PANCE/PANRE HEENT Review

The history and physical are consistent with oral thrush. A wet mount potassium hydroxide preparation will reveal fungal spores and nonseptated mycelia.

Oropharyngeal melanoma is characterized by varying pigment occurring in an irregularly shaped lesion. Although this is a rarely occur in melanoma, a biopsy should be done and any pigmented oral lesion should be excised. Areas which are raised within the lesion usually indicate sites of invasion.

Oral leukoplakia cannot be removed from the mucosa using a tongue depressor like oral thrush can. It is considered a premalignant lesion and the chance of transformation into oral squamous cell carcinoma is 0-20%. The vast majority will not turn malignant. The condition is more common in smokers and people should be advised to stop smoking and limit alcohol consumption to reduce their risk. Management usually involves regular review of the lesion to detect any possible malignant change early, and thereby significantly improve the prognosis, which normally is relatively poor for OSCC.

The clinical vignette describes a chronic otitis media. Usually, this refers to a complication of acute otits media with perforation. Pathogens that culture from these infections are usually pseudomonas, proteus, or staphylococcus aureus.

This patient has Meniere disease. The classic features of Meniere disease are recurrent episodes of vertigo, fluctuating low-frequency sensorineural hearing loss, tinnitus (ringing or buzzing in the ears), and aural fullness in the affected ear. The vertigo typically lasts hours, not minutes or days. The fluctuating hearing may not be related temporally to the vertigo. For the diagnosis of Meniere disease, the characteristic pattern of vertigo lasting a matter of hours as well as sensorineural hearing loss must be present. One additional factor (aural fullness or buzzing tinnitus) should also be present.

A cataract is a defect in the lens. Cataracts are the leading cause of blindness in the world. The only treatment is surgical correction.

Contact lens wearers are prone to getting bacterial infections especially pseudomonas of the eye.   Ciloxan has the best pseudomonas coverage.

The major organisms associated with bacterial acute sinusitis is streptococcus pneumonia, H. influenzae, and M. Catarrhalis. With the patients history of anaphylaxis with penicillin, the best choice is D bactrim

Open angle glaucoma is an optic neuropathy that has a progressive peripheral visual field loss and is eventually followed by central visual loss.

Both vestibular neuritis and labyrinthitis have vertigo with usually a viral syndrome proceeding it.   The key characteristic is there is no hearing loss associated with acute vestibular neuritis.

Diving, flying, and blast injuries are identified as circumstances predisposing patients to barotrauma.   Barotrauma is caused by pressure difference between the outside world and the inside of the middle ear.   Allergic rhinitis can cause eustachian tube dysfunction but usually does not cause barotrauma.   There usually is significant pressure difference between the middle ear and the outside world when the patient is exposed to pressure differences of diving, flying or blast injuries.

Ninety percent of nose bleeds arising from Kiesselbach's Plexus.    

Cerumen impaction in and of itself is not an etiologic factor of otitis externa. Aggressive cleaning abrading the external auditory canal can.

Streptococcus pneumoniae is the most common organism that causes mastoiditis.  Mastoiditis is the most common suppurative complication of otitis media. Pseudomonas is another consideration especially on recurrent infections with a ruptured tympanic membrane.

Blepharitis is characterized by swelling of the eyelid.   Blepharitis is best treated with warm compresses and topical antibiotics such as bacitracin, erythromycin, or azithromycin.

Parkinson's is characterized by a decreased production of Dopamine from the Substantia Nigra of the brain.   Parkinson's does not lead to increased intracranial pressure.

Treatment management options for acoustic neuroma include surgery, radiation, and observation. Larger tumors can cause compression of adjacent structures which lead to facial and trigeminal nerve pain, and paresthesias. Because these nerves innervate the tongue they can affect taste.

Meniere's disease is characterized by episodic vertigo, hearing loss and tinnitus.

Peritonsillar abscess present with trismus, fever, sore throat and hot potato voice. Peritonsillar abscess are typicaly caused by Group A Strep. They can compromise the upper airway. Empiric treatment is with Unasyn or Clindamycin. Ultimate treatment is incision and drainage.

Cerumen impaction by far is the most common cause of hearing loss

Benign Paroxysmal Positional Vertigo tends to have brief recurrent episodes of vertigo with predictable head movements or positions. There is no auditory symptoms. BPPV usually has a positive Hallpike Maneuver.

While AV malformation is a plausible explanation, the fact there is some right sided lymphadenopathy with recurrent nosebleeds should raise the suspicion for malignancy.

Epiglottitis is characterized by a thumb sign.

Whenever there is unexplained thrush is a healthy individual, HIV should be considered as an etiology.

A chalazion is an inflammatory lesion that developed when the meibomian tear gland becomes obstructed. They are usually not painful. Treatment is warm compresses or surgical correction.

Iritis presents as a red eye, photophobia, and tearing. Iritis is often not improved when the eyes are anesthetized with alacaine. A common treatment is eye drops that ease the inflammation. If uveitis is a result of an infection, antibiotics or antiviral medication may be prescribed.

Eye patching is no longer recommended for corneal abrasions. A meta-analysis of five randomized controlled trials (RCTs) failed to reveal an increase in healing rate or improvement on a pain scale. Two subsequent RCTs (one in children, one in adults) reported similar results. In the past, patching was thought to reduce pain by reducing blinking and decreasing eyelid-induced trauma to the damaged cornea. However, the patch itself was the main cause of pain in 48 percent of patients. Children with patches had greater difficulty walking than those without patches. Furthermore, patching can result in decreased oxygen delivery, increased moisture, and a higher chance of infection. Thus, patching may actually retard the healing process

Macular degeneration causes central vision loss and can have Drusen Spots.

Dacryocystitis is caused by the nasolacrimal duct being blocked. The most common organism is alpha hemolytic strep, staph epidermis, and staph aureus. Empiric therapy with clindamycin and doxycycline or Bactrim is helpful. This can lead to periorbital cellulitis.

Augmentin is the correct answer as this patient is at risk for beta-lactam resistance.

Auricular hematomas should be drained as soon as possible. Delay in treatment can lead to a cauliflower ear that is permanent deformity of the fibrocartilage of the ear that is an overgrowth.

Cerumen impaction is not an etiology of tinnitus.

A perforated tympanic membrane caused by infection needs to be treated with oral antibiotics as well as topical antibiotic ear drops.   When there is a perforation the ear canal is contaminated with the purulent drainage

All of the following are possible causes of bacterial tonsillitis: Group A Streptococcus, Neisseria Gonorrhea, Mycoplasma, Chlamydia, Tularemia, and Group C and Group G Strep. Group C and Group G Strep do not cause rheumatic fever. Viral etiologies include CMV, HSV, Mononucleosis, and Influenza.

Atopic Dermatitis, sinusitis, and asthma are common diseases seen with allergic rhinitis.   In additional allergic conjunctivitis is commonly seen with allergic rhinitis.   Urticaria does not have an association with allergic rhinitis.

In the treatment of epiglottitis racemic epinephrine can help momentarily, but ultimately the patient needs to be intubated and admitted to the hospital. Airway protection is the mainstay of treatment. The patient usually needs to be intubated for 2-3 days prior to weaning attempts. The role of steroids is controversial. Vancomycin helps with anti-staph coverage and Ceftriaxone covers the most common organism haemophilus influenza type B. Anesthesia and/ or ENT should be consulted for airway management.

CT scan of soft tissue of the neck with IV contrast is the imaging study of choice.Group A Streptococcus is the most common organism.   There are also so cases of staph.   Appropriate empiric antibiotic therapy includes Clindamycin and Unasyn. Vancomycin is an appropriate add-on antibiotic when there are airway issues.

Potential etiologies of parotitis include: anything that obstructs Stensen's Duct (Stone or Tumor), poor oral hygiene, dehydration, retrograde salivary stasis and seeding of Stensen's Duct with oral flora, viruses, or staphylococcus aureus.

Empiric therapy for parotitis involves nafcillin and metronidazole. Vancomycin and cefepime or imipenem is recommend for immunocompromised patients. Azithromycin does not cover staph.

The imaging modality of choice for sialadenitis is a CT scan of soft tissue neck with IV contrast.

Fordyce spots are associated with benign sebaceous cyst tumors.

Entropion usually affects the lower eyelid.

Magnets are not safe for removal metal foreign bodies from the eye.

This patient has acute closure glaucoma. Installation of a cycloplegic can increase the pressure and make the patient worse. A cycloplegic drop causes paralysis of the ciliary muscle of the eye, resulting in a loss of accommodation and flexibility.

Pseudotumor cerebri usually affects both eyes and is accompanied with a headache. Ophthalmic migraine usually has headaches with it and will not have any optic disc changes on exam. Retinal detachment does not have these visual field changes and will not have these optic disc changes on physical exam.

This is a common presentation of retinal detachment.

d.This patient has orthostatic hypotension. This case illustrates the importance of obtaining an accurate history in the patient who complains of “feeling dizzy.” In any patient who has this complaint, it is important to ask four specific questions: (1) Can you describe your dizziness? (2) How much of the dizziness is a sensation of the “world spinning around you,” and how much would be a sensation of “things going black in front of you and a feeling that you’re about to pass out”? (3) How long does the feeling of dizziness last— seconds, minutes, or hours? and (4) Are there any other symptoms present when you feel dizzy, such as deafness, ear fullness, or ringing in the ears? The answers to these questions are the most important clues to leading you toward a diagnosis. This patient does not have clear symptoms of vertigo, and one should focus on non– vertigo-related dizziness. Orthostatic hypotension is typically initiated after standing up suddenly. There is a transient lack of cerebral blood flow. The feeling described is that of a subjective dizziness, and the patient feels as if he or she might faint. It is not associated with any other neurologic sensations or ear symptoms. It is also characterized by a lack of symptoms when sitting or lying. Medications are the most likely culprits in this scenario, but occasionally there is no clear etiology for the autonomic disturbance. In this clinical case problem, the orthostatic hypotension is almost certainly associated with the beginning of the tricyclic antidepressant therapy 6 months ago.

This patient has positional paroxysmal vertigo (PPV), a disorder that consists of brief episodes (lasting 2 to 10 seconds) usually caused by turning the head. PPV is caused by the formation of crystalline debris in the semicircular canals that leads to labyrinthine irritation, causing vertigo and nystagmus.

This patient has a left vestibular neuronitis. The etiology of this disorder is commonly associated with a viral infection (such as adenovirus) that follows a respiratory tract infection and involves some portion of the vestibular system but with total sparing of the cochlear area. It most commonly affects young or middle-aged adults. The disorder consists of severe vertigo with associated ataxia and nausea and vomiting. There is no hearing loss, aural pain, or other symptoms, which is helpful in distinguishing it from other causes of vertigo. Recovery usually takes 1 or 2 weeks. The treatment of choice for a patient with vestibular neuronitis is rest, reassurance, and antiemetics.

The characterization of hearing loss can be localized by a combination of the Weber test and the Rinne test. In the Weber test, placement of a 512-Hz tuning fork on the skull in the midline or on the teeth stimulates both cochleae simultaneously. If the patient has a conductive hearing loss in one ear, the sound will be perceived loudest in the affected ear (i.e., it will lateralize). When a unilateral sensorineural hearing loss is present, the tone is heard in the unaffected ear. The Rinne test compares air conduction with bone conduction. Normally, AC is greater than BC. Sound stimulation by air in front of the pinna is normally perceived twice as long as sound placed on the mastoid process (AC > BC). With conductive hearing loss, the duration of AC is less than BC (i.e., negative Rinne test result). In the presence of sensorineural hearing loss, the durations of both AC and BC are reduced; however, the 2: 1 ratio remains the same (i.e., a positive Rinne test result). Facts for this question: (1) Bone conduction is greater than air conduction. This indicates that this is a conductive hearing loss. (2) In conductive hearing loss, the Weber test lateralizes to the affected ear, and because the Weber test lateralized to the right ear in this patient, she has a unilateral right-sided conductive hearing loss.