonas aeruginosa; empiric treatment
regimens should include drugs with antipseudomonal activity (eg, fluoroquinolone
drops). Staphylococcus aureus is also common; other gram-positive, anaerobic (eg,
Bacteroides), and mixed infections may occur but are less common.

(Choice A) Actinomyces is a commensal anaerobe that can cause invasive disease in

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the ear canal. Cerumen is acidic and has antibacterial properties; loss of cerumen due to
swimming or excessive ear cleaning can increase the risk of otitis. Conditions that
disrupt the skin barrier (eg, eczema. psoriasis) or retain foreign material and water in the
canal (eg, headphones. hearing aids, diving caps) also increase the risk.
The ear canal is colonized by a variety of organisms. However. by far the most common
pathogenic organism in otitis externa is Pseudomonas aeruginosa; empiric treatment
regimens should include drugs with antipseudomonal activity (eg, fluoroquinolone
drops). Staphylococcus aureus is also common; other gram-positive, anaerobic (eg.
Bacteroides), and mixed infections may occur but are less common.

(Choice A) Actinomyces is a commensal anaerobe that can cause invasive disease in


patients with dental infections or trauma. Infection is characterized by a slow-growing.
indurated mass that forms multiple sinus tracts to the skin and a purulent discharge with
yellow "sulfur granules."
(Choices Band C) Fungal otitis (eg, Aspergillus fumigatus) is uncommon but may
occur following eradication of a bacterial otitis. Candida species are typically seen in
otitis associated with a foreign body (eg, hearing aid).

(Choices 0, F, and I) Haemophilus influenzae. Moraxella catarrhalis, and


Streptococcus pneumoniae are the most common bacterial causes of otitis media but are
infrequent in otitis externa. This patient's examination shows no abnormalities of the
tympanic membrane. making otitis media unlikely.
(Choice E) Klebsiella oxytoca most commonly causes opportunistic infections in
patients who are hospitalized or immunocompromised.
(Choice G) Proteus mirabilis is a urease-producing facultative anaerobe that is a
notable cause of complicated urinary tract infections.
Educational objective:
Otitis externa ("swimmers ear") is characterized by pain. erythema, edema, and
discharge. It is more common in children and adolescents and frequently occurs after
swimming in outdoor water sources. Loss of cerumen due to swimming or excessive ear
cleaning can increase the risk. The most common pathogen is Pseudomonas
aeruginosa.

References:
1. Acute otitis externa: an update.

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A 32-year-old male complains of difficulty hearing in his left ear for the past month. He
denies any headaches, fever, chills, weight loss, or ear discharge. He is HIV positive,
and is currently being treated with highly active antiretroviral therapy (HAART). He also
takes trimethoprim/sulfamethoxazole daily. His most recent CD4 count was 425/ mm3.
Examination of the affected ear shows a dull, hypomobile tympanic membrane. What is
the most likely cause of hearing loss in this patient?

o A Neoplasia
o B. Non-infectious effusion
0 C. Oto.sclerosis
o D. Opportunistic infection
0 E. Demyelinization

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A 32-year-old male complains of difficulty hearing in his left ear for the past month. He
denies any headaches, fever, chills, weight loss, or ear discharge. He is HIV positive,
and is currently being treated with highly active antiretroviral therapy (HAART). He also
takes trimethoprim/sulfamethoxazole daily. His most recent CD4 count was 425/ mm3.
Examination of the affected ear shows a dull, hypomobile tympanic membrane. What is
the most likely cause of hearing loss in this patient?

A. Neoplasia [2%)

B. Non-infectious effusion [45%)


C. Otosclerosis [38%)
D. Opportunistic infection [11%)
E. Demyelinization [4%)

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Explanation: User
Serous otitis media is the most common middle ear pathology in patients with acquired
immunodeficiency syndrome. It is due to the auditory tube dysfunction arising from HIV
lymphadenopathy or obstructing lymphomas. Serous otitis media is characterized by the
presence of a middle ear effusion without evidence of an acute infection. Conductive
hearing loss is the most common symptom experienced by patients with serous otitis
media, and examination typically reveals a dull tympanic membrane that is hypomobile on
pneumatic otoscopy.
(Choice A) HIV-infected individuals are at risk of developing one of many different
malignancies. This patient, however, appears to be fairly well-controlled on his HAART
therapy. In addition, unilateral hearing loss would be an unusual presentation of an
HIV-associated malignancy.
(Choice C) Otosclerosis is a form of conductive hearing loss that results from bony
overgrowth of the stapes. It does occur in middle-aged individuals, but would not be
associated with the examination findings seen in this patient.
(Choice 0) As mentioned above, patients with HIV are at risk of developing one of
several opportunistic infections. This patient, however, is well-controlled on the current
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C. Otosclerosis [38%]
D. Opportunistic infection [11%]
E. Demyelinization [4%]

. . . '

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Explanation: User ld
Serous otitis media is the most common middle ear pathology in patients with acquired
immunodeficiency syndrome. It is due to the auditory tube dysfunction arising from HIV
lymphadenopathy or obstructing lymphomas. Serous otitis media is characterized by the
presence of a middle ear effusion without evidence of an acute infection. Conductive
hearing loss is the most common symptom experienced by patients with serous otitis
media, and examination typically reveals a dull tympanic membrane that is hypomobile on
pneumatic otoscopy.
(Choice A) HIV-infected individuals are at risk of developing one of many different
malignancies. This patient, however, appears to be fairly well-controlled on his HAART
therapy. In addition, unilateral hearing loss would be an unusual presentation of an
HIV-associated malignancy.
(Choice C) Otosclerosis is a form of conductive hearing loss that results from bony
overgrowth of the stapes. It does occur in middle-aged individuals, but would not be
associated with the examination findings seen in this patient.

(Choice 0) As mentioned above, patients with HIV are at risk of developing one of
several opportunistic infections. This patient, however, is well-controlled on the current
regimen of HAART and trimethoprim/sulfamethoxazole, and therefore an opportunistic
infection is unlikely to be the cause of his hearing loss.

(Choice E) Progressive multifocalleukoencephalopathy (PML) is a demyelinating


disease that can occur in patients with HIV/AIDS, but is less likely in patients on HAART
and usually only occurs in patients with CD4 counts < 200/mm3. In addition, hearing loss
would be an atypical presenting symptom in patients with PML.
Educational objective:
Serous otitis media is defined as the presence of a middle ear effusion without signs of
an active infection. Examination commonly reveals a dull tympanic membrane that is
hypomobile on pneumatic otoscopy.

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A 5-year-old boy is brought to the physician for left ear pain. He has had a "runny nose"
for the past week and low-grade fever. For the past 2 days, he has tugged on his left
ear. He seems to have trouble hearing from it as he keeps turning his head to the right
when called. The boy has received all recommended vaccinations and recently started
kindergarten. His temperature is 38.1 C (1 00.5 F), blood pressure is 110/60 mm Hg, and
pulse is 110/min. Examination shows bulging and erythema of the left tympanic
membrane, which is immobile and extremely painful with pneumatic insufflation. The right
tympanic membrane, auditory canal, and both pinnae appear normal. His nasal mucosa
appears boggy and postnasal drip is present. The maxillary and frontal sinuses are
nontender. What is the most likely diagnosis in this patient?

0 A. Acute otitis media


0 B. Bullous myringitis
0 C. Cerumen impaction
0 D. Cholesteatoma
0 E. Chronic suppurative otitis media
0 F. Hemotympanum
0 G. Otitis externa
0 H. Otitis media with effusion

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a. ld : 2830 PreVIOUS Next lab Values Notes Calculator Reverse Color Text Zoom

A 5-year-old boy is brought to the physician for left ear pain. He has had a "runny nose"
for the past week and low-grade fever. For the past 2 days, he has tugged on his left
ear. He seems to have trouble hearing from it as he keeps turning his head to the right
when called. The boy has received all recommended vaccinations and recently started
kindergarten. His temperature is 38. 1 C (1 00.5 F), blood pressure is 110/60 mm Hg, and
pulse is 11 0/min. Examination shows bulging and erythema of the left tympanic
membrane, which is immobile and extremely painful with pneumatic insufflation. The right
tympanic membrane, auditory canal, and both pinnae appear normal. His nasal mucosa
appears boggy and postnasal drip is present. The maxillary and frontal sinuses are
nontender. What is the most likely diagnosis in this patient?

A Acute otitis media [76%]


B. Bullous myringitis [1 %]
C. Cerumen impaction [0%]
D. Cholesteatoma [0%]
E. Chronic suppurative otitis media [1%]
F. Hemotympanum [0%]
G. Otitis externa [1%]
H. Otitis media with effusion [21%]

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Explanation: User ld

Differential diagnosis of otalgia


Diagnosis Clinical features

Acute otitis Middle ear effusion plus acute eardrum


media inflammation (eg, bulging eardrum, fever)

Otitis media Middle ear effusion without


wit h effusion acute inflammation

Bullous Serous liquid-filled blisters on the


Explanation: User

Differential diagnosis of otalgia


Dia.gnosis Clinical features

Acute otitis Middle ear effusion plus acute eardrum


media inflammation (eg, bulging eardrum, fever)

Otitis media Middle ear effusion without


with effusion acute inflammation

Bullous Serous liquid-filled blisters on the


myringitis tympanic membrane

Cerumen Liquid or hard wax in auditory canal


impaction obstructing eardrum visualization

Hemotympanum Purple or red eardrum+/- bulging

Otitis Pain with tragal traction, erythematous &


externa swollen external auditory canal +/-otorrhea
@USMLEWorld, LlC

Earache (otalgia) is one of the most common reasons for pediatric office visits. This
patient's clinical presentation is most consistent with acute otitis media (AOM) triggered
by a viral upper respiratory infection. AOM affects mostly children age 6-18 months
(especially those in day care) and those around age 5 years (school initiation). Young
children are predisposed to middle ear infections due to narrower and straighter
Eustachian tubes.

AOM often follows an upper respiratory infection, as nasal congestion contributes to


Eustachian tube inflammation, fluid accumulation (effusion) in the middle ear space, and
bacterial growth and infection of the tympanic membrane (eardrum). The cardinal
otoscopic findings are decreased mobility and bulging of the tympanic membrane on
pneumatic insufflation, which reflects middle ear effusion. Tympanic membrane
erythema and fever are also common, nonspecific inflammatory findings.
- - - . -
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erythema and fever are also common, nonspecific inflammatory findings.
(Choice B) Bullous myringitis is an uncommon complication of AOM. The absence of
eardrum blisters rules out this diagnosis.
(Choice C) Cerumen (earwax) impaction is usually asymptomatic. However, it can
cause ear discomfort, itchiness, and conductive hearing loss. Cerumen often obscures
full visualization of the auditory canal and tympanic membrane and would not cause
acute signs of inflammation (eg, fever, erythema, eardrum bulging).
(Choice 0) Cholesteatoma is an abnormal growth of squamous epithelium in the middle
ear. Significantly large growths can damage the ossicles, resulting in conductive hearing
loss. Fever and acute inflammato.ry signs are unlikely.
(Choice E) Chronic suppurative otitis media is a common pediatric problem. Typical
symptoms include hearing loss, tympanic membrane perforation, and otorrhea for >6
weeks. It can be distinguished from AOM by lack of fever and ear pain as well as the
prolonged duration of symptoms.
(Choice F) Barotrauma or blunt trauma can cause bleeding in the middle ear space
(hemotympanum), which can be extremely painful and give a purple or red hue to the
eardrum.
(Choice G) External otitis can present with hearing loss and ear discharge, but fever
does not occur unless the infection is severe.
(Choice H) Otitis media with effusion can be distinguished from AOM by the lack of
acute inflammatory signs (eg, fever, bulging of the tympanic membrane). Children who
recover from AOM often have persistent effusion for weeks but do not require ongoing
antibiotic treatment.
Educational objective:
Acute otitis media is a common cause of otalgia and is characterized by the presence of
middle ear effusion and signs of eardrum inflammation. Fluid in the middle ear space
limits eardrum mobility on pneumatic insufflation. Bulging is the most specific sign of
eardrum inflammation.

References:
1. Otitis media: diagnosis and treatment.
2. The diagnosis and management of acute otitis media.

Time Spent 2 seconds Copyright © UWorld Last updated: [1 0/13/2016)

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An 11 -month-old girl is brought to the physician for fever. For the past few days, she has
had rhinorrhea and nasal congestion. The fever started 2 days ago and the girl has
since been pulling at both ears. The ear pain seems worse when she lies down. The girl
has no medical problems and takes no medications. She attends day care and her diet
consists of infant formula and finger foods. Both parents smoke cigarettes. Her
temperature is 38.9 C (102 F). Otoscopy shows bulging, erythematous bilateral tympanic
membranes with decreased mobility on air compression. Crusted rhinorrhea is present at
the nares. Her hearing is intact and the rest of her examination is normal. Which of the
following is the most appropriate next step in management of this patient?

0 A. Acetaminophen, follow-up in 2 days


0 B. Myringotomy with tympanostomy tube placement
o C. Oral antibiotics
0 D. Ototopical antibiotics
0 E. Tympanocentesis and culture
o F. Viral nasopharyngeal polymerase chain reaction testing

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An 11-month-old girl is brought to the physician for fever. For the past few days, she has
had rhinorrhea and nasal congestion. The fever started 2 days ago and the girl has
since been pulling at both ears. The ear pain seems worse when she lies down. The girl
has no medical problems and takes no medications. She attends day care and her diet
consists of infant formula and finger foods. Both parents smoke cigarettes. Her
temperature is 38.9 C (102 F). Otoscopy shows bulging, erythematous bilateral tympanic
membranes with decreased mobility on air compression. Crusted rhinorrhea is present at
the nares. Her hearing is intact and the rest of her examination is normal. Which of the
following is the most appropriate next step in management of this patient?

A. Acetaminophen, follow-up in 2 days [9%)


B. Myringotomy with tympanostomy tube placement [3%)
C. Oral antibiotics [81%)
D. Ototopical antibiotics [4%)
E. Tympanocentesis and culture [3%)
_. F. Viral nasopharyngeal polymerase chain reaction testing [1%)

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Explanation: User

Acute otitis media

• Streptococcus pneumoniae
Microbiology • Nontypeable Haemophilus influenzae
• Moraxella catarrhalis

• Middle ear effusion


Clinical
plus
features
• Bulging tympanic membrane

• Initial: Amoxicillin
Treatment
• 2nd line: Amoxicillin-clavulanic acid

• Conductive hearing loss

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Explanation: User ld

Acute otitis media

• Streptococcus pneumoniae
Microbiology • Nontypeable Haemophilus influenzae
• Moraxe/la catarrhalis

• Middle ear effusion


Clinical plus
features
• Bulging tympanic membrane

Treatment • Initial: Amoxicillin


• 2nd line: Amoxicillin-clavulanic acid

• Conductive hearing loss


Complications • Mastoiditis
• Meningitis
@USMLEWorld, LLC

This patient's clinical presentation is consistent with acute otitis media (AOM). AOM is an
extremely common condition in children age 6-36 months as their Eustachian tubes are
short and easily clogged. Risk factors include formula intake (rather than breast milk),
exposure to cigarette smoke, allergic rhinitis or viral upper respiratory infection,
craniofacial anomalies, and chronic middle ear effusion.

The most common offending pathogens include Streptococcus pneumoniae, nontypeable


Haemophilus inf/uenzae, and Moraxella catarrha/is. The first-line treatment is a 10-day
course of high-dose amoxicillin. If AOM returns within a month of initial treatment,
amoxicillin-clavulanic acid should be given in anticipation of infection with beta-lactamase-
resistant strains. Potential complications of recurrent AOM are numerous and include
chronic suppurative otitis media, mastoiditis, labyrinthitis, cholesteatoma,
tympanosclerosis, eardrum perforation, and conductive hearing loss.
(Choice A) Analgesia (eg, ibuprofen, acetaminophen) is appropriate for relief from
otalgia, but delaying antibiotics in infants and young children could increase the risk of
developing complications. Observation is a reasonable option if the child is age <:2

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exposure or upper re!>Pilratclry into:-~tin
craniofacial anomalies, and chronic middle ear effusion.
The most common offending pathogens include Streptococcus pneumoniae, nontypeable
Haemophilus influenzae, and Moraxel/a catarrha/is. The first-line treatment is a 10-day
course of high-dose amoxicillin. If AOM r.eturns within a month of initial treatment,
amoxicillin-clavulanic acid should be given in anticipation of infection with beta-lactamase-
resistant strains. Potential complications of recurrent AOM are numerous and include
chronic suppurative otitis media, mastoiditis, labyrinthitis, cholesteatoma,
tympanosclerosis, eardrum perforation, and conductive hearing loss.

(Choice A) Analgesia (eg, ibuprofen, acetaminophen) is appropriate for relief from


otalgia, but delaying antibiotics in infants and young children could increase the risk of
developing complications. Observation is a reasonable option if the child is age 2:2
years, has a normal immune system, and symptoms are mild and unilateral.
(Choices e and E) Empiric antibiotics are usually adequate for complete treatment of
AOM. Tympanocentesis and culture during myringotomy with tympanostomy tube
placement should be considered in children with multiple episodes of AOM (eg, <:3
episodes within 6 months or 2:4 episodes within 12 months) despite appropriate antibiotic
treatment.
(Choice D) Therapy with otic drops is appropriate for otorrhea from tympanostomy
tubes, chronic suppurative otitis media, or external otitis, but not for AOM.
(Choice F) Although viral upper respiratory infections often precede or occur with AOM,
viral identification would not change management, which consists of empiric antibiotic
treatment.
Educational objective:
Acute otitis media is a common infection in infants and young children, especially with
cigarette smoke exposure, recent or concurrent upper respiratory infection, day care
attendance, and formula intake. The most common causative organisms are
Streptococcus pneumoniae, non-typeable Haemophilus influenzae, and Moraxella
catarrha/is. Oral amoxicillin should be administered to prevent complications (eg,
mastoiditis).

References:
1. Otitis media: diagnosis and treatment.
2. The diagnosis and management of acute otitis media.

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Media Exhibit

ute Mastoiditis

-c>titis media - • Q
1 Ear, Nose & Throat (ENT)
1- - - - - - - - - - - - - - - -
_________________________F
_e_e_d_b_a_ck
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A 27-year-old woman at 30 weeks gestation complains of difficulty hearing, especially on


the right side. She has no ear pain or discharge. At 22 weeks, her pregnancy was
complicated by acute pyelonephritis, which was treated with antibiotics. The patient eats
a balanced diet and does not use tobacco or alcohol. She takes no medications aside
from a multivitamin. Her blood pressure is 160/1 00 mm Hg and pulse is 75/min. Cardiac
and pulmonary examinations are unremarkable. She can hear a vibrating sound when a
tuning fork is placed on her right mastoid process for nearly 10 seconds. When the
vibrating tuning fork is immediately placed near her right external auditory meatus, she
can no longer hear the sound. When it is placed on the middle of her forehead, she feels
the vibration better in her right ear than the left. No other focal abnormalities are found
on neurologic examination. Audiometry shows right low-frequency hearing loss. Which
of the following is the most likely cause of this patient's complaints?

0 A. Acoustic neuroma
0 B. Antibiotic treatment
0 C. Chronic otitis media
0 D. Hypertension of pregnancy
0 E. Meniere's disease
0 F. Otosclerosis
0 G. Presbycusis

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A 27-year-old woman at 30 weeks gestation complains of difficulty hearing, especially on


the right side. She has no ear pain or discharge. At 22 weeks, her pregnancy was
complicated by acute pyelonephritis, which was treated with antibiotics. The patient eats
a balanced diet and does not use tobacco or alcohol. She takes no medications aside
from a multivitamin. Her blood pressure is 160/100 mm Hg and pulse is 75/min. Cardiac
and pulmonary examinations are unremarkable. She can hear a vibrating sound when a
tuning fork is placed on her right mastoid process for nearly 10 seconds. When the
vibrating tuning fork is immediately placed near her right external auditory meatus, she
can no longer hear the sound. When it is placed on the middle of her forehead, she feels
the vibration better in her right ear than the left. No other focal abnormalities are found
on neurologic examination. Audiometry shows right low-frequency hearing loss. Which
of the following is the most likely cause of this patient's complaints?

A. Acoustic neuroma [4%)


B. Antibiotic treatment [49%)
C. Chronic otitis media [5%)
D. Hypertension of pregnancy [4%)
E. Meniere's disease [3%)
.; I F. Otosclerosis [33%)
G. Presbycusis [2%)

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Explanation: User ld
This patient presents with hearing loss and an abnormal Rinne test on the right
consistent with conductive hearing loss. Hearing loss is classified as conductive
(obstruction of external sound to inner ear) or sensorineural (involving the inner ear,
cochlea, or auditory nerve). Mixed hearing loss is defined as having both processes.
The Rinne test is performed by placing a vibrating tuning fork on the patient's mastoid
bone until the patient indicates that it can no longer be heard. The still-vibrating tuning
fork is then quickly held outside the external auditory meatus (EAC) until the patient can
no longer hear the sound. Air-conducted (AC) sound should be heard twice as long as
bone-conducted (BC) sound. A normal Rinne test (AC > BC) is defined as the patient
being able to hear the vibrating tuning fork at the EAC after moving it from the mastoid.
An abnormal Rinne test is defined as the patient sensing the vibrating tuning fork on the
mastoid but being unable to hear it when placed outside the EAC. An abnormal Rinne

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Explanation: User

This patient presents with hearing loss and an abnormal Rinne test on the right
consistent with conductive hearing loss. Hearing loss is classified as conductive
(obstruction of external sound to inner ear) or sensorineural (involving the inner ear,
cochlea, or auditory nerve). Mixed hearing loss is defined as having both processes.
The Rinne test is performed by placing a vibrating tuning fork on the patient's mastoid
bone until the patient indicates that it can no longer be heard. The still-vibrating tuning
fork is then quickly held outside the external auditory meatus (EAC) until the patient can
no longer hear the sound. Air-conducted (AC) sound should be heard twice as long as
bone-conducted (80) sound. A normal Rinne test (AC > BC) is defined as the patient
being able to hear the vibrating tuning fork at the EAC after moving it from the mastoid.
An abnormal Rinne test is defined as the patient sensing the vibrating tuning fork on the
mastoid but being unable to hear it when placed outside the EAC. An abnormal Rinne
test (BC > AC) suggests conductive hearing loss.
The Weber test may also help differentiate between conductive and sensorineural
hearing loss. The Weber test is performed by placing a vibrating tuning fork on the
middle of the head or forehead equidistant from both ears and then asking the patient if
the vibration is sensed equally in both ears. A normal test (midline Weber) is the
vibration being heard equally with no lateralization. An abnormal test is the vibration
being heard louder and lateralizing to one ear. Patients with conductive hearing loss
lateralize to the affected ear on this test because the affected ear cannot hear the
ambient noise of the room. As a result, the inner ear is able to pick up the vibration better
and perceives it as louder. Patients with sensorineural hearing loss lateralize to the
unaffected ear on Weber as the inner ear of the affected ear cannot sense the vibration
(Table).

Interpretation of Weber & Rinne tests

Rinne result Weber result

Normal Air conducted > bone


conducted bilaterally Midline

Conductive BC > AC in affected ear,


hearing loss AC > BC in unaffected ear Lateralizes to affected ear
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(Table).

Interpretation of Weber & Rinne tests


Rinne result Weber result

Normal Air conducted > bone


Midline
conducted bilaterally

Conductive BC > AC in affected ear,


Lateralizes to affected ear
hearing loss AC > BC in unaffected ear

Sensorineural AC > BC in both ears Lateralizes to unaffected ear,


hearing loss away from affected ear

Mixed hearing BC > AC in affected ear, Lateralizes to unaffected ear,


loss AC > BC in unaffected ear away from affected ear
@USMLEWo tld, l LC

Conductive hearing loss is commonly caused by cerumen impaction, middle ear fluid or
infection, decreased movement of the small bones of the ear, or bony tumors of the
middle ear. Otosclerosis is a common cause of conductive hearing loss in adults,
especially those in their 20s and 30s, with a slight female predominance. The disorder
involves an abnormal remodeling of the otic capsule thought to be a possible
autoimmune process in genetically susceptible individuals. The stapes footplate.
becomes fixed to the oval window, resulting in loss of its piston action. This disorder is
sometimes referred to as otospongiosis as CT scan may show a lucent (as opposed to
sclerotic) focus in the temporal bone near the oval window. Treatment involves hearing
amplification or surgical stapedectomy.
(Choice A) An acoustic neuroma, also known as a vestibular schwannoma, typically
results in sensorineural hearing loss.

(Choice B) Ototoxic antibiotics such as aminoglycosides usually result in sensorineural


as opposed to conductive hearing loss.
(Choice C) Chronic otitis media may cause conductive hearing loss, but it is typically
accompanied by ear pain and tinnitus.

(Choice 0) This patient's high blood pressure will likely require further evaluation and
treatment, but it is unlikely to be contributing to her hearing loss.
(Choice E) Meniere's disease affects the inner ear and typically presents with aural

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loss AC > BC in unaffected ear away from affected ear
@USMLEWotld. LLC

Conductive hearing loss is commonly caused by cerumen impaction, middle ear fluid or
infection, decreased movement of the small bones of the ear, or bony tumors of the
middle ear. Otosclerosis is a common cause of conductive hearing loss in adults,
especially those in their 20s and 30s, with a slight female predominance. The disorder
involves an abnormal remodeling of the otic capsule thought to be a possible
autoimmune process in genetically susceptible individuals. The stapes footplate
becomes fixed to the oval window, resulting in loss of its piston action. This disorder is
sometimes referred to as otospongiosis as CT scan may show a lucent (as opposed to
sclerotic) focus in the temporal bone near the oval window. Treatment involves hearing
amplification or surgical stapedectomy.
(Choice A) An acoustic neuroma, also known as a vestibular schwannoma, typically
results in sensorineural hearing loss.
(Choice B) Ototoxic antibiotics such as aminoglycosides usually result in sensorineural
as opposed to conductive hearing loss.
(Choice C) Chronic otitis media may cause conductive hearing loss, but it is typically
accompanied by ear pain and tinnitus.
(Choice 0) This patient's high blood pressure will likely require further evaluation and
treatment, but it is unlikely to be contributing to her hearing loss.

(Choice E) Meniere's disease affects the inner ear and typically presents with aural
fullness, tinnitus, and sensorineural hearing loss.
(Choice G) Presbycusis is sensorineural hearing loss that occurs in adults of advanced
age.
Educational objective:
Bone conduction that is greater than air conduction on the Rinne test is suggestive of
conductive hearing loss and can be combined with the Weber test to confirm the
findings. Otosclerosis is a common cause of conductive hearing loss in adults,
particularly those in their 20s and 30s.

References:
1. The etiology of otosclerosis: a combination of genes and environment

Time Spent: 1 seconds Copyright © UWorld Last updated: [06/11/2016)

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A 30-year-old school teacher presents with a three-day history of fever, chills, and sore
throat. He also complains of difficulty swallowing that started yesterday. He denies any
cough, chest pain, or difficulty breathing. He is married and denies any new sexual
encounters. His temperature is 39.8° C (1 02.2° F), blood pressure is 11 8/76 mmHg,
pulse is 102/min, and respirations are 19/min. On examination, his voice is muffled.
Enlarged, tender cervical lymph nodes are palpated on the left, and his uvula is deviated
to the right. What is the most appropriate treatment for this patient?

o A. Throat swabs and oral antibiotics


0 B. Monospot test and oral antibiotics
0 C. Emergency laryngoscopy
o D. Cricothyroidotomy
o E. Needle peritonsillar aspiration

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A 30-year-old school teacher presents with a three-day history of fever, chills, and sore
throat. He also complains of difficulty swallowing that started yesterday. He denies any
cough, chest pain, or difficulty breathing. He is married and denies any new sexual
encounters. His temperature is 39.8° C (1 02.2° F), blood pressure is 11 8/76 mmHg,
pulse is 102/min, and respirations are 19/min. On examination, his voice is muffled.
Enlarged, tender cervical lymph nodes are palpated on the left, and his uvula is deviated
to the right. What is the most appropriate treatment for this patient?

A. Throat swabs and oral antibiotics [23%)


B. Monospot test and oral antibiotics [9%)
C. Emergency laryngoscopy [1 4%)
D. Cricothyroidotomy [1%)
E. Needle peritonsillar aspiration [53%)
' . ..
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Explanation: User

This patient's symptoms are most likely secondary to a peritonsillar abscess. Although
the three-day history of fever, chills, and sore throat were most likely secondary to
tonsillitis, his muffled or "hot potato voice" and deviation of the uvula suggest that a
peritonsillar abscess has developed as a complication of his tonsillitis. Patients with a
peritonsillar abscess typically have prominent unilateral lymphadenopathy, as seen in this
patient. This condition can be fatal secondary to either airway obstruction or spread of
the infection into the parapharyngeal space, which may lead to involvement of the carotid
sheath. Initial treatment consists of aspiration of the peritonsillar abscess and initiation of
intravenous antibiotics. Surgical intervention may be necessary if the purulent material
cannot be removed with aspiration alone.
(Choice A) Throat swabs and oral antibiotics are the. usual treatment of
tonsillopharyngitis, but this patient's muffled voice and deviation of his uvula suggest that
a more complicated infection is present.
(Choice B) This patient's unilateral lymphadenopathy, deviation of his uvula, and muffled
voice are not consistent with mononucleosis.
(Choice C) Emergency laryngoscopy is typically required in patients with epiglottitis to
ensure adequate protection of the airway. Epiglottitis can present with difficulty
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Explanation: User

This patient's symptoms are most likely secondary to a peritonsillar abscess. Although
the three-day history of fever, chills, and sore throat were most likely secondary to
tonsillitis, his muffled or "hot potato voice" and deviation of the uvula suggest that a
peritonsillar abscess has developed as a complication of his tonsillitis. Patients with a
peritonsillar abscess typically have prominent unilateral lymphadenopathy, as seen in this
patient. This condition can be fatal secondary to either airway obstruction or spread of
the infection into the parapharyngeal space, which may lead to involvement of the carotid
sheath. Initial treatment consists of aspiration of the peritonsillar abscess and initiation of
intravenous antibiotics. Surgical intervention may be necessary if the purulent material
cannot be removed with aspiration alone.
(Choice A) Throat swabs and oral antibiotics are the. usual treatment of
tonsillopharyngitis, but this patient's muffled voice and deviation of his uvula suggest that
a more complicated infection is present.
(Choice B) This patient's unilateral lymphadenopathy, deviation of his uvula, and muffled
voice are not consistent with mononucleosis.
(Choice C) Emergency laryngoscopy is typically required in patients with epiglottitis to
ensure adequate protection of the airway. Epiglottitis can present with difficulty
swallowing and a muffled voice similar to that seen in this patient, but the unilateral
lymphadenopathy and deviation of the uvula are more suggestive of a peritonsillar
abscess. In addition, the epiglottis is located more distal in the airway and is not adjacent
to the uvula.
(Choice 0) Cricothyroidotomy is used as a last resort in patients who are unable to
protect their airway. This patient, however, is not complaining of any difficulty breathing
at this time.
Educational objective:
A muffled voice should make one consider a diagnosis other than uncomplicated
pharyngitis or tonsillitis. A peritonsillar abscess is a potential complication of tonsillitis
and requires both intravenous antibiotic therapy and urgent drainage of the abscess.
Deviation of the uvula and unilateral lymphadenopathy can be helpful in distinguishing a
peritonsillar abscess from epiglottitis.

Time Spent: 1 seconds Copyright © UWorld Last updated: [1 0/1 7/2016)

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A 16-year-old boy comes to the emergency department due to sore throat and fever. He
started having a mild sore throat after returning from summer camp about a week ago,
and it has worsened in the last 2 days. The patient also has right neck pain and earache
but no cough or shortness of breath. He does not use tobacco or illicit drugs and is not
sexually active. Temperature is 38.8 C (102 F), blood pressure is 118/74 mm Hg, and
pulse is 104/min. Enlarged and tender cervical lymph nodes are present. The patient is
not able to fully open his mouth, but examination of the oral cavity shows pooling of
saliva, a large right tonsil with swelling of the right soft palate, and deviation of the uvula
to the left. Ear examination shows normal tympanic membranes. A rapid test for
Streptococcus pyogenes is negative. Which of the following is the most likely diagnosis?

0 A. Acute epiglottitis
o B. Acute tonsillitis
0 C. Adenoidal hypertrophy
0 D. Herpangina
0 E. Infectious mononucleosis
0 F. Peritonsillar abscess

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A 16-year-old boy comes to the emergency department due to sore throat and fever. He
started having a mild sore throat after returning from summer camp about a week ago,
and it has worsened in the last 2 days. The patient also has right neck pain and earache
but no cough or shortness of breath. He does not use tobacco or illicit drugs and is not
sexually active. Temperature is 38.8 C (1 02 F), blood pressure is 11 8/74 mm Hg, and
pulse is 104/min. Enlarged and tender cervical lymph nodes are present. The patient is
not able to fully open his mouth, but examination of the oral cavity shows pooling of
saliva, a large right tonsil with swelling of the right soft palate, and deviation of the uvula
to the left. Ear examination shows normal tympanic membranes. A rapid test for
Streptococcus pyogenes is negative. Which of the following is the most likely diagnosis?

A Acute epiglottitis [3%]


B. Acute tonsillitis [1 0%]
C. Adenoidal hypertrophy [1%]
D. Herpangina [1%]
E. Infectious mononucleosis [11 %]
F. Peritonsillar abscess [76%]

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Explanation: User

Peritonsillar abscess

Clinical features
Right
peritonsillar Fever
abscess Sore throat, difficulty swallowing
Trismus
Muffled " hot potato" voice
Uvula deviation away from enlarged tonsil
Pooling of saliva
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Explanation: User

Peritonsillar abscess

Clinical features
Right
peritonsillar Fever
abscess Sore throat, difficulty swallowing
Trism us
Muffled " hot potato" voice
Uvula deviation away from enlarged tonsil
Pooling of saliva

@UWorld

This patient has fever, pharyngeal pain, and earache suggesting a possible peritonsillar
abscess (PTA). PTA, also known as quinsy, is an acute bacterial infection of the region
between the tonsil and the pharyngeal muscles. It begins as persistent
tonsillitis/pharyngitis and progresses to cellulitis/phlegmon, with pus collecting into an
abscess within a week of symptom onset. PTA is most common in older adolescents and
young adults, and drug or alcohol use increases the risk.
Examination findings in PTA can include spasm of the jaw muscles (trismus) (which often
limits the physical examination), muffled "hot potato" voice, and swelling of peritonsillar
tissues with deviation of the uvula to the contralateral side. Treatment involves needle
aspiration or incision and drainage plus antibiotic therapy to cover Group A hemolytic
streptococci and respiratory anaerobes.
(Choice A) Epiglottitis is characterized by high-grade fever, severe sore throat, and
abscess (PTA). PTA, also known as quinsy, is an acute bacterial infection of the region
between the tonsil and the pharyngeal muscles. It begins as persistent
tonsillitis/pharyngitis and progresses to cellulitis/phlegmon, with pus collecting into an
abscess within a week of symptom onset. PTA is most common in older adolescents and
young adults, and drug or alcohol use increases the risk.
Examination findings in PTA can include spasm of the jaw muscles (trismus) (which often
limits the physical examination), muffled "hot potato" voice, and swelling of peritonsillar
tissues with deviation of the uvula to the contralateral side. Treatment involves needle
aspiration or incision and drainage plus antibiotic therapy to cover Group A hemolytic
streptococci and respiratory anaerobes.
(Choice A) Epiglottitis is characterized by high-grade fever, severe sore throat, and
odynophagia that can rapidly progress to airway obstruction. Pharyngeal findings in
epiglottitis are typically normal.
(Choice B) Uncomplicated tonsillitis is characterized by tonsillar erythema and exudates,
often with tender anterior cervical nodes and palatal petechiae. However, trismus,
po.oling of saliva, and uvular deviation are more consistent with PTA
(Choice C) Enlarged adenoids are usually seen in early childhood and regress with
age. They are unlikely to cause symptoms in an adolescent but may occasionally
obstruct the nasopharynx.
(Choice 0) Herpangina is caused by the coxsackie A virus and presents with fever, sore
throat, and odynophagia. It is most common in children and is characterized by vesicles
on the tonsils and soft palate.
(Choice E) Infectious mononucleosis is characterized by the triad of fever, pharyngitis,
and posterior cervical lymphadenopathy. Mononucleosis is not typically complicated by
abscess formation.

Educational objective:
Peritonsillar abscess is characterized by fever, pharyngeal pain, and earache.
Examination findings include trismus, muffled voice, and swelling of peritonsillar tissues
with deviation of the uvula. Treatment involves needle aspiration or incision and
drainage plus antibiotic therapy.

References:
1. Peritonsillar abscess

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A 36-year-old woman comes to the emergency department with worsening fever and sore
throat. Four days ago, the patient accidently 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 also reports neck pain and stiffness. Her temperature is 39 C
(1 02.2 F), blood pressure is 126/80 mm Hg, and pulse is 106/min. Examination shows
pooling of saliva in the hypopharynx. The posterior pharyngeal wall is red and bulging.
The neck is stiff with reduced passive range of motion. Lung auscultation is normal.
Lateral radiographs of the neck reveal increased thickness of the prevertebral soft
tissues with an air-fluid level. Due to potential contiguous spread of the disease process,
this patient is at greatest risk of developing which of the following?

o A. Acute necrotizing mediastinitis


o B. Cranial subdural empyema
o C. Ludwig angina
o D. Septic cavernous sinus thrombosis
o E. Spinal epidural abscess

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A 36-year-old woman comes to the emergency department with worsening fever and sore
throat. Four days ago, the patient accidently 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 also r.eports neck pain and stiffness. Her temperature is 39 C
(1 02.2 F), blood pressure is 126/80 mm Hg, and pulse is 106/min. Examination shows
pooling of saliva in the hypopharynx. The posterior pharyngeal wall is red and bulging.
The neck is stiff with reduced passive range of motion. Lung auscultation is normal.
Lateral radiographs of the neck reveal increased thickness of the prevertebral soft
tissues with an 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 [53%)


B. Cranial subdural empyema [3%)
C. Ludwig angina [1 3%)
D. Septic cavernous sinus thrombosis [7%)
-· E. Spinal epidural abscess [24%)

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Explanation : User

Deep neck space anatomy

+t-.- -----o;...:....__ _ _ _ _ Pretracheal


fascia
H+- ...,.,.........,..,c:-:----- Ret ropharyngeal
space
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Explanation: User ld

Deep neck space anatomy

·- ...

+t-r- - + - - - - - - - Pretracheal
fascia
H+--r--:.,..,.,....- - - Retropharyngeal
space

H+:::-=- + - --:-7- - Alar fascia

\-\.h.--'---1-~=:-:L---- "Danger" space

\ti::;::--t-~::::::=---- Prevertebra I
Pharynx fascia

Mediastinum ---:..._

@USMLEWorld, LLC

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. It communicates laterally with the parapharyngeal space. This patient has a
retropharyngeal abscess with neck pain, odynophagia, and fever following penetrating
trauma to the posterior pharynx. Examination findings can include nuchal rigidity and
bulging of the pharyngeal wall. Although deep space infections of the neck have become
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@USMLEWorld, LLC

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. It communicates laterally with the parapharyngeal space. This patient has a
retropharyngeal abscess with neck pain, odynophagia, and fever following penetrating
trauma to the posterior pharynx. Examination findings can include nuchal rigidity and
bulging of the pharyngeal wall. Although deep space infections of the neck have become
less common since the advent of widespread antibiotic use, they can progress rapidly
with potentially fatal complications.
Infection within the retropharyngeal space drains inferiorly to the superior
mediastinum. Spread to the carotid sheath can cause thrombosis of the internal
jugular vein and deficits in cranial nerves IX, X, XI, and XII. Extension through the alar
fascia into the "danger space" (between the alar and prevertebral fasciae) can rapidly
transmit infection into the posterior mediastinum to the level of the diaphragm. Acute
necrotizing mediastinitis is a life-threatening complication characterized by fever, chest
pain, dyspnea, and odynophagia, and requires urgent surgical intervention.

(Choice S) Extension of infection from the paranasal sinuses through the underlying
bone can lead to subdural empyema. Clinical findings include fever, headache, and
mass effect signs (eg, altered mental status).

(Choice C) Ludwig angina is a rapidly progressive bilateral cellulitis of the


submandibular and sublingual spaces, most often arising from an infected mandibular
molar. Clinical findings include fever, dysphagia, odynophagia, and drooling.

(Choice 0) Cavernous sinus thrombosis is most often due to contiguous spread of


infection from the medial third of the face, sinuses, or teeth via the valveless facial
venous system. Clinical findings include headache, fever, cranial nerve deficits (eg,
diplopia), and proptosis.
(Choice E) Spinal epidural abscess can be caused by hematogenous dissemination (eg,
intravenous drug abuse), contiguous spread from vertebral osteomyelitis, or direct
inoculation (eg, epidural anesthesia). Symptoms include fever, focal back pain, and
neurologic deficits.
Educational objective:
Retropharyngeal abscess presents with neck pain, odynophagia, and fever following
penetrating trauma to the posterior pharynx. Infection within the retropharyngeal space
can drain into the superior mediastinum. Extension through the alar fascia into the.
"danger space" can transmit infection into the posterior mediastinum and result in acute
necrotizing mediastinitis.

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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. It communicates laterally with the parapharyngeal space. This patient has a
retropharyngeal abscess with neck pain, odynophagia, and fever following penetrating
trauma to the posterior pharynx. Examination findings can include nuchal rigidity and
bulging of the pharyngeal wall. Although deep space infections of the neck have become
less common since the advent of widespread antibiotic use, they can progress rapidly
with potentially fatal complications.
Infection within the retropharyngeal space drains inferiorly to the superior
mediastinum. Spread to the carotid sheath can cause thrombosis of the internal
jugular vein and deficits in cranial nerves IX, X, XI, and XII. Extension through the alar
fascia into the "danger space" (between the alar and prevertebral fasciae) can rapidly
transmit infection into the posterio.r mediastinum to the level of the diaphragm. Acute
necrotizing mediastiniti!! is a life-threatening complication characterized by fever, chest
pain, dyspnea, and odynophagia, and requires urgent surgical intervention.
(Choice B) Extension of infection from the paranasal sinuses through the underlying
bone can lead to subdural empyema. Clinical findings include fever, headache, and
mass effect signs (eg, altered mental status).
(Choice C) Ludwig angina is a rapidly progressive bilateral cellulitis of the
submandibular and sublingual spaces, most often arising from an infected mandibular
molar. Clinical findings include fever, dysphagia, odynophagia, and drooling.

(Choice 0) Cavernous sinus thrombosis is most often due to contiguous spread of


infection from the medial third of the face, sinuses, or teeth via the valveless facial
venous system. Clinical findings include headache, fever, cranial nerve deficits (eg,
diplopia), and proptosis.
(Choice E) Spinal epidural abscess can be caused by hematogenous dissemination (eg,
intravenous drug abuse), contiguous spread from vertebral osteomyelitis, or direct
inoculation (eg, epidural anesthesia). Symptoms include fever, focal back pain, and
neurologic deficits.
Educational objective:
Retropharyngeal abscess presents with neck pain, odynophagia, and fever following
penetrating trauma to the posterior pharynx. Infection within the retropharyngeal space
can drain into the superior mediastinum. Extension through the alar fascia into the
"danger space" can transmit infection into the posterior mediastinum and result in acute
necrotizing mediastinitis.

Time Spent: 3 seconds Copyright © UWorld Last updated: [08/08/2016)

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Media Exhibit

veless ophthalmic venous system

The valveless ophthalmic venous system

Lacrimal vein

Superior ophthalmic vein

Cavernous sinus

Inferior Posterior Anterior Nasofrontal


ophthalmic ethmoidal ethmoidal vein
vein vein vein
© USMLEWorki. LLC

Q
ll
~tropharyngeal abscess -- •
Ear, Nose & Throat (ENT) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Fe_e_d_b_a_ck_ _ End Block
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A 43-year-old man is found wandering in the street in winter and is brought to the
emergency department by a passing motorist. The patient is confused and unable to
provide any additional history. He has no previous hospital records. On examination,
there is mild hypothermia at 35 C (95 F), but vital signs are otherwise normal. The
patient appears disheveled and lethargic but follows commands. Oral mucosa is moist
and he has extensive dental caries. He has no cervical lymphadenopathy, but there is
bilateral nontender submandibular swelling consistent with salivary gland enlargement.
Which of the following is the most likely cause of this latter finding?

o A. Alcoholism
o B. Mumps
o C. Pleomorphic adenoma
0 D. Salivary gland stone
o E. Sjogren syndrome
o F. Vitamin A deficiency

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A 43-year-old man is found wandering in the street in winter and is brought to the
emergency department by a passing motorist. The patient is confused and unable to
provide any additional history. He has no previous hospital records. On examination,
there is mild hypothermia at 35 C (95 F), but vital signs are otherwise normal. The
patient appears disheveled and lethargic but follows commands. Oral mucosa is moist
and he has extensive dental caries. He has no cervical lymphadenopathy, but there is
bilateral nontender submandibular swelling consistent with salivary gland enlargement.
Which of the following is the most likely cause of this latter finding?

A. Alcoholism [62%)
B. Mumps [4%)
C. Pleomorphic adenoma [8%)
D. Salivary gland stone [8%)
E. Sjogren syndrome [9%)
v F. Vitamin A deficiency [1 0%)

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Explanation: User

This patient has nontender enlargement of the submandibular glands, which is consistent
with sialadenosis. Sialadenosis is commonly found in patients with advanced liver
disease (eg, alcoholic and nonalcoholic cirrhosis). It is also seen in patients with altered
dietary patterns or malnutrition (eg, diabetes, bulimia).

Sialadenosis is a benign, noninflammatory swelling of the salivary glands. It is


associated with abnormal autonomic innervation of the glands, with accumulation of
secretory granules in acinar cells. Differential diagnosis includes sialadenitis (focal
tenderness, erythema, fever), salivary gland stones (glandular swelling and pain with
meals) (Choice 0), and malignancy. No management is needed other than to address
any underlying nutritional disorders.

(Choice B) Parotitis due to mumps or other viral infections presents with pain and
swelling in the parotid glands, often with systemic symptoms (eg, fever). lnvo.lvement of
the other salivary glands is uncommon.

(Choice C) Pleomorphic adenoma is a benign neoplasm affecting the salivary glands


that presents as a firm nodule. Bilateral or diffuse enlargement of the gland is more

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Explanation: User
This patient has nontender enlargement of the submandibular glands, which is consistent
with sialadenosis. Sialadenosis is commonly found in patients with advanced liver
disease (eg, alcoholic and nonalcoholic cirrhosis). It is also seen in patients with altered
dietary patterns or malnutrition (eg, diabetes, bulimia).
Sialadenosis is a benign, noninflammatory swelling of the salivary glands. It is
associated with abnormal autonomic innervation of the glands, with accumulation of
secretory granules in acinar cells. Differential diagnosis includes sialadenitis (focal
tenderness, erythema, fever), salivary gland stones (glandular swelling and pain with
meals) (Choice 0), and malignancy. No management is needed other than to address
any underlying nutritional disorders.
(Choice B) Parotitis due to mumps or other viral infections presents with pain and
swelling in the parotid glands, often with systemic symptoms (eg, fever). Involvement of
the other salivary glands is uncommon.

(Choice C) Pleomorphic adenoma is a benign neoplasm affecting the salivary glands


that presents as a firm nodule. Bilateral or diffuse enlargement of the gland is more
consistent with sialadenosis.
(Choice E) Sjogren syndrome is characterized by autoimmune sialadenitis and presents
with dry mouth associated with enlargement of the parotid and submandibular glands.
The lacrimal glands are also usually affected.
(Choice F) Vitamin A deficiency causes a number of ocular manifestations, including
impaired night vision, dry eyes, and keratinization of the conjunctiva and corneas.

Educational objective:
Sialadenosis is a benign, noninflammatory enlargement of the salivary glands. It is seen
in patients with advanced liver disease as well as a variety of dietary and nutritional
disorders.

References:
1. Sialadenosis in patients with advanced liver disease.

Time Spent: 2 seconds Copyright © UWorld Last updated: [09/13/201 6)

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A previously healthy 4-year-old girl is brought to the office with a cough. Two weeks ago,
she began having nasal congestion and a runny nose that initially improved. However,
over the past week she has been waking up at night with a dry cough. She also has had
worsening thick, "yellow-green" nasal discharge. Temperature is 37.2° C (99° F), pulse
is 90/min, and respirations are 15/min. Pulse oximetry is 99% on room air. Examination
shows an alert, active child with intermittent coughing. Thick, purulent mucus is dripping
from the nares and visualized in the posterior oropharynx. Nasal turbinates are red and
swollen. Maxillary sinuses are mildly tender. Lungs are clear on auscultation. What is
the most appropriate next step in management of this patient?

o A. Computed tomography scan of sinuses


o B. Intranasal corticosteroids
o C. Observation, follow-up in 3 days
o D. Oral antihistamines
o E. Oral antibiotics
o F. Sinus aspiration
o G. X-ray of the paranasal sinuses

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a. ld : 3285 PreVIOUS Next lab Values Notes Calculator Reverse Color Text Zoom

A previously healthy 4-year-old girl is brought to the office with a cough. Two weeks ago,
she began having nasal congestion and a runny nose that initially improved. However,
over the past week she has been waking up at night with a dry cough. She also has had
worsening thick, "yellow-green" nasal discharge. Temperature is 37.2° C (99° F), pulse
is 90/min, and respirations are 15/min. Pulse oximetry is 99% on rqom air. Examination
shows an alert, active child with intermittent coughing. Thick, purulent mucus is dripping
from the nares and visualized in the posterior oropharynx. Nasal turbinates are red and
swollen. Maxillary sinuses are mildly tender. Lungs are clear on auscultation. What is
the most appropriate next step in management of this patient?

A. Computed tomography scan of sinuses [5%]


B. Intranasal corticosteroids [4%]
C. Observation, follow-up in 3 days [8%]
D. Oral antihistamines [4%]
E. Oral antibiotics [71%]
F. Sinus aspiration [3%]
G. X-ray of the paranasal sinuses [6%]

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Explanation: User

This patient's presentation is consistent with acute bacterial rhinosinusitis (ABRS).


However, distinguishing between viral and bacterial sinusitis can be difficult. Most cases
of rhinorrhea and nasal congestion are due to virus infections. Viral upper respiratory
infections can be observed with follow-up (Choice C). It is important to avoid excessive
and unnecessary antibiotics due to increasing antibiotic resistance. However, if
symptoms persist or worsen, treatment for bacterial sinusitis should be initiated. ABRS is
generally a clinical diagnosis; typical features are shown in the table.

Diagnostic features of acute bacterial rhinosinusitis

• Persistent symptoms > 10 days without improvement


OR
• Severe symptoms, fever > 39 C (102 F), purulent nasal

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generally a clinical diagnosis; typical features are shown in the table.

Diagnostic features of acute bacterial rhinosinusitis

• Persistent symptoms > 10 days without improvement


OR
• Severe symptoms, fever > 39 C (1 02 F), purulent nasal
discharge, or face pain > 3 days
OR
• Worsening symptoms > 5 days after initially improving viral
upper respiratory infection

~UWOIId

If the patient develops complications such as periorbital edema, vision abnormalities, or


altered mental status, computed tomography scan (Choice A) is the imaging modality of
choice in identifying suppurative complications. Sinus x-rays (Choice G) are less
sensitive and not recommended in the diagnosis of sinusitis or its complications.
Oral amoxicillin-clavulanic acid is the treatment of choice for coverage of the most
common organisms, Streptococcus pneumoniae and nontypeable Haemophilus
influenzae, Intranasal corticosteroids (Choice B) may be a helpful adjunctive therapy in
patients with a history of allergic rhinitis. However, oral antihistamines (Choice 0) are
not recommended for treatment of ABRS.
Microbiology studies are unnecessary for children with uncomplicated ABRS who
improve as expected with antibiotics. If symptoms persist or worsen after 3 days of
antibiotics, cultures should be obtained by sinus aspiration (Choice F) to better target
antimicrobial therapy.
Educational objective:
Viral upper respiratory infections are the most common predisposing factor of acute
bacterial rhinosinusitis. Persistent or worsening symptoms should raise concern for
progression to bacterial sinusitis. Uncomplicated acute bacterial rhinosinusitis should be
treated with oral amoxicillin-clavulanic acid.

References:
1. Upper respiratory tract infections in young children: duration of and
frequency of complications.
Item: ~'?Mark ~ f> 6t ~ ~ , GJIIA)
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Diagnostic features of acute bacterial rhinosinusitis

• Persistent symptoms > 10 days without improvement


OR
• Severe symptoms, fever > 39 C (1 02 F), purulent nasal
discharge, or face pain > 3 days
OR
• Worsening symptoms > 5 days after initially improving viral
upper respiratory infection
@UWorld

If the patient develops complications such as periorbital edema, vision abnormalities, or


altered mental status, computed tomography scan (Choice A) is the imaging modality of
choice in identifying suppurative complications. Sinus x-rays (Choice G) are less
sensitive and not recommended in the diagnosis of sinusitis or its complications.
Oral amoxicillin-clavulanic acid is the treatment of choice for coverage of the most
common organisms, Streptococcus pneumoniae and nontypeable Haemophi/us
influenzae. Intranasal corticosteroids (Choice B) may be a helpful adjunctive therapy in
patients with a history of allergic rhinitis. However, oral antihistamines (Choice 0 ) are
not recommended for treatment of ABRS.
Microbiology studies are unnecessary for children with uncomplicated ABRS who
improve as expected with antibiotics. If symptoms persist or worsen after 3 days of
antibiotics, cultures should be obtained by sinus aspiration (Choice F) to better target
antimicrobial therapy.

Educational objective:
Viral upper respiratory infections are the most common predisposing factor of acute
bacterial rhinosinusitis. Persistent or worsening symptoms should raise concern for
progression to bacterial sinusitis. Uncomplicated acute bacterial rhinosinusitis should be
treated with oral amoxicillin-clavulanic acid.

References:
1. Upper respiratory tract infections in young children: duration of and
frequency of complications.
2. IOSA clinical practice guideline for acute bacterial rhinosinusitis in
children and adults.

Time Spent 2 seconds Copyright© UWorld Last updated: [09/22/2016)

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A 26-year-old man comes to your office with a one-week history of right-sided ear pain.
The pain often wakes him up at night, and increases in severity when he chews food. He
cannot recall any recent episodes of pharyngitis. He denies having any ear discharge,
sinus tenderness, or skin rash. He exercises by swimming frequently at a local club. He
is sexually active and uses condoms "quite regularly." He lives with his brother, who
often comments on his habit of grinding his teeth at night. On examination, his ears are
normal with a mild amount of wax. Pain is not elicited by pulling on the pinna. There are
no hearing deficits appreciated. Mobility of the tympanic membrane is normal, and the
Weber and Rinne test results are within normal limits. What is the most likely diagnosis?

0 A. Ramsay Hunt syndrome


o B. Glossopharyngeal neuralgia
0 C. Otitis media
0 D. Temporomandibular joint dysfunction
o E. Otitis externa
0 F. Cerumen impaction

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a. ld : 2154 PreVIOUS Next lab Values Notes Calculator Reverse Color Text Zoom

A 26-year-old man comes to your office with a one-week history of right-sided ear pain.
The pain often wakes him up at night, and increases in severity when he chews food. He
cannot recall any recent episodes of pharyngitis. He denies having any ear discharge,
sinus tenderness, or skin rash. He exercises by swimming frequently at a local club. He
is sexually active and uses condoms "quite regularly." He lives with his brother, who
often comments on his habit of grinding his teeth at night. On examination, his ears are
normal with a mild amount of wax. Pain is not elicited by pulling on the pinna. There are
no hearing deficits appreciated. Mobility of the tympanic membrane is normal, and the
Weber and Rinne test results are within normal limits. What is the most likely diagnosis?

A. Ramsay Hunt syndrome [4%1

B. Glossopharyngeal neuralgia [5%)

C. Otitis media [3%)

D. Temporomandibular joint dysfunction [80%)


E. Otitis externa [7%)
F. Cerumen impaction [2%)

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Explanation: User

The most likely diagnosis in this patient is temporomandibular joint (TMJ) dysfunction.
Most patients with TMJ dysfunction have a history of nocturnal teeth grinding, and
patients often interpret the pain as coming from the ear due to anatomic proximity. The
pain associated with TMJ dysfunction is characteristically worsened with chewing
because of the strain that this places on the TMJ. Although many patients may have
audible clicks or crepitus in the TMJ with jaw movement, this is not seen in all patients. A
thorough physical examination should be done to exclude other conditions within the ear
itself. Radiologic imaging of the TMJ is often of limited utility. Initial treatment consists
primarily of conservative measures such as a nighttime bite guard, but surgical

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., D. Temporomandibular joint dysfunction [80%)


E. Otitis externa [7%)
F. Cerumen impaction [2%)

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Explanation: User

The most likely diagnosis in this patient is temporomandibular joint (TMJ) dysfunction.
Most patients with TMJ dysfunction have a history of nocturnal teeth grinding, and
patients often interpret the pain as coming from the ear due to anatomic proximity. The
pain associated with TMJ dysfunction is characteristically worsened with chewing
because of the strain that this places on the TMJ.. Although many patients may have
audible clicks or crepitus in the TMJ with jaw movement, this is not seen in all patients. A
thorough physical examination should be done to exclude other conditions within the ear
itself. Radiologic imaging of the TMJ is often of limited utility. Initial treatment consists
primarily of conservative measures such as a nighttime bite guard, but surgical
intervention is sometimes necessary.

(Choice A) Ramsay Hunt syndrome is a form of herpes zoster infection that causes Bell's
palsy. In this condition, vesicles are typically seen on the outer ear.

(Choice B) Glossopharyngeal neuralgia is a condition in which patients experience


intermittent, severe, stabbing pain in areas innervated by cranial nerves IX and X, which
includes the ear. However, this patient's history of worsening pain with chewing makes
TMJ dysfunction more likely.

(Choice C) Otitis media can result in ear pain, but it will usually cause erythema and/or
limited mobility of the tympanic membrane as well.

(Choice E) Otitis externa usually results in ear discharge and pain with pulling on the
pinna, neither of which is seen in this patient.

(Choice F) Cerumen impaction usually causes conductive hearing loss as opposed to


pain, and can easily be excluded with otoscopic examination.

Educational objective:
Temporomandibular joint (TMJ) dysfunction can result in referred pain to the ear that is
worsened with chewing. Patients typically report a history of nocturnal teeth grinding.

Time Spent: 1 seconds Copyright © UWorld Last updated: [1 0/1 7/2016)

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