PANCE Blueprint EENT (6%)

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PANCE Blueprint EENT (6%)
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PANCE Blueprint EENT (6%)

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112 Lessons

2 hours 15 mins

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Follow along with the NCCPA™ PANCE and PANRE EENT Content Blueprint

Lessons

  4. EENT 109 Question Comprehensive Exam (Members Only)

    Comprehensive PANCE/PANRE EENT Blueprint Exam

      1. Conjunctivitis (ReelDx + Lecture)

        • Viral: copious watery discharge, scant mucoid discharge. Adenovirus (most common). Self-limiting associated with URI.
        • Bacterial:  Pt will present with purulent (yellow) discharge, crusting, usually worse in the morning. May be unilateral.
          • S. pneumonia, S. aureus – acute mucopurulent
          • M. catarrhalis, Gonococcal – copious purulent discharge, in a patient who is not responding to conventional treatment
          • Chlamydia– newborn, giemsa stain - inclusion body, scant mucopurulent discharge
        • Allergic: red eyes, itching and tearing, usually bilateral, cobblestone mucosa on the inner/upper eyelid.

      1. Cataract (Lecture)

        Blurred vision over months or years, halos around lights. Clouding of the Lens (versus clouding of cornea = glaucoma). Fundoscopy "black on red background."

      2. Corneal ulcer

         Contact lense wearers, caused by deep infection in the cornea by bacteria, viruses or fungi. White spot on surface of cornea that stains with fluorescein: round "ulceration" versus "dendritic" pattern like herpes

      3. Keratitis and infectious corneal disorders

        Keratitis is inflammation of the cornea that can lead to vision loss if not treated promptly, and may be infectious or non-infectious in origin.
        • Common causes include bacterial, viral (especially HSV), fungal, and amoebic infections; non-infectious causes include contact lens overuse, UV exposure, and trauma
        • Symptoms include eye pain, redness, photophobia, tearing, blurred vision, and foreign body sensation
        • Physical exam may reveal conjunctival injection, corneal opacity or ulcer, and ciliary flush; fluorescein staining shows corneal epithelial defects
        • Herpes simplex keratitis presents with dendritic ulcers on fluorescein staining; avoid steroids unless under ophthalmology supervision
        • Bacterial keratitis is often associated with contact lens wear and may present with a corneal ulcer and hypopyon
          • Pseudomonas aeruginosa – most common in contact lens wearers
        • Diagnosis is clinical, supported by slit-lamp exam with fluorescein staining; corneal scrapings may be needed for gram stain and culture in severe or atypical cases
        • Treatment depends on etiology:
          • Bacterial: Topical antibiotics (e.g., fluoroquinolones)—(ideally after obtaining cultures)
          • Viral: Topical or oral antivirals (e.g., acyclovir)
          • Fungal: Antifungal drops (e.g., natamycin)
          • Amoebic: Requires antiparasitic treatment
        • Urgent ophthalmology referral is essential to prevent corneal scarring and vision loss

      4. Pterygium (ReelDx + Lecture)

        Elevated, superficial, fleshy, triangular-shaped “growing” fibrovascular mass (most common in inner corner/nasal side of the eye). Only surgically remove when vision is affected

      1. Iritis (Anterior Uveitis)

        Iritis (Anterior Uveitis) is inflammation of the anterior uveal tract, primarily affecting the iris and ciliary body, and is the most common form of uveitis.
        • Idiopathic (most cases), autoimmune diseases: HLA-B27–associated conditions (e.g., ankylosing spondylitis, reactive arthritis, psoriatic arthritis, IBD)
          • Infectious: Herpes simplex/zoster, tuberculosis, syphilis, Lyme disease
          • Trauma or post-surgical inflammation
        • Presents with eye pain, photophobia, blurred vision, and redness, especially around the limbus (ciliary flush). May also have excessive tearing and decreased visual acuity
          • Consensual photophobia (pain when light is shone in the unaffected eye)
          • Miotic (constricted), irregular pupil due to posterior synechiae
          • Cell and flare seen in the anterior chamber on slit-lamp exam (hallmark sign)
        • Diagnosis is clinical, often confirmed by slit-lamp examination showing leukocytes (cells) and protein (flare) in the anterior chamber
          • Systemic workup (e.g., HLA-B27 antigen) may be necessary to identify underlying autoimmune or infectious causes in recurrent or bilateral cases
        • Treat with topical corticosteroids (e.g., prednisolone acetate) to reduce inflammation, cycloplegic agents (e.g., homatropine or atropine) to relieve pain and prevent synechiae
        • Ophthalmology referral is mandatory for confirmation and close monitoring
        • Treat the underlying systemic disease if identified
        • If left untreated, it can lead to glaucoma, cataracts, posterior synechiae, vision loss, or macular edema

      2. Scleritis

        Inflammation of the sclera associated with systemic immunologic disease, such as rheumatoid arthritis
        • It causes significant eye pain (severe, deep pain)
        • On examination, there is ocular redness and pain on palpation of the eyeball. It can cause visual impairment
        TX: Refer the patient for prompt evaluation by an ophthalmologist.
        • Treatment involves topical and sometimes systemic corticosteroids.

      3. Uveitis

        Uveitis is inflammation of the uveal tract (iris, ciliary body, choroid) and can be associated with autoimmune, infectious, or idiopathic causes.
        • Types:
          • Anterior uveitis (iritis) – Most common; inflammation of the iris and ciliary body
          • Intermediate uveitis – Involves the vitreous
          • Posterior uveitis – Affects the retina and choroid
          • Panuveitis – Involves all layers of the uveal tract
        • Causes:
          • Autoimmune diseases: Ankylosing spondylitis, reactive arthritis, psoriatic arthritis, inflammatory bowel disease (HLA-B27-associated)
          • Infectious causes: Herpes simplex, cytomegalovirus, syphilis, tuberculosis, toxoplasmosis
          • Idiopathic: No identifiable cause in many cases
        • Symptoms:
          • Anterior uveitis: Eye pain, photophobia, redness, blurred vision
          • Posterior uveitis: Painless vision loss, floaters
          • May be unilateral or bilateral, depending on etiology
        • Diagnosis:
          • Slit-lamp exam:
            • Anterior uveitis – Ciliary flush, hypopyon, keratic precipitates
            • Posterior uveitis – Vitritis, choroiditis, retinal vasculitis
          • Fundoscopy for posterior involvement
          • Lab tests if systemic disease is suspected (e.g., HLA-B27, syphilis, TB testing)
        • Management:
          • Anterior uveitis:
            • Topical corticosteroids (prednisolone acetate)
            • Cycloplegic agents (atropine, scopolamine) to relieve pain from ciliary spasm
          • Posterior uveitis: Systemic corticosteroids or immunosuppressive agents
          • Treat underlying cause if infectious or systemic disease is present
        • Complications: If untreated, can lead to glaucoma, cataracts, permanent vision loss

      1. Dacryoadenitis and Dacryocystitis

        • Dacryoadenitis is inflammation of the nasolacrimal duct or the nasolacrimal gland (supratemporal)
        • Dacryocystitis is an infectious obstruction of the lacrimal sac (inferomedial region)

      2. Dacryostenosis (Nasolacrimal Duct Obstruction)

        Dacryostenosis is a condition characterized by the obstruction of the nasolacrimal duct, leading to excessive tearing (epiphora).
        • Most common cause of persistent tearing in infants, usually due to incomplete canalization of the nasolacrimal duct at birth
        • In adults, it can result from infection, trauma, inflammation, or age-related narrowing of the duct
        • Presents with chronic tearing, crusting of the eyelids, and occasionally recurrent conjunctivitis
        • Diagnosis is clinical, based on symptoms and examination showing a blocked tear drainage system; additional tests like fluorescein dye disappearance test may help confirm obstruction
        • Initial management in infants involves lacrimal sac massage (Crigler maneuver) and monitoring, as many cases resolve spontaneously by 6-12 months
        • Persistent cases or adult-onset dacryostenosis may require probing, balloon catheter dilation, or stenting of the nasolacrimal duct
        • Dacryocystorhinostomy (DCR) is the definitive surgical treatment for severe or refractory cases, creating a new drainage pathway into the nasal cavity
        • Complications include recurrent infections such as dacryocystitis and chronic conjunctivitis if untreated

      3. Keratoconjunctivitis sicca (Lecture)

        Keratoconjunctivitis sicca, or dry eye syndrome, is characterized by chronic cornea and conjunctiva dryness due to insufficient tear production or increased tear evaporation
        • Common causes include autoimmune diseases, aging, certain medications, and environmental factors like prolonged screen exposure
        • Symptoms typically involve dryness, burning, and blurred vision, often worsening at night or after extended screen use
        • Diagnosis relies on clinical symptoms and tests like Schirmer's Test, Tear breakup test (TBUT), and fluorescein staining
        • Treatment strategies include artificial tears, anti-inflammatory eye drops, environmental modifications, and punctal plugs to relieve symptoms and prevent complications like corneal ulcers or vision impairment

      1. Blepharitis (Lecture)

        Eyelid changes: crusting, greasy, scaling, red-rimming of eyelid and eyelash flaking along with dry eyes and associated seborrhea and rosacea

      2. Chalazion (Lecture)

        A chalazion is a sterile painless (non-infectious) granuloma of the internal meibomian sebaceous gland, painless "cold" lid nodule

      3. Ectropion

        Ectropion (eversion of the eyelid) occurs when the eyelid turns outward exposing the palpebral conjunctiva, conjunctiva will appear red from air exposure and inflammation

      4. Entropion (Lecture)

        Entropion (inversion of an eyelid) occurs when the eyelid turns inward. It is most commonly caused by age-related tissue relaxation, surgical correction is definitive

      5. Hordeolum (ReelDx + Lecture)

        Painful, warm (hot), swollen red lump on the eyelid (different from a chalazion which is painless) Think “H” for Hot = Hordeolum. Most common organism S.  aureus.

      1. Nystagmus (ReelDx)

        • Down/upbeat: CNS dysfunction
        • Vestibular (horizontal): labyrinth or vestibular nerve dysfunction
        • Gaze-evoked: most common and often benign

      2. Optic neuritis (ReelDx + Lecture)

        Acute inflammation and demyelination of the optic nerve leading to acute monocular vision loss/blurriness and pain on extraocular movements. Typically occurs over hours or days. Fundoscopy: inflammation of the optic disc. Associated with multiple sclerosis.

      3. Papilledema (ReelDx)

        Optic disc swelling that is caused by increased intracranial pressure. The swelling is usually bilateral and can occur over a period of hours to weeks. Causes include brain tumor/abscess, meningitis, cerebral hemorrhage, encephalitis, pseudotumor cerebri. Immediate neuroimaging to rule out mass lesion, then CSF analysis. Treat underlying cause.

      1. Orbital cellulitis (ReelDx)

        Orbital Cellulitis is an infection of the orbital tissues posterior to the orbital septum, often secondary to sinusitis
        • Proptosis (protrusion of the eye), decreased extraocular movement (ophthalmoplegia), and pain with eye movements
        • Erythema, swelling, and tenderness of the eyelid and surrounding tissues
        • May present with fever, decreased vision, and diplopia
        • Occurs more often in children than adults. Potentially sight-threatening and requires urgent evaluation
        • Diagnosed with CT scan or MRI to assess the extent of infection and rule out abscess formation
        • Common pathogens include Staphylococcus aureus, Streptococcus species, and Haemophilus influenzae
        • Treated with IV antibiotics (e.g., vancomycin plus ceftriaxone) and possibly surgical drainage if abscess is present
        • Requires hospitalization and close monitoring for complications such as cavernous sinus thrombosis or intracranial spread

      2. Periorbital (Preseptal) Cellulitis (Lecture)

        Periorbital (Preseptal) Cellulitis is an infection of the eyelid and surrounding skin anterior to the orbital septum
        • Typically caused by skin trauma, insect bites, or sinusitis
        • Erythema, swelling, and tenderness of the eyelid
        • No proptosis, ophthalmoplegia, or pain with eye movements (distinguishes from orbital cellulitis)
        • May be associated with fever and systemic symptoms
        • Diagnosed clinically, but CT scan can be used if orbital cellulitis is suspected
        • Common pathogens include Staphylococcus aureus (including MRSA), Streptococcus species, and Haemophilus influenzae
        • Treated with oral antibiotics (e.g., amoxicillin-clavulanate or clindamycin) for mild cases; IV antibiotics for more severe cases or if orbital cellulitis cannot be ruled out

      1. Macular degeneration (Lecture)

        Gradual painless loss of central vision. The macula is responsible for central visual acuity which is why macular degeneration causes gradual central field loss. Metamorphopsia (distortion on Amsler grid)
        • Dry macular degeneration (85% of cases): atrophic changes with age – slow gradual breakdown of the macula (macular atrophy), with DRUSEN (DRY)= yellow retinal deposits.
        • Wet macular degeneration: hemorrhage, neovascuration. New abnormal vessels grow under central retina which leak and bleed causing retinal scarring.

      2. Retinal detachment (ReelDx + Lecture)

        Vertical curtain coming down across the field of vision, may sense floaters or flashes at onset, loss of vision over several hours
        • Asymmetric red reflex
        • Retinal detachment is visualized on fundoscopy as an irregular elevation of the retina with crinkling of retinal tissue and changes in vessel direction
        •  Consult ophthalmologist. Stay supine (lying face upward) with head turned towards the side of the detached retina

      3. Retinopathy (Lecture)

        Retinopathy refers to damage to the retina, often due to chronic systemic conditions like diabetes or hypertension
        • Diabetic retinopathy is the leading cause of blindness in adults, categorized as non-proliferative (microaneurysms, flame hemorrhages, hard exudates) and proliferative (neovascularization, vitreous hemorrhage)
        • Hypertensive retinopathy presents with arteriovenous (AV) nicking, retinal hemorrhages, cotton wool spots, and papilledema in severe cases
        • Symptoms may include gradual painless loss of vision, blurred vision, floaters, and dark spots (scotomata)
        • Screening for diabetic retinopathy should begin 5 years after the onset of type 1 diabetes and at diagnosis for type 2 diabetes, with annual follow-ups
        • Fundoscopic exam is key for diagnosis; findings vary depending on the type and severity of retinopathy
        • Management includes strict control of blood glucose and blood pressure
        • Laser photocoagulation, intravitreal injections, or vitrectomy for advanced cases
        • Prevention through regular eye exams and control of underlying systemic conditions

      1. Retinal vascular occlusion (Lecture)

        Sudden, painless, unilateral, and usually severe vision loss (Amaurosis fugax). Embolism from the same side (ipsilateral) carotid artery, ophthalmic artery, and heart, or giant cell arteritis. Rule out carotid artery stenosis by carotid ultrasound. Look for the cherry red spot.

      1. Amaurosis fugax

        Transient partial or complete loss of vision in one eye - The most common cause of amaurosis fugax is a cholesterol plaque emboli from a carotid artery plaque
        • Blockage of the central retinal artery leads to sudden, painless, monocular vision loss due to retinal hypoxia
        • Vision loss is classically described as a curtain coming down over one eye
        • Amaurosis fugax (an example of a TIA) occurs if the clot passes and the vision loss is transient. If the clot cannot pass, central retinal artery occlusion occurs
        • A fundus exam may reveal optic disk pallor, a cherry-red macula, and retinal edema
        TX: If it does not resolve spontaneously, treatment is recommended within an hour of the occlusion
        • Treatment involves surgical decompression, but if unavailable, digital massage of the globe and CO2 rebreathing should be initiated in an attempt to pass the clot

      2. Amblyopia (lazy eye)

        Amblyopia (lazy eye) is reduced visual acuity is not correctable by refractive means
        • It may be caused by strabismus (crossed eye); uremia; or toxins, such as alcohol, tobacco, lead, and other toxic substances
        • treatment includes correction of refraction error as well as forced use of the amblyopic eye by patching the better eye or blurring with glasses or drops

      3. Glaucoma (Lecture)

        • Open angle glaucoma: most common, aqueous outflow obstruction, > 40 y/o,  African Americans, often asymptomatic, peripheral to central gradual visual loss (versus macular degeneration which is central loss)
        • Acute angle closure glaucoma: Iris against lens, dark environment, acute loss of vision, nausea, and vomiting. Classic triad: injected conjunctiva, steamy cornea, and fixed dilated pupil, this is an ophthalmic emergency

      4. Strabismus (ReelDx + Lecture)

        • Strabismus is defined as any form of ocular misalignment. The cover/uncover test is used to diagnose strabismus
        • There are many types of strabismus, which are defined by the direction of misalignment
          • Exotropia: out-turning of eyes
          • Esotropia: in-turning of eyes (see ReelDx video in presentation tab)
          • Hypertropia: Upward deviation of eyes
          • Hypotropia: Downward deviation of eyes
        • Treatment options can include glasses, occlusion therapy, orthoptic exercises, surgery, or a combination of these therapies

      5. Presbyopia (Lecture)

        Presbyopia is an age-related condition causing gradual loss of the eye's ability to focus on nearby objects, typically starting in the early to mid-40s and affecting nearly everyone by age 65
        • Common symptoms include difficulty reading small print, needing to hold reading materials farther away, eye strain, and headaches during close work
        • It results from the hardening of the lens inside the eye, reducing its flexibility and ability to change shape for focusing on close objects
        • Diagnosis is confirmed through a comprehensive eye exam, including visual acuity tests, refraction assessments, near vision tests, and slit-lamp examinations
        • Treatment options focus on improving near vision and include eyeglasses, contact lenses, refractive surgery, lens implants, and lifestyle modifications such as using good lighting and taking breaks during prolonged near work

    12. Ocular Foreign body (ReelDx)

      Ocular Foreign Body refers to a foreign material lodged on or within the eye, commonly affecting the cornea or conjunctiva.
      • Common causes include small particles from metal grinding, wood, or dust, often encountered in industrial or outdoor settings
      • Presents with eye pain, tearing, redness, foreign body sensation, and photophobia
      • Examination should include visual acuity testing, inspection with fluorescein staining, and use of a slit lamp to localize and assess the foreign body
      • Complications include corneal abrasion, infection, or, in severe cases, penetrating ocular injury
      • Management:
        • Superficial foreign bodies can be removed with irrigation or a sterile cotton swab
        • Embedded foreign bodies may require removal with a sterile needle or ophthalmic burr under magnification
        • Topical antibiotics (e.g., erythromycin ointment) should be prescribed to prevent infection
        • Referral to ophthalmology is necessary for large, deeply embedded, or suspected penetrating injuries
      • Preventive measures include wearing protective eyewear during activities with a high risk of exposure
      • Patients should be educated to avoid rubbing the eye, which can exacerbate injury

      1. Cerumen impaction

        Cerumen impaction—buildup obstructs the auditory canal and is the most common cause of conductive hearing loss
        • Abnormal Rinne test—bone conduction is better than air conduction
        • Weber—sound lateralizes to the affected side (tuning fork is perceived more loudly in the ear with a conductive hearing loss)
        TX: Irrigation after several days of softening with carbamide peroxide (Debrox) or triethanolamine (Cerumenex)

      2. Otitis externa

        Edema with cheesy white discharge, palpation of the targus is painful, Pseudomonas aeruginosa (swimmer’s ear), S. aureus (digital trauma), malignant otitis externa is commonly seen in diabetics

      3. External Ear Trauma

        Trauma to the external ear may result in hematoma, laceration, avulsion, or fracture
        • Subperichondrial hematoma
          • Blunt trauma to the pinna may cause a subperichondrial hematoma and accumulation of large amounts of blood between the perichondrium and cartilage
          • This can interrupt the blood supply to the cartilage and render all or part of the pinna a shapeless, reddish purple mass
          • Avascular necrosis of the cartilage may follow
          • The resultant destruction causes the characteristic cauliflower ear of wrestlers and boxers
          • The most appropriate course of action for this patient is to refer immediately for I & D by an ENT specialist for the best results
          • The cartilage of the pinna requires vascular supply from the perichondrium. If deprived of blood, the devascularized tissue can become permanently damaged, resulting in the so-called “cauliflower ear”

      1. Acoustic neuroma

        Acoustic Neuroma (vestibular schwannoma) is a benign, slow-growing tumor arising from Schwann cells of cranial nerve VIII (vestibulocochlear nerve).
        • Most common tumor of the cerebellopontine angle
        • Presents with unilateral sensorineural hearing loss (most common), tinnitus, and vertigo
        • May cause facial numbness or weakness due to compression of cranial nerve VII
        • Large tumors can lead to ataxia, headache, and hydrocephalus from brainstem compression
        • Diagnosis is confirmed with MRI with gadolinium, showing an enhancing mass in the internal auditory canal or cerebellopontine angle
        • Audiometry often shows asymmetric sensorineural hearing loss
        • Management depends on size and symptoms:
          • Observation with serial MRI for small, asymptomatic tumors
          • Surgical resection or stereotactic radiosurgery (e.g., Gamma Knife) for symptomatic or enlarging tumors
        • Complications include permanent hearing loss and facial nerve injury, especially with larger tumors

      2. Dysfunction of the eustachian tube

        6 mins

        Ear fullness, popping of ears, underwater feeling, intermittent sharp ear pain, fluctuating conductive hearing loss, tinnitus. All children < 7 years old have some ET dysfunction (based on the angle of the eustachian tube) will resolve with age

      3. Labyrinthitis (Lecture)

        Acute onset, vertigo + hearing loss, tinnitus of several days to a week. Usually, viral absence of neurologic deficits. Diazepam or meclizine vertigo, promethazine for nausea

      4. Vertigo (ReelDx + Lecture)

        • Central vertigo: more gradual onset and vertical nystagmus. Unlike peripheral vertigo, it does not present with auditory symptoms. Romberg Sign. Brainstem vascular disease, arteriovenous malformations, tumors, multiple sclerosis, and vertebrobasilar migraine.
        • Peripheral (inner ear) sudden onset, nausea/vomiting, tinnitus, hearing loss, and horizontal nystagmus. Labyrinthitis, benign paroxysmal positional vertigo, endolymphatic hydrops (Ménière syndrome), vestibular neuritis, and head injury.

      1. Cholesteatoma

        Painless otorrhea, brown/yellow discharge with strong odor, caused by chronic eustachian tube dysfunction which results in chronic negative pressure and inverts part of the TM causing granulation tissue that over time, erodes the ossicles and leads to conductive hearing loss. Surgical removal.

      2. Otitis media (ReelDx)

        Age 2 and under, limited mobility of the TM with pneumotoscopy. S. pneumoniae 25%, H. influenzae 20%, M. catarrhalis 10%, first line Amoxicillin, second line Augmentin, macrolides if pen allergic, complications mastoiditis and bullous myringitis.

      3. Tympanic membrane perforation (ReelDx)

        Pain, otorrhea, and hearing loss/reduction, most heal spontaneously, keep clean and dry, treat with antibiotics, the only class of antibiotics that are non-ototoxic are Floxin drops.Surgery if persists past 2 months.

      4. Otosclerosis (Lecture)

        Otosclerosis is a progressive disorder characterized by abnormal bone remodeling in the middle ear, leading to conductive hearing loss.
        • Commonly affects the stapes, causing fixation of the stapes footplate
        • Presents with gradual conductive hearing loss that typically begins in early to mid-adulthood
        • Tinnitus may be present
        • Normal tympanic membrane on otoscopic examination
        • Positive family history in some cases, suggesting a genetic component
        • Diagnosed with audiometry, showing conductive hearing loss with a normal tympanogram. CT scan of the temporal bone may show bony changes
        • Treatment options include hearing aids for amplification and surgical stapedectomy or stapedotomy to improve hearing

    5. Hearing impairment (PEARLS + Lecture)

      The most common causes of hearing impairment/loss are cerumen impaction, eustachian tube dysfunction (secondary to upper respiratory tract infection [URI]), and increasing age (presbycusis)
      • Weber test: Tuning fork is placed on center of the head and see if sound lateralizes - Sound lateralizes to affected ear in conductive hearing loss, Sound lateralizes to unaffected ear in sensorineural hearing loss
      • Rinne test: Tuning fork placed on mastoid and then up to the ear (should continue to hear) conductive hearing loss if bone > air, sensorineural hearing loss if air > bone

      1. Hearing impairment (Conductive)

        Conductive Hearing Impairment occurs when sound transmission is blocked in the external or middle ear, preventing sound from reaching the inner ear.
        • Common causes include cerumen impaction, otitis media, otosclerosis, tympanic membrane perforation, and ear canal foreign body
        • Presents with hearing loss, often described as muffled or reduced sound clarity, while speech discrimination remains relatively preserved
        • Patients may report better hearing in noisy environments and own voice sounding louder (autophony)
        • Weber test lateralizes to the affected ear; Rinne test shows bone conduction > air conduction (negative Rinne)
        • Diagnosis is clinical and confirmed with otoscopic exam, audiometry, and possibly tympanometry
        • Management depends on the cause:
          • Cerumen removal or foreign body extraction
          • Antibiotics for infections like otitis media
          • Surgical repair for tympanic membrane perforation (myringoplasty)
          • Stapedectomy or hearing aids for otosclerosis

      2. Hearing impairment (Sensorineural)

        Sensorineural Hearing Loss (SNHL) is caused by damage to the inner ear (cochlea) or the auditory nerve, resulting in permanent hearing impairment
        • Common causes include aging (presbycusis), noise exposure, ototoxic medications (e.g., aminoglycosides, cisplatin), viral infections, Meniere’s disease, and acoustic neuroma
        • Symptoms include difficulty understanding speech, especially in noisy environments, and perception of muffled sounds; may be associated with tinnitus or vertigo in some conditions
        • Weber test lateralizes to the better ear; Rinne test shows air conduction > bone conduction in both ears (normal or positive result)
        • Diagnosis confirmed with audiometry, which shows elevated thresholds for air and bone conduction with no air-bone gap
        • Imaging (e.g., MRI) may be indicated if unilateral SNHL or asymmetric symptoms are present to rule out retrocochlear pathology (e.g., acoustic neuroma)
        • Treatment depends on the cause and severity:
          • Hearing aids for amplification in most cases
          • Cochlear implants for severe or profound bilateral SNHL
          • Avoidance of ototoxic agents and protective measures in noise-induced cases
        • Prognosis varies—SNHL is typically irreversible, but early intervention can improve communication and quality of life

      1. Mastoiditis (ReelDx)

        Complication of acute otitis media. Fever, otalgia, pain & erythema posterior to the ear, and forward displacement of the external ear. Organisms: S. pneumoniae, H. influenzae, M. catarrhalis, S. aureus, S. pyogenes. IV antibiotics (ceftriaxone), drainage of middle ear fluid.

      2. Meniere disease (Lecture)

        Vertigo attacks lasting hours, classic triad of low-frequency hearing loss, tinnitus with aural (ear) fullness and vertigo, treat with low salt diet, diuretics (HCTZ + triamterene) to reduce aural pressure

      3. Tinnitus

        Perceived sensation of sound in the absence of an external acoustic stimulus; often described as a ringing, hissing, buzzing, or whooshing. 90% is associated with sensorineural hearing loss – caused by loud noise, presbycusis, medications (aspirin, antibiotics, aminoglycosides, loop diuretics and CCBs), Meniere's disease, acoustic neuroma.

    7. Foreign body in ear (ReelDx)

      Insects must be immobilized prior to removal. Drown insects with mineral oil or viscous lidocaine before attempting removal, After irrigation, if the child is uncomfortable, consider treating with topical pain agents such as benzocaine-antipyrine

    1. Barotrauma

      Barotrauma presents with ear pain and hearing loss that persists past the inciting event, associated with pressure changes. Common injury in divers or while flying, sudden onset of pain that may resolve with a "pop."

    2. Blowout fracture (orbital floor fracture) (ReelDx)

      History of blunt trauma, muscle entrapment, eyelid swelling, gaze restriction, double vision, decreased visual acuity, enophthalmos (sunken eye). Anesthesia/paresthesia in the gums, upper lips, and cheek due to damage to the infraorbital nerve

    3. Corneal abrasion (ReelDx)

      Sudden onset of eye pain, photophobia, tearing, foreign body sensation, blurring of vision, and/or conjunctival injection, fluorescein dye - increased absorption in devoid area, antibiotic eye ointment, no patching. 

    4. Globe rupture

      Globe rupture occurs when the integrity of the outer membranes of the eye is disrupted by blunt or penetrating trauma
      • Any full-thickness injury to the cornea, sclera, or both is considered an open globe injury
      • The vitreous and/or aqueous humour drain through the site of the rupture causing the eye to deflate
      • Immediate ophthalmology consultation
      • CT scan: non-contrast 1 to 2 mm cuts axial and coronal through the orbits
      TX: Avoid any examination procedure that might apply pressure to the eyeball, such as eyelid retraction or intraocular pressure measurement by tonometry
      • Do not remove any protruding foreign bodies
      • Begin IV antibiotics with Vancomycin PLUS either ceftazidime or fluoroquinolone
      • Avoid placing any medication (eg, tetracaine) or diagnostic eye drops (eg, fluorescein) into the eye
      • A Fox eye shield or other rigid device (bottom of a polystyrene foam cup) should be placed over the affected eye
      • Ensure definitive management by an ophthalmologist
      • Surgical repair should be expedited

    5. Hyphema (ReelDx + Lecture)

      Trauma causes blood in the anterior chamber of the eye (between the cornea and the iris). The blood may cover part or all of the iris (the colored part of the eye) and the pupil, and may partly or totally block vision in that eye. Treat with eye protection and rest with the head of the bed at 30 degrees all the time.

  10. EENT Benign and Malignant Neoplasms

    • Thyroid neoplastic disease (blueprint endocrinology): Papillary is the most common type
    • Oral Cancer: Most often squamous cell carcinoma (blueprint dermatology) - It has been estimated that the use of tobacco and alcohol account for up to 80 percent of cases of squamous cell carcinoma of the head and neck
    • Branchial Cleft Cyst: Cyst appearing after URI anterior to sternocleidomastoid, most common lateral neck mass
    • Thyroglossal duct cyst: Hyoid or sub-hyoid soft mass that rises with tongue protrusion - most common midline neck mass
    • Lymphadenopathy: Unilateral, painless, persistent, and cervical-think lymphoma (blueprint hematology)
    • Leukoplakia: A white oral lesion that is painless and cannot be rubbed or scraped off. Lesions are often linked with tobacco, alcohol, or denture use. About 5% are dysplastic or squamous cell carcinomas. If there is an associated erythematous appearance (erythroplakia), there is a higher risk of dysplasia or cancer (90%)

    2. Epistaxis (ReelDx + Lecture)

      4 mins

      Kiesselbach's Plexus or Little's Area is the most common site for anterior bleeds, sphenopalatine artery (Woodruff’s plexus) is generally the source of severe posterior nosebleed, direct pressure for 15 minutes, posterior balloon packing is used to treat posterior epistaxis

    3. Nasal polyps

      Teardrop-shaped growths that form in the nose or sinuses, usually benign, associated with allergic rhinitis. Samter's triad: Asthma, Aspirin sensitivity, and nasal polyps. Consider Cystic Fibrosis when multiple polyps are seen

    4. Rhinitis (ReelDx)

      Rhinitis is inflammation of the nasal mucosa characterized by sneezing, nasal congestion, runny nose (rhinorrhea), and postnasal drip
      • Types include:
        • Allergic rhinitis (IgE-mediated mast cell histamine release, seasonal or perennial)
        • Viral (infectious) rhinitis (common cold)
        • Nonallergic rhinitis (vasomotor, hormonal, medication-induced)
      • Allergic rhinitis presents with sneezing, clear rhinorrhea, nasal congestion, itchy eyes/nose, allergic shiners, and often atopic comorbidities (e.g., asthma, eczema)
      • Physical exam may reveal pale, boggy nasal turbinates, allergic shiners, and a transverse nasal crease
      DX: Diagnosis is clinical; skin testing or serum IgE testing may help confirm allergen sensitivities TX: Avoid any known allergens and use antihistamines, cromolyn sodium, nasal or systemic corticosteroids, nasal saline drops or washes, and immunotherapy
      • Intranasal corticosteroids (first-line for allergic rhinitis)
      • Antihistamines (oral or intranasal)
      • Decongestants (short-term use only)
        • Intranasal decongestants should not be used for more than 3-5 days as they may cause rhinitis medicamentosa
      • Allergen avoidance and immunotherapy in selected cases
      • Nonallergic rhinitis may be triggered by temperature changes, strong odors, medications, or hormonal shifts
        • Vasomotor rhinitis responds well to intranasal iproptrium bromide
      • Complications include sinusitis, sleep disturbance, and impaired quality of life

    5. Acute and chronic sinusitis (ReelDx + Lecture)

      After URI. Sinus pain/pressure (worse with bending down and leaning forward). Facial tap elicits pain. Viral: Most common, symptoms < 7 days. Bacterial: Symptoms 7+ days and associated with bilateral purulent nasal discharge. Indications for antibiotics in rhinosinusitis include duration of symptoms >10 days without improvement, Augmentin 875 BID, kids Amoxicillin x 10-14 days. Organisms: S. pneumoniae, H. influenzae, M.catarhalis. Chronic: Plainview X-ray (waters view) is a good initial screening, CT is the gold standard.

    1. Diseases of the teeth and gums (ReelDx)

      • Gingivitis: the patient should be counseled about increased risk for cardiovascular events.
      • Gingival Hyperplasia: Overgrowing of gums so that it blocks the teeth, commonly caused by medications: phenytoin, CCBs, and cyclosporine.
      • Vincent's Angina: “Trench Mouth” necrotizing gingivitis: characterized by the “punched-out” appearance of the gingival papillae.
      • Dental abscess: Poor dental health is a risk factor for dental abscess or facial cellulitis. Treat with IM ceftriaxone and amoxicillin.

      1. Angioedema (Lecture)

        Angioedema is localized swelling of the deeper layers of the skin and mucous membranes due to increased vascular permeability.
        • Non-pitting, non-itchy swelling typically affecting the face, lips, tongue, and throat
        • Can involve the respiratory and gastrointestinal tracts, causing difficulty breathing or abdominal pain
        • Common causes include allergic reactions, medications (especially ACE inhibitors), hereditary angioedema (C1 inhibitor deficiency), and idiopathic
        • Rapid onset and can be life-threatening if airway obstruction occurs
        • Hereditary angioedema presents with recurrent episodes and may not respond to typical allergy treatments
        • Diagnosed clinically, but C4 and C1 inhibitor levels can help diagnose hereditary angioedema
        • Immediate management includes securing the airway, and treatment with epinephrine, antihistamines, and corticosteroids for allergic causes. C1 inhibitor concentrate or bradykinin receptor antagonists for hereditary angioedema.

      2. Aphthous ulcers (ReelDx + Lecture)

        Single or multiple small, shallow ulcers with yellow-gray fibrinoid center with red halos, biopsy should be considered for ulcers lasting more than 3 weeks, viscous lidocaine 2–5% applied to ulcer QID after meals until healed

      3. Oral Candidiasis (ReelDx)

        Immunocompromised, young patients.  Painful, white fluffy patches that can be scraped off and may bleed when scraped (candidiasis can "come off"), leaving an erythematous, friable base. Diagnose with Potassium Hydroxide (KOH) prep

      4. Deep neck infection

        Deep neck space infections most commonly arise from a septic focus of the mandibular teeth, tonsils, parotid gland, deep cervical lymph nodes, middle ear, or sinuses
        • Classic manifestations of these infections include high fever, systemic toxicity, and local signs of erythema, edema, and fluctuance
        • Computed tomography (CT) is the imaging modality of choice for the diagnosis of deep neck space infection
        • The most common organisms isolated from deep neck space infections are viridans streptococci
        TX: Antibiotics, aspiration or surgical drainage should be performed

      5. Dental abscess

        Dental Abscess is a localized collection of pus in the teeth or gums due to bacterial infection.
        • Caused by dental caries, trauma, or periodontal disease
        • Severe, persistent, throbbing toothache that may radiate to the jaw, neck, or ear
        • Swelling in the face or cheek, tender lymph nodes under the jaw or in the neck
        • Fever, bad breath, and difficulty swallowing or opening the mouth
        • Diagnosed by clinical examination and dental X-rays
        • Complications can include spread of infection to surrounding tissues, leading to cellulitis or osteomyelitis, and systemic involvement such as sepsis
        • Treatment involves draining the abscess via incision and drainage or root canal, antibiotics (e.g., amoxicillin, clindamycin), and pain management (e.g., NSAIDs)
        • Preventive measures include good oral hygiene, regular dental check-ups, and prompt treatment of dental caries and periodontal disease

      6. Dental caries

        Dental Caries is the decay of tooth enamel and dentin caused by bacterial activity.
        • The primary causative bacteria are Streptococcus mutans and Lactobacillus species
        • Risk factors include poor oral hygiene, frequent consumption of sugary or acidic foods and drinks, and reduced salivary flow
        • Presents as white spots, brown spots, or visible holes on the tooth surface; may cause tooth pain or sensitivity
        • Diagnosis is based on visual inspection, dental radiographs, and clinical examination
        • Preventive measures include regular brushing with fluoride toothpaste, flossing, dental sealants, fluoride treatments, and dietary modifications
        • Treatment ranges from fluoride applications for early lesions to dental fillings, crowns, or root canals for more advanced decay
        • Severe cases may require tooth extraction if the decay is extensive

      7. Epiglottitis

        Unvaccinated patient leaning forward, drooling, stridor and distress (tripod position, muffled voice), H. influenza type B (Hib). Lateral radiograph: Thumbprint sign. Secure airway, IV Ceftriaxone, and IV fluids.

      8. Gingivitis

        Gingivitis is the inflammation of the gingiva (gums) caused by plaque accumulation
        • Characterized by red, swollen gums that may bleed easily during brushing or flossing
        • Caused by poor oral hygiene, leading to plaque buildup and bacterial colonization
        • Risk factors include smoking, diabetes, certain medications, hormonal changes (e.g., pregnancy, puberty), and systemic diseases
        • Symptoms include tender gums, bad breath (halitosis), and gum recession
        • Diagnosed through clinical examination by a dentist or periodontist, observing signs of inflammation and measuring periodontal pockets
        • Preventive measures include good oral hygiene practices, such as regular brushing, flossing, and professional dental cleanings
        • Treatment involves thorough dental cleaning, improved oral hygiene practices, and addressing underlying conditions or risk factors

      9. Oral herpes simplex (ReelDx)

        HSV type 1, vesicular lesions all in the same stage of development, prodromal period of tingling discomfort or itching

      10. Laryngitis

        Almost always viral, hoarseness following a URI, consider squamous cell carcinoma if hoarseness persists > 2 weeks, history of ETOH and or smoking, laryngoscopy is required for symptoms persisting > 3 wks.

      11. Peritonsillar abscess (ReelDx + Lecture)

        Peritonsillar Abscess is a collection of pus located between the tonsil and the pharyngeal muscles.
        • Severe sore throat, often unilateral
        • Fever, muffled "hot potato" voice
        • Trismus (difficulty opening the mouth)
        • Swelling and erythema of the affected tonsil with deviation of the uvula to the opposite side
        • Tender cervical lymphadenopathy
        • Diagnosed clinically, but a CT scan or ultrasound can be used if the diagnosis is uncertain
        • Common pathogens include Streptococcus pyogenes, Staphylococcus aureus (including MRSA), and anaerobes
        • Treatment involves needle aspiration or incision and drainage, along with antibiotics (e.g., amoxicillin-clavulanate or clindamycin)
        • Consider tonsillectomy in recurrent cases

      12. Acute pharyngitis (ReelDx + Lecture)

        • Viral - Adenovirus most common
        • Mononucleosis: Epstein Barr virus, fever, sore throat, lymphadenopathy, splenomegaly, atypical lymphocytes, + heterophile agglutination test (monospot). Symptomatic and avoid contact sports, antibiotics such as amoxicillin or ampicillin may cause a rash.
        • Consider gonorrhea pharyngitis in patients with recent sexual encounters, or with non-resolving pharyngitis
        • Fungal causes in patients using inhaled steroids
        • Group A Streptococcal pharyngitis: S. pyogenes. Centor Criteria: Absence of cough, Exudates, Fever, Cervical lymphadenopathy. Throat culture is gold standard, Penicillin is first line, Azithromycin if Pen allergic. Complications: Rheumatic fever and post-strep glomerulonephritis.

      1. Parotitis (ReelDx)

        Mumps is caused by Paramyxovirus (Mumps), in adult males look for an associated orchitis

      2. Sialadenitis (Lecture)

        Sialadenitis is a bacterial infection of a salivary gland (S. aureus) usually caused by sialolithiasis (obstructing stone) in the salivary gland.  Acute swelling of the cheek, which worsens with meals. Diagnose with CT, ultrasonography, or MRI.

    4. Oropharyngeal trauma

      Avulsed teeth
      • Avulsed permanent teeth should be reimplanted immediately by the first capable person (eg, the injured child, a parent, teacher, coach, or primary care provider)
      • Remove debris by gentle rinsing with saline or tap water; do not attempt to sterilize or scrub the tooth
      • The tooth should be placed back in the socket ideally within 15 minutes and up to one hour (or longer if stored in cold milk)
      • Avulsed primary teeth should not be reimplanted because of the potential for injury to the developing tooth bud

      1. Temporomandibular Disorders (TD) (Lecture)

        Temporomandibular Disorders (TMD) encompass a group of conditions affecting the temporomandibular joint (TMJ), masticatory muscles, and associated structures.
        • Jaw pain or tenderness at the TMJ
        • Clicking, popping, or crepitus with jaw movement
        • Limited range of motion or locking of the jaw
        • Headaches, ear pain, or facial pain
        • Tinnitus (ringing in the ears): Less common, but possible.
        • Bruxism (teeth grinding) and stress are common contributing factors
        • Diagnosed clinically with a focus on history and physical exam
        • For patients with more severe symptoms and those with persistent symptoms that fail to respond to education and self-care, a screening panoramic radiograph or cone beam computed tomography (CBCT) are both reasonable choice
        • Imaging (e.g., MRI or CT) may be used for severe cases or when structural abnormalities are suspected
        • Treatment includes conservative measures such as jaw rest, soft diet, moist heat, and physical therapy. Medications (e.g., NSAIDs, muscle relaxants) and occlusal splints may be helpful. Surgical interventions are reserved for refractory cases.

      2. Oral leukoplakia

        Smokers, alcohol abuse. Painless, precancerous (SCC) white lesions on the side of the tongue that cannot be scraped off

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