Old Q&A – ENT

The correct answer is C. Nasolacrimal duct obstruction is a very common condition in pediatrics. The nasolacrimal ducts are usually patent at 3-4 weeks. Tearing and crusting are the typical features of an obstruction. The primary treatment is nasolacrimal duct massage. Approximately 90% of nasolacrimal duct obstructions spontaneously resolve in the first year of life.

IV antibiotics (choice A) are appropriate for preseptal or postseptal orbital cellulites but the patient does not present with red, swollen, and tender lids.

Warm compresses (choice B) are the appropriate treatment for a chalazion. This patient did not present with a nodular, non-infectious swelling in the eyelids.

Since most obstructions spontaneously resolve, surgical intervention and probing are usually not recommended until age 6 months (choice D).

When a patient has a nasolacrimal duct obstruction and there are signs of a localized infection (mucoid discharge with matting of the eyelashes) then topical antibiotics have a role. However, if the patient is just experiencing tearing, antibiotics are not indicated (choice E).

The correct answer is B. This patient has acute sinusitis. The most common etiology is infection and the organisms most responsible are rhinovirus, H. influenza, S. pneumoniae, and influenza virus. The hallmark of acute sinusitis compared with sinus inflammation is total ostial obstruction. Once obstructed, fluid accumulates and becomes infected. The diagnosis is suggested by clinical signs and symptoms. The 5 findings that have a combined likelihood ratio of greater than 7 for acute sinusitis are: mucopurulence, toothache, impaired transillumination, poor response to decongestants, and tenderness.

The presence of a heart murmur (choice A) is not relevant to sinusitis, but may be an associated finding in many young people or can be present in acute rheumatic disease, which this patient does not have.

The presence of photophobia (choice C) along with neck stiffness and headache are highly suggestive of meningitis, not sinusitis.

Although tenderness and congestion of sinuses are common, swelling maxillary sinuses(choice D), even with massive fluid accumulation is not seen, since the bony containment of the sinuses prevents any significant swelling.

The correct answer is C. This patient has clinical and MRI evidence of non-Hodgkin’s lymphoma (NHL) metastatic to the extraocular muscles. This is causing secondary compression of the optic nerve which manifests as blurry vision. Immediate intravenous steroid administration is critical to reduce inflammation and relieve optic nerve pressure.

Antibiotics (choice A) are not necessary as there are no clinical signs of infection. Sinusitis and/or orbital cellulitis are common causes of unilateral optic nerve compression. This patient has clinical and MRI evidence of non-Hodgkin’s lymphoma (NHL) metastatic to the extraocular muscles. This is causing secondary compression of the optic nerve. Immediate intravenous steroid administration is critical to reduce inflammation and relieve optic nerve pressure.

Anticoagulation with heparin (choice B) is not necessary since her symptoms are not related to a stroke.

Orbital decompression surgery (choice D) has no role in the treatment of this patient.

Metastatic non-Hodgkin’s lymphoma (NHL) is the primary cause of extraorbital muscle enlargement and secondary optic nerve decompression. Chemotherapy (choice E) should continue on an urgent basis. Intravenous steroid therapy is the most important immediate treatment to reduce inflammation and relieve optic nerve pressure.

The correct answer is B. This child has a classical appearance of acute epiglottitis, which is a life-threatening illness. Epiglottitis in children is usually associated with sudden difficulty in breathing, sore throat, and dysphagia. Acute epiglottitis in children is usually because of Haemophilus influenza. The child classically appears in severe acute respiratory distress of sudden onset, leaning forward in a sitting position with drooling of saliva from the mouth. The voice is muffled and the strider is softer than with croup. This emergency should be diagnosed immediately and help must be obtained by calling an anesthesiologist and a senior pediatrician. The operating room must be alerted for an emergency cricothyroidotomy, if emergency intubation fails. An oxygen mask should be held close to the child’s face and one should wait by the child’s side until senior help arrives. Prepare to intubate the child with the smallest endotracheal tube. This is an essential life-saving step and no delay should be allowed in getting this child intubated by a senior physician.

This child should not be examined in a flat position as it might worsen the respiratory distress. Acute epiglottitis is characterized by the swelling of the epiglottis. Laying the child in a flat position to examine the oral cavity and the pharynx might obstruct the airway because of the swollen epiglottis (choice A).

Intubating this child (choice C) is going to be challenging and difficult, and should be done by only an experienced anesthesiologist. The child should be immediately taken to the operating room for appropriate intubation, and if that fails, then a cricothyroidectomy is necessary. Repeated failed attempts to intubate may result in airway edema and may be life threatening.

A chest x-ray (choice D) is not essential in the diagnosis of this child. This can be performed only when a pulmonary infection is suspected and in this child, it might delay the diagnosis and therapy.

Obtaining the temperature (choice E) is not essential when acute epiglottitis is suspected. Once acute epiglottitis is ruled out, one should examine for the evidence of a peritonsillar abscess causing high fever. Before proceeding with the differential diagnosis, acute epiglottitis must be excluded.

The correct answer is C. Since this is his first nosebleed (epistaxis), it seems as if this boy has a common nosebleed, which is often due to forceful nose picking and dry nasal passages. The blood typically comes from the anteroinferior portion of the nose and it is usually controlled within 5-10 minutes by applying steady pressure to the mobile part of the nose. If this is ineffective, a topical vasoconstrictor or cautery with silver nitrate or electrocautery may be indicated.

It is inappropriate to advise him to tilt his head back (choice A) because the blood will drip down the nasopharynx and into the esophagus and gastrointestinal tract. There is also a risk for aspiration.

It is unnecessary to obtain hematologic laboratory studies (choice B) at this time. Nosebleeds are extremely common and since this is his first one, it is most likely due to a dry environment or nasal picking, as opposed to a bleeding disorder. Liver disease is a consideration in a person with severe epistaxis, however, he has no other signs or symptoms associated with liver disease.

He should not be told to continuously blow his nose to evacuate the blood (choice D). The pressure should stop the bleeding. The increased pressure generated when he blows his nose will only lead to further bleeding.

While cocaine use is associated with nosebleeds, it is inappropriate to test his blood for cocaine (choice E) at this time. He has no other signs or symptoms of cocaine use and this is only his first nosebleed (or so he says). If you somehow feel that he may be using drugs, it is appropriate to ask his mother to leave the room and then ask him about his drug use. It is incorrect to test his blood without asking him about his drug use.

The correct answer is B. This patient has glossitis, which is most likely due to anemia. He is an alcoholic with a macrocytic anemia (decreased hemoglobin, hematocrit and an elevated MCV), and therefore, vitamin B₁₂ levels should be determined. It is very likely that he has a vitamin B₁₂ deficiency.

While it is always appropriate to advise him to decrease his alcohol consumption, you need to determine his vitamin B₁₂ levels, so performing no further studies (choice A) is incorrect. If he is vitamin B12 deficient, vitamin replacement is indicated.

A brush biopsy of the tongue for cytologic evaluation (choice C) and an incisional biopsy (choice E) are usually performed to evaluate a lesion for malignancy. This patient has a generalized glossitis without a specific lesion.

Fluconazole (choice D) is prescribed for candidiasis, which typically presents with a white coating on the tongue. This patient’s physical findings are inconsistent with this diagnosis.

The correct answer is D. Herpes simplex keratitis should be suspected in patients with recurrent symptoms of unilateral pain, redness, and photophobia in the presence of an epithelial staining defect. Under slit lamp biomicroscopy these staining defects often take on a “dendritic” appearance, but without a slit lamp they may appear as just fluoroscein uptake. These patients should be referred to an ophthalmologist for treatment. Never prescribe topical corticosteroids for patients with suspected herpes simplex keratitis.

Angle closure glaucoma (choice A) could be consistent with recurrent episodes, but not with this clinical presentation. Patients with angle closure glaucoma will present with poorly reactive pupils, marked decrease in visual acuity, and corneal edema making the cornea unclear.

Allergic diseases (choice B) are most commonly bilateral and are associated with a mucoid discharge and are less likely to cause pain, photophobia, and epithelial defects.

Bacterial conjunctivitis (choice C) rarely produces an epithelial defect, is often associated with copious mucoid discharge, and would not be expected to be recurrent.

Subconjunctival hemorrhage (choice E) is a benign clinical finding. In this case, it would not explain pain, photophobia, tearing, or decreased visual acuity.

The correct answer is C. This patient has a cellulitis of the right eyelid. One of the most important things to find out in order to guide therapy is whether the infection is preseptal or postseptal. The orbital septum can be thought of as running along the anterior aspect of the bones of the orbit separating the superficial tissues from the orbital contents themselves. Some signs of postseptal infection that this patient has are ophthalmoplegia and proptosis. The risk of visual loss and spread to deeper structures such as the cavernous sinus are why this diagnosis is important to make, as opposed to a superficial orbital cellulitis, which is fairly easily treated. It is also important to look for any abscesses that might need to be drained. CT scanning can help to elucidate many of these.

Amphotericin B (choice A) is an important tool in the treatment of fungal infections such as mucormycosis. Infection with this fungus is extremely deadly and should be considered in the differential diagnosis of any patient with a severe sinus infection. There is often evidence of devitalized tissue and patients often have some sort of relative immune suppressive disease such as diabetes or chronic renal insufficiency. There is nothing in this case to suggest that amphotericin should be added at this point.

Discharge of the patient should be only after adequate treatment, which may take more than 24 hours (choice B). Intravenous antibiotics can be discontinued and switched to oral after the patient has been stable and afebrile for 24 hours.

Surgical exploration of the sinuses or orbit (choice D and E) should not be performed prior to a CT scan. If an abscess or other signs of more severe infection are seen on the scan, then surgical debridement may be warranted.

The correct answer is A. This patient most likely has acute angle-closure glaucoma, which is an ocular emergency that requires immediate treatment to prevent blindness. It is characterized by a rapid increase of IOP, often occurring when the pupil is dilated (such as in a dark movie theater). The symptoms include severe eye pain, blurry vision, a headache, nausea, and vomiting. The physical examination usually shows a tender, firm eye with conjunctival hyperemia, lid edema, a hazy cornea, and a fixed, mid-dilated pupil. Immediate treatment includes mannitol (to reduce vitreous volume), acetazolamide and topical beta-blockers, such as timolol (to block aqueous production), and pilocarpine (to facilitate aqueous outflow). Ophthalmologic consultation should also be sought as soon as possible. A peripheral laser iridectomy is the definitive procedure and is usually performed after the IOP is controlled.

A CT scan of the head (choice B) is indicated in the evaluation of papilledema, not acute angle-closure glaucoma. Papilledema, which is optic disc swelling caused by elevated intracranial pressure, typically presents with a headache, nausea, vomiting, and transient visual obscurations.

A lumbar puncture (choice C) is performed after a CT scan of the head as part of the evaluation of papilledema, not acute angle-closure glaucoma. If the CT scan is normal and the opening pressure is elevated the most likely diagnosis is a pseudotumor cerebri. This typically affects young, obese women and is treated with weight reduction and acetazolamide.

A peripheral iridotomy (choice D) is the definitive procedure for acute angle-closure glaucoma, but it is usually performed after the IOP is controlled with mannitol, acetazolamide, timolol, and pilocarpine.

Corticosteroids (choice E) are not typically included in the initial management of acute angle-closure glaucoma and they are contraindicated in patients with dendritic herpetic ulcers.

The correct answer is B. The condition described in this farmer is malignant external otitis. Malignant external otitis is an unusually virulent form of external otitis caused by Pseudomonas aeruginosa, which occurs particularly in poorly controlled diabetics. It produces pain, purulent otorrhea, hearing loss, and characteristically, the external auditory canal contains granulation tissue. There is destruction of the bone of the external auditory canal, and the osteomyelitis may spread along the base of the skull to the midline or to the opposite side. Facial paralysis often occurs due to involvement of the tubes. Therapy is directed towards the causative organisms. While waiting for the organisms to be isolated, the patient should be admitted to the hospital for therapy with intravenous systemic penicillin and aminoglycoside. Once the appropriate culture results are obtained, the organisms should be identified and the sensitivity should be followed to change the antibiotics. Apart from treating this condition with intravenous antibiotics, the diabetes mellitus should be controlled well with insulin or an oral antidiabetic regimen.

Antibiotic eardrops are not sufficient to treat this aggressive form of otitis externa (choice A). This patient needs to be admitted to the hospital for intravenous antibiotic therapy. Failing to do this, will result in the progress of the disease process.

Although care of the auditory canals is very essential in diabetics, mere regular cleaning (choice C) is not sufficient enough to prevent or treat malignant otitis externa. Hence, the patient should be advised before leaving the hospital about taking care of his both ears, but by itself is not sufficient to treat malignant otitis externa.

Oral penicillin is not adequate antibiotic therapy for this form of aggressive otitis externa (choice D). Hence, this patient should be admitted to the hospital for intravenous antibiotic therapy.

Surgical intervention (choice E) is not of much help in malignant external otitis. Therapy is directed towards the causative organisms and usually requires 6 weeks of oral ciprofloxacin or intravenous aminoglycoside and synthetic penicillin.

The correct answer is B. Recurrent otitis media in an adult leads to the suspicion for cholesteatoma, which is a congenital or acquired epidermoid inclusion cyst of the middle ear. The physical exam confirms this diagnosis given “white, amorphous debris in the right middle ear,” which is desquamated epithelial debris. It often destroys the external auditory canal bone and leads to a perforation of the tympanic membrane. It typically requires surgical therapy.

Preoperatively, most surgeons obtain a detailed temporal bone CT to evaluate the cholesteatoma. A bone scan with SPECT images of the skull (choice A) is useful to look for osteomyelitis, but osteomyelitis would be low on the differential diagnosis in this patient given the lack of fever.

Antibiotics such as erythromycin (choice C) may treat the current infection, but will not treat the underlying cholesteatoma leading to the infection.

Antibiotics such as imipenem (choice D) may treat the current infection, but will not treat the underlying cholesteatoma leading to the infection.

Prednisone (choice E) would not be helpful in this patient. Workup for cholesteatoma should commence with a CT of the temporal bones.

Myringotomy (choice F) is indicated for recurrent ear infections, but the physical exam findings in this patient suggests cholesteatoma.

The correct answer is E. This patient has laryngitis, which is an inflammation of the laryngeal mucous membranes that is most likely caused by a viral infection. The history and physical examination are usually enough to establish a diagnosis. If an exudate were present, diphtheria, mononucleosis, candidiasis, and a streptococcal infection should be considered. Treatment includes resting the voice and inhaling humidified air.

A laryngeal biopsy (choice A) is not indicated at this time in this case of laryngitis. A biopsy is indicated if a lesion is visualized or suspected.

A laryngeal culture (choice B) is not indicated at this time in this case of laryngitis, which is most likely viral in origin. It should be obtained if you suspect a bacterial infection or an etiology other than a viral infection.

A radiograph of the neck (choice C) is indicated when there is severe airway narrowing with marked hoarseness, a fever, and drooling. This patient does not have difficulty breathing, a fever, or severe airway narrowing.

Antibiotics (choice D) are indicated if a bacterial infection is present. This patient has a history consistent with an acute viral infection and therefore, antibiotics are not indicated at this time.

The correct answer is A. Otalgia, fever, irritability, previous or coexisting upper respiratory tract infections, ear rubbing, and feeding problems are common presenting symptoms of otitis media. Many of these episodes are viral in origin. The most common bacterial pathogens are Pneumococcus, Haemophilus influenza, and Moraxella catarrhalis. Diagnosis involves adequate observation of the tympanic membrane, which might reveal hyperemia, bulging, indistinct landmarks, diminished light reflex, and limited mobility on pneumatic insufflations. Treatment of acute otitis media with the above symptoms and signs is by means of oral antibiotics. For recurrent acute otitis media, antibiotic prophylaxis (such as a single dose of amoxicillin at bedtime) should be considered. Referrals for discussion of a tympanostomy tube placement should be considered if there is chronic bilateral effusion for more than 3 months in duration, unilateral effusion for more than 3 months in duration, language development delay, hearing loss of more than 20 decibels, or failure of antibiotic prophylaxis. This particular child has a history of recurrent acute otitis media treated with antibiotic prophylaxis. Failure of antibiotic prophylaxis requires tympanostomy tube placement.

Continuation of antibiotic prophylaxis (choice B) is not going to treat the recurrence of acute otitis media in this child and hence, is not advisable.

Oral antibiotics (choice C) are indicated in the treatment of acute otitis media. Amoxicillin is the first antibiotic of choice and should be given for 10 days. But for recurrent episodes of acute otitis media, a tympanostomy tube placement is indicated rather than mere oral antibiotics.

Decongestants (choice D) are not indicated in the resolution of acute otitis media, although they might be needed for any associated conditions.

Intravenous antibiotics play no role (choice E) in the treatment of recurrent acute otitis media. The surgical option should be advised to the parents.

The correct answer is D. This patient with a headache and a red eye either has acute glaucoma or a cluster headache. The partially dilated pupil is more consistent with acute glaucoma. Acute glaucoma, which is caused by increased intraocular pressure, often presents with abdominal pain, nausea, vomiting, and a headache. It is an ophthalmologic emergency that may lead to blindness, so this diagnosis should be included in your differential when a patient presents with these other symptoms. The patient usually has eye pain, but it may be overshadowed by the other symptoms. The diagnosis is established by measuring intraocular pressure. You should call for an immediate ophthalmologic consultation and possibly administer acetazolamide, topical beta blockers, mannitol, and pilocarpine. A cluster headache is an episodic headache that typically presents with a few short headaches a day for a few weeks that is associated with periorbital pain, reddening of the eye, and lacrimation. A partially dilated pupil is not a common finding.

Administer glucocorticoids, intravenously (choice A) is the appropriate treatment to prevent blindness in a suspected case of temporal arteritis. Temporal arteritis typically presents with a unilateral headache, myalgias, jaw pain, fever, and weight loss. A tender, reddened temporal artery is often found. Visual changes may occur and blindness is a feared complication. This patient does not have any of the usual systemic symptoms associated with temporal arteritis. Also, the red eye with a dilated pupil is inconsistent with this diagnosis. The diagnosis of temporal arteritis is established with a temporal artery biopsy. The erythrocyte sedimentation rate (choice F) is typically elevated in temporal arteritis

Sumatriptan (choice B) is the treatment for a migraine headache, which typically presents with a throbbing headache, nausea, vomiting, photophobia, and functional impairment. An aura consisting of hallucinations and scotomas sometimes occurs before the headache. A partially dilated pupil is inconsistent with a migraine.

Oxygen therapy, 100% for 15 minutes (choice C), is the treatment for a cluster headache. Sumatriptan may also be given to shorten the attack.

A CT scan of the head (choice E) is important if an intracranial hemorrhage is suspected. An intracranial hemorrhage may present with a headache and nuchal rigidity, seizures and confusion. A red, tender eye is not a typical finding.

A lumbar puncture (choice G) should be performed in a suspected case of meningitis and possibly in a suspected intracranial hemorrhage, if the CT scan fails to show the bleed. Meningitis often presents with a headache, nuchal rigidity, and photophobia. Fever and a rash may be present. A tender, red eye with a partially dilated pupil is not typically found in meningitis or an intracranial hemorrhage.

The correct answer is D. This patient has chronic sinusitis. The definition of chronic is a sinus infection greater than 3 months. The most common etiology is infectious and the organisms most responsible are rhinovirus, H. influenza, S. pneumoniae, and influenza. The hallmark of acute sinusitis compared with sinus inflammation is total ostial obstruction. Once obstructed, fluid accumulates and becomes infected. The diagnosis is suggested by clinical signs and symptoms although certain imaging studies are very useful. The only imaging study to consider is a sinus CT. If positive, the maxillary or ethmoid sinuses will be opacified.

The localized nature of the infection often times means that there will usually be no elevation in the systemic white blood cell count (choice A). If this test were normal, it in no way rules out the presence of a sinus infection.

A facial MRI (choice B) actually offers much less sensitivity that a CT scan since the high resolution imaging of the sinus material is confusing to the diagnosis. CT is superior because opacification is a highly abnormal finding.

A plain radiograph of the face (choice C) offers no utility in the diagnosis of chronic sinusitis because the visualization of all of the sinuses is inadequate.

A maxillary sinus irrigation-inferior meatus puncture is performed for diagnostic and therapeutic purposes (choice E). Since this is an invasive procedure, a rigid nasal endoscopy can be used to directly visualize the nasal discharge in situ and should be performed before the puncture. For this reason, to avoid the invasive puncture study, a sinus CT should be performed.

The correct answer is E. A large body of evidence exists to show that children in group day care are significantly more likely to develop otitis media after an upper respiratory tract infection compared to those in home care. One study showed that the rate of tympanostomies and adenoidectomies is 59-67% higher in children younger than 3 who attend day care. In addition, having older siblings, as this child does, has also been shown to significantly increase the risk of otitis media.

The data on the effect of passive smoke on the prevalence of otitis media in children are inconclusive. One study showed a higher incidence of tympanostomy tubes, chronic and recurrent otitis media, and otorrhea in children whose mothers smoke (choice A), but many other studies have failed to find a significant relationship between passive smoke and otitis media.

The 23-valent pneumococcal vaccine (choice B) is not effective in children younger than 2. However, a recent study showed that in children who received one or more doses of the heptavalent pneumococcal vaccine, the incidence of total invasive pneumococcal disease was reduced by 89.1% and the need for myringotomy and tubes was reduced by 20.1%.

In patients with otitis media who fail to respond to amoxicillin or develop a recurrent infection after amoxicillin, amoxicillin-clavulanate, cefuroxime, cefprozil, or ceftriaxone are the antibiotics of choice. Evidence exists that a child with persistent otitis media with effusion (3 months or more) is much more likely to respond to a 1-month course of amoxicillin-clavulanate than amoxicillin (choice C).

This child does not meet the criteria for myringotomy and tympanostomy tube placement (choice D). For recurrent otitis media, the criteria for tube placement are 3 or more episodes of otitis media in 6 months or 4 or more episodes in 12 months.

The correct answer is A. It is important to evaluate the visual acuity of each eye separately with the appropriate refractive correction. Refractive errors are generally not considered a medical reason for decreased vision. Eliminating or reducing this factor will best allow the clinician to assess the patient’s vision. Remember that the testing of visual acuity is a subjective test and that many factors need to be considered such as lighting, patient effort, and patient concentration.

Color vision and stereovision are more specific methods of evaluating visual acuity. These tests are used in more special circumstances in ophthalmology clinics. They would not be more helpful than Snellen visual acuity in this instance (choice B).

Record the visual acuity in both eyes simultaneously to best evaluate the functional vision of the patient (choice C) is incorrect because recording the visual acuity of both eyes is rarely helpful. Patients may have 20/20 vision with one eye and no light perception in the other eye and still have 20/20 vision if both eyes are tested together. Often patients do not notice marked decreased vision if only one eye is affected.

Again, visual acuity without correction can be misleading (choice D).

Near cards are helpful in the hospital setting, but they are not as accurate as a standardized Snellen vision measured at 20 feet (choice E). Also, remember that accurate near visual acuity needs appropriate near correction (bifocal). Thus, checking a near visual acuity in a presbyopic patient without their glasses can be misleading (for example a hospitalized patient who has forgotten to bring their glasses with them to the hospital).

The correct answer is D. This patient is presenting with a thyroglossal duct cyst. These cysts are remnants of the primitive thyroid, which descend from the foramen cecum at the base of the tongue, to below the level of the hyoid bone where the adult thyroid resides. Thyroglossal duct cysts account for 70% of all congenital neck anomalies. The typical appearance is a mobile mass on the anterior neck. Although they are benign lesions, they may become infected and painful. They must be surgically extirpated to avoid recurrence. Care must be taken during preoperative evaluation with an ultrasound to exclude an ectopic thyroid gland, which may occur along the thyroglossal duct.

Antibiotics (choice A) are necessary if the cyst is infected. The patient, however, denies any symptoms such as pain that would indicate an infected cyst.

Laryngoscopy (choice B) will provide direct visualization of the airway. Since the cyst is external to the larynx, it will not be visualized and thus a laryngoscopy is not indicated.

Percutaneous drainage (choice C) is insufficient treatment for a thyroglossal duct cyst, since the cyst will very likely recur without surgical extirpation.

Thyroid biopsy (choice E) is unnecessary as the thyroid is normal on ultrasound.

A thyroid stimulating hormone (TSH) assay (choice F) is unnecessary as there are no clinical signs of thyroid dysfunction. Thyroglossal cysts are not associated with thyroid dysfunction.

The correct answer is C. This patient has angle closure or acute glaucoma. These patients often have unilateral headaches from referred pain in the distribution of the ophthalmic division of the trigeminal nerve. They experience blurry vision from corneal edema. Perhaps the most important clinical sign is a mid-dilated fixed pupil in the context of a red eye and headache. Most patients also complain of ocular pain. In acute glaucoma, the optic nerve often appears normal, unlike chronic open angle glaucoma where cupping and pallor of the nerve are present. This patient was also recently placed on a tricyclic antidepressant that has anticholinergic effects, promoting dilation of the pupil and placing the patient at increased risk for angle closure glaucoma. Urgent ophthalmic consultation is indicated for the treatment of this patient.

A migraine headache is not the right diagnosis. Although this patient does have a unilateral headache, visual disturbance, nausea, and vomiting, a migraine headache would not be responsible for a fixed mid-dilated pupil. Treatment with antimigraine therapy (choice A) would not be indicated.

Depression would not cause the clinical signs presented above. Attributing this presentation to depression (choice B) would miss the diagnosis and potentially cost this patient her vision.

An MRI of the brain and orbits (choice D) would not be helpful in angle closure glaucoma.

An investigation for syphilis (choice E) is not likely to be positive. An Argyll-Robertson pupil is one that accommodates to near but does not react to light. This is a chronic finding of tertiary neurosyphilis. The optic nerve would demonstrate pallor.

The correct answer is B. This patient has Meniere’s syndrome (endolymphatic hydrops). Meniere’s syndrome is characterized but intermittent vertigo lasting about 1-8 hours with associated hearing loss, aural pressure, and tinnitus. Symptoms tend to wax and wane. It differs from benign positional vertigo in that the symptoms do not necessarily worsen with positional changes. In addition, positional vertigo doesn’t have the same associated factors as Meniere’s syndrome does. The treatment is a low salt diet and HCTZ. If the patient is resistant to medical therapy, surgery to decompress the endolymphatic sac can be a last resort.

Diazepam (choice A) is a useful treatment to ablate an acute episode of acute vertigo but is not a first line therapy for Meniere’s syndrome.

Meclizine (choice C) is an antihistamine, which is useful in the management of less severe attacks of vertigo.

Scopolamine (choice D) is sometimes used in a transdermal preparation to be beneficial in the management of chronic vertigo. The anticholinergic side effects can limit its usefulness.

Physical therapy (choice E) is becoming more important in the management of vertigo. It is thought to help the enhance CNS ability to compensate for labyrinthine dysfunction. Recently, use of specific head maneuvers has been incorporated into the management of vertigo.

The correct answer is C. This patient has orbital cellulitis. Patients present with lethargy, fevers, signs and symptoms consistent with sinusitis, proptosis of the globe, restriction of extraocular movements, periorbital edema, injected conjunctiva, and afferent pupillary defects. Hospitalization and intravenous therapy should be started at once as this condition is potentially fatal, especially if the cavernous sinus becomes involved. In children, most cases are a result of ethmoid sinusitis and periosteal abscess formation. ENT and ophthalmology consults are necessary to follow this patient in the hospital. Surgical drainage of abscesses are considered in patients who are not responding to antibiotic therapy or if visual acuity/pupil function is deteriorating.

A CT of the head (choice A) would not be as helpful as a CT of the orbits. Orbital scans should be ordered with axial and coronal views.

Gentamycin eye drops (choice B) are of no value. Orbital signs such as restriction of ocular movement, proptosis, and an afferent pupillary defect should not be overlooked to treat a “red eye.”

Oral antibiotics (choice D) are not adequate treatment for orbital cellulitis. Preseptal cellulitis may be treated with oral antibiotics. Patients with preseptal cellulitis have periorbital erythema and edema, but do not display the orbital symptoms described above. The globe is usually white and quiet with preseptal cellulitis.

Otitis media (choice E) is not a cause of orbital cellulitis. As mentioned above, sinusitis is the most frequent source of infection. Severe otitis media can erode through to the sigmoid sinus and cause venous sinus thrombosis resulting in cranial nerve palsies and increased intracranial pressure.

The correct answer is B. When performing an ophthalmologic examination you should hold the ophthalmoscope in your left hand, up to your left eye when examining the patient’s left eye, and in the right hand when examining the patient’s right eye. If you picture this, you will realize that this allows you to stand on the patient’s side and invade their personal space as little as possible. If you hold the instrument in your right hand, up to your right eye and examine the patient’s left eye, you need to stand directly in front of them, and basically on top of them. This is totally inappropriate. It will make you and the patient very uncomfortable.

You should tell the patient to look straight ahead and stare at a distant target, not to look directly at your nose as you approach with the ophthalmoscope (choice A).

You should not hold the ophthalmoscope 6 inches in front of your face as you approach the patient’s eye (choice C). You should function as a single unit with the instrument by holding it against your own forehead as you approach her. This allows you to have the most coordinated actions, and allows you to visualize the red reflex as you approach.

You invade the patient’s personal space by holding the ophthalmoscope up to your right eye as you examine the patient’s left eye (choice D). You should hold the instrument in your left hand to your left eye when examining the patient’s left eye, and then switch to your right hand and eye to examine the patient’s right eye. Also, you cannot really be as stable and visualize the eye as well if you hold the instrument in your left hand, up to your right eye as you examine the patient’s left eye. And even then you invade their personal space more than if you held it in left hand to your left eye to examine the patient’s left eye.

You should not press the ophthalmoscope against the patient’s cheek and keep the hand that is holding the instrument in the air (choice E). The instrument should be held against your forehead and you can gently hold the hand with the scope against the patient’s cheek, but not the instrument, for stabilization. You are not very stable if you keep the hand with the instrument in the air.

The correct answer is B. Peritonsillar abscess (quinsy) is a localized area of abscess that is typically unilateral and occurs in patients with tonsillitis. Group A beta-hemolytic Streptococcus followed by anaerobes are the most common causative organisms. Children usually present with sore throats which progress to peritonsillar abscesses. Symptoms include severe throat pain with radiation to the ear, drooling from inability to swallow saliva, trismus, and fever. Almost pathognomonic of the peritonsillar abscess is a muffled, “hot potato” voice. On examination, there is unilateral swelling of the palate and anterior pillar with the displacement of the tonsil downward and medially. The uvula is moved away, off the fundi involved side. Treatment includes intravenous penicillin and tonsillectomy. Although some series have documented good results using oral antibiotics and needle drainage, it may need to be done many times. The major concern in this patient, is the possibility of airway obstruction, although it’s a rare event. Hence, this patient should undergo an emergency tonsillectomy. Other indications for a tonsillectomy are obstructive tonsils associated with sleep apnea, dysphagia, speech defects, and failure to cry. Recurrent sore throats are relative indications for a tonsillectomy. American Academy of Otolaryngology guidelines suggest that 7 sore throats in 1 year or 5 sore throats in each of 2 years or 3 in each of 3 years, associated with either fever of more than 38 C (100.4 F) or swollen anterior cervical nodes or tonsillar exudate or positive strep culture are indications for tonsillectomy, not 3 sore throats in 1 year (choice E).

Fever by itself is not an indication for tonsillectomy (choice A). Most of the time tonsillitis is associated with sore throat and fever and this can be adequately treated with oral antibiotics using penicillin. If the patient is allergic to penicillin, erythromycin oral antibiotics can be used. If these fail, a first-generation cephalosporin may be used.

Swollen anterior cervical nodes (choice D) are not an indication for tonsillectomy by itself. Swollen lymph nodes reflect the bacterial process from tonsillitis. These usually respond to either oral or intravenous antibiotics, which will control tonsillitis.

Group A beta-hemolytic Streptococcus (choice C) is a common causative organism that can be isolated from pharyngeal culture in children with tonsillitis. A positive culture by itself, is not an indication for tonsillectomy, unless associated with the above-mentioned complications.

The correct answer is D. This patient has a retinal detachment, which is a known complication of cataract surgery. This patient has the typical symptoms like flashing lights, floaters, and “a curtain.” This condition requires immediate evaluation by an ophthalmologist and the treatment is to reattach the retina. Blindness is the feared complication.

Mannitol (choice A) is given in acute glaucoma, not in a retinal detachment. Glaucoma typically presents with severe pain and a red eye. It is associated with an increase of intraocular pressure.

After you obtain consultation with an ophthalmologist, you should advise him to limit his physical activity (choice B) to prevent further extension of the detachment.

If this patient had temporal arteritis it would be correct to begin corticosteroids, intravenously (choice C). Temporal arteritis is associated with a unilateral headache, a palpable, tortuous temporal artery, fatigue, myalgias, an elevated erythrocyte sedimentation rate, and a visual loss. This patient’s history and physical findings are more consistent with retinal detachment than temporal arteritis.

A laser iridectomy (choice E) is part of the treatment for acute glaucoma, not a retinal detachment. It is not usually performed as an emergent procedure during the acute attack, it is often performed after the attack subsides.

The correct answer is C. This gentleman has signs and symptoms of otitis externa. His previous episodes were treated with antibiotic eardrops and oral antibiotics. Otitis externa due to Pseudomonas in a diabetic patient can lead to malignant otitis externa. Malignant otitis externa can invade the mastoid causing mastoiditis, and can result in complications like meningitis and abscess. In this patient, the otitis externa, treated by the patient himself with antibiotic eardrops, turned into malignant otitis externa. Mastoiditis may be present and cannot be ruled out from mastoid non-tenderness. If this invasive form of otitis externa is not diagnosed and appropriately treated with antibiotic therapy, there is a potential for meningitis. Hence, a CT scan with contrast should be performed to rule out any involvements of the mastoid. Once malignant otitis externa is diagnosed and the extent of it is defined by means of clinical examination, an otolaryngological examination and a CT scan with contrast, the patient should be admitted for intravenous antibiotic therapy.

The patient is already taking antibiotic eardrops (choice A). These eardrops are not enough to control and treat malignant otitis externa.

Administration of antibiotic eardrops and oral antibiotics against Pseudomonas, which is the most common organism for malignant otitis externa, is essential once the diagnosis is made (choice B). But most of the time, intravenous antibiotic therapy (choice D) is essential in malignant otitis externa rather than oral antibiotics. Culture of the ears, hydrogen peroxide irrigation, and acetic acid drops (choice E) are forms of the therapy in otitis externa. But these measures, by themselves, would not treat malignant otitis externa and a CT scan must be performed to rule out mastoid involvement.

The correct answer is D. This patient most likely has acute otitis media, which is most likely due to an infection of the middle ear. It is often preceded by an upper respiratory infection that leads to the accumulation of fluid in the middle ear that becomes infected by viruses and bacteria. It is treated with amoxicillin for at least 7 days. Pain relief with acetaminophen is also indicated. A follow-up visit should be scheduled in 2 weeks to check if the otitis has resolved.

A consultation with an otolaryngologist for evaluation for tympanostomy tubes (choice A) is inappropriate at this time. This is indicated if the patient has a persistent middle ear effusions for more than 3 months that is unresponsive to antibiotic therapy.

A tympanocentesis (choice B) may be used in a child that is critically ill and fails to respond to standard antimicrobial therapy. This patient should be treated with amoxicillin at this time.

This patient most likely has acute otitis media and should be treated with a 7-10 day course of antibiotics, not a 1-month course (choice C). Also, she does not have recurrent otitis media, which is defined as 3 or more episodes of otitis media in 6 months or 4-5 episodes in 1 year. Individuals with recurrent otitis media are usually given daily antibiotic prophylaxis with amoxicillin or sulfamethizole.

It is inappropriate to reassure the mother that no treatment is necessary because this is most likely due to a viral infection (choice E) because this child most likely has acute otitis media, which requires an antibiotic. It is often due to bacterial infections, however viruses may be present in the middle ear fluid.

The correct answer is E. This patient has allergic rhinitis (AR). AR may be seasonal or perennial with significant overlap. For seasonal rhinitis there are well identified triggers in spring and summer. Perennial is characterized by more chronic symptoms with occasional flares. The diagnosis is solely based upon the history and physical examination. Additional work-up is not cost effective and should be reserved for refractory cases. The most common findings are sneezing, nasal pruritus, rhinorrhea, postnasal drip, nasal discharge, eye watering, and pharyngeal itching.

A head CT scan (choice A) is useful in the diagnosis of sinusitis which is often infectious.

Both serum eosinophil levels (choice B) and serum IgE levels (choice C) are markers of allergic disorders, but as with most such diseases the levels of these markers show a poor correlation with disease presence or severity.

Skin testing (choice D) is a method of immediate hypersensitivity testing, the gold standard of allergy diagnosis. Because such tests, although useful in identifying specific allergens, are expensive and add marginal diagnostic yield when compared to physical findings alone, they are not routinely recommended except in refractory cases.

The correct answer is C. The pupillary exam reveals an afferent pupillary defect (APD) or Marcus-Gunn pupillary defect. This is an important clinical sign that is always indicative of pathology. An APD is present when the central pupillary regulatory centers receive unequal input from the optic nerves. Thus, with a swinging flashlight test, the affected optic nerve “sees” less light and the pupil dilates. Any optic nerve injury such as optic neuritis, ischemia, or compression will cause an APD. In this case, a meningioma is causing compression of the optic nerve. The presence of an APD that otherwise has not been explained is an indication for an ophthalmology consultation.

Optic tract lesions are a cause of APDs, but they are seen on the contralateral side. This is because more nasal (contralateral) retinal fibers desiccate at the optic chiasm than there are temporal (ipsilateral) retinal fibers (choice A).

Media opacities such as cataracts (choice B), corneal disease, or vitreous hemorrhage are not a cause of an APD.

Physiologic anisocoria (choice D) is common. It denotes unequal pupils, but it is a diagnosis of exclusion. Furthermore, pupillary responses are normal and an APD would be absent in physiologic anisocoria.

The retinal ganglion cells synapse in the lateral geniculate bodies (LGB). Fibers in the optic tract that regulate pupillary function exit the optic tract anterior to the LGB. Thus, lesions posterior to the LGB do not cause pupillary abnormalities. Therefore, cerebral vascular accidents (choice E) involving the posterior circulation do not cause APDs.

The correct answer is D. This patient has the classic findings of pituitary compression of the optic chiasm. The acuteness of his presentation suggests that he has pituitary apoplexy or hemorrhage and sudden enlargement of a pituitary adenoma. The most important clinical symptoms/signs are sudden loss of vision (in this patient even between the triage nurse and physician exam), abnormal pupils, headache with nausea, and a bitemporal visual field deficit. Urgent neuroimaging and neurosurgical consultation is indicated.

A positive blood alcohol or toxicology screen (choice A) would not explain the important clinical signs of an afferent pupillary defect and bitemporal hemianopsia.

Ophthalmology consultation (choice B) is unnecessary at this point and delays appropriate triage of this patient.

Secondary gain (choice C) is a common concern when patients complain of sudden visual loss, but it is important to realize that in this case there are worrisome clinical signs that are consistent with his presentation. The saying of “pupils never lie” means that an afferent pupillary defect is always indicative of pathology.

A lumbar puncture (choice E) could be a potentially dangerous procedure in this context of intracranial hemorrhage and increased intracranial pressure. Neuroimaging should be performed first prior to lumbar puncture in patients where increased intracranial pressure is a possibility.

The correct answer is B. This patient most likely has developed orbital cellulitis, which is one of the most common complications of sinusitis. Orbital cellulitis develops by direct spread of infection from the ethmoid sinus through the lamina papyracea (the very thin bone that separates the orbit from the ethmoid sinus). A CT scan or MRI should be obtained and the treatment consists of intravenous antibiotics and possibly surgical drainage of the ethmoid sinus. Blindness and meningitis may occur if this is not treated aggressively.

An allergic reaction to amoxicillin-clavulanate (choice A) is an unlikely explanation for his symptoms because of the lack of a rash and the presence of such localized symptoms (one eye).

It is unlikely that this patient’s symptoms are caused by the direct spread of inflammation or infection from the sinuses to the meninges (choice C) because he does not have a headache or a stiff neck. This patient’s symptoms are more consistent with orbital cellulitis than meningitis, but both are complications of sinusitis.

The development of a frontal subperiosteal abscess (choice D), which is a complication of frontal sinusitis, typically presents with a tender, “doughy” swelling on the forehead. It is also called Pott’s puffy tumor. This diagnosis is inconsistent with this patient’s presentation.

The development of a tumor in the cavernous sinus (choice E) is an unlikely explanation for this patient’s symptoms because it is usually associated with ophthalmoplegia and 3^rd cranial nerve abnormalities. Also, it is extremely unlikely that this patient would have developed a tumor so quickly.

The correct answer is E. This patient has cataracts in both eyes. The typical clinical presentation of a patient with cataracts is that of slowly progressive visual loss. Patients may also complain of difficulty with glare and bright lights. They often note decreased color brightness and contrast sensitivity. On exam, a lens that has a cataract will appear yellow-green to yellow-brown. A mature cataract will present as a white lens and visual acuity of hand motions or light perception. With advanced cataracts, the fundoscopic exam may be difficult or not possible. The treatment for cataracts depends on the level of visual deficit experienced by the patient. Appropriate treatments range from observation/education, spectacles, and cataract surgery. If a patient with cataracts is comfortable with his current vision, then treatment with glasses or surgery is not necessary. Referral to an ophthalmologist may be appropriate for more in depth counseling based on the level of concern of the patient.

The level of visual acuity (choice A) should not be expected to decrease with age. Age alone is not an appropriate reason for decreased vision. A patient with healthy eyes and visual pathways should expect to see 20/20 regardless of age.

Although cataract surgery (choice B) is very successful in restoring vision, it is not a necessary procedure to prevent blindness. Cataracts alone do not cause a loss of light perception. It is appropriate to educate patients that they have cataracts and that a surgery exists that may help them see better. However, cataract surgery remains an elective procedure.

Patients with glaucoma (choice C) do not complain of decreased visual acuity. They may have decreased peripheral vision or scotomata, but even in advanced cases of glaucoma the visual acuity may remain 20/20.

Macular degeneration (choice D) is a common cause of decreased vision in the elderly. With this case, the macula could not be viewed, suggesting a media opacity as the cause of visual impairment.

The correct answer is B. This patient is presenting with symptoms consistent with acute conjunctivitis. The most common causes are infectious (viral and bacterial), allergic, and chemical. Treatment usually consists of comfort measures such as a cool compress and topical antibiotics or ocular allergy medications if indicated. One of the most important considerations in evaluating patients with conjunctivitis is to rule out any vision-threatening conditions such as iritis, keratitis, glaucoma, or a corneal ulceration. Symptoms such as marked photophobia, decreased visual acuity, or globe pain suggest that ocular structures other than the conjunctiva are involved and should trigger immediate ophthalmologic evaluation.

Upper respiratory symptoms (choice A) are often found in association with viral conjunctivitis.

A history of asthma, (choice C) and pruritus (choice E) suggest allergic conjunctivitis as the etiology of this patient’s symptoms. Other associated allergic disorders, such as atopic dermatitis or allergic rhinitis, would also support this diagnosis.

A history of varicella infection (choice D) without any current lesions is not significant in this case. However, if there were symptoms suggestive of active Herpes simplex or Varicella zoster infection, ophthalmologic referral would be appropriate.

A yellow-green discharge (choice F) may raise suspicion of bacterial infection and prompt the addition of topical antibiotics to the therapeutic regimen. In addition, a culture of the discharge may be sent. However, ophthalmologic evaluation is not necessary.

The correct answer is E. This patient has a septal hematoma from the nasal trauma. A septal hematoma is a collection of blood between the nasal mucosa and the cartilaginous septum. It can develop after nasal trauma (including nasal surgery) and can be unilateral, but is more commonly bilateral. Patients typically complain about difficulty in breathing or may sound hyponasal. If the hematoma is left untreated, it might become infected, resulting in increasing pain. Examination of the nose shows a swelling in the region of the septum. Pressing on this swelling with a nasal speculum reveals a soft and fluctuant mass, (contrary to a hard and non-fluctuating mass as in a deviated septum or preexisting deformity). The cartilage of the nasal septum receives its nourishment from the overlying mucosa. The hematoma blocks this supply. If the hematoma is not cleared quickly, the cartilage can become ischemic and ultimately necrotic. The necrotic tissue can slough, eventually resulting in a septal perforation or a saddle nose deformity. Both of these deformities are almost impossible to fix. Once a septal hematoma is identified in the nose, the patient should be advised for adequate drainage. The nasal septum should be anesthetized either topically and/or by means of injection. A large spinous needle should be introduced at a dependent area to evacuate the hematoma. Ideally, this opening is enlarged with a #11 blade. A Penrose drain can be left through this incision to keep this opening open for a day or two. Then, a bilateral, tight anterior nasal pack needs to be placed to re-appose the septal mucosa. The patient needs to be monitored for re-accumulation of the septal hematoma for one or two days.

Continuing to observe the patient in the hospital (choice A) is not a good option. For the reasons explained above, an increase in the hematoma size within the nasal septum might compromise the blood supply to the cartilage, which can become ischemic and necrotic. To prevent this, early drainage of the septal hematoma is advised.

Intravenous antibiotics (choice B) are not indicated in a non-infected septal hematoma.

Oral antibiotics are not indicated in a clean nasal septal hematoma (choice C). A hematoma, when adequately and appropriately drained early in the process, will resolve spontaneously and no antibiotic therapy will be needed.

The patient should not be discharged (choice D), as the septal hematoma can worsen causing increased pain and cartilage necrosis. Even when adequately drained, this patient needs to be followed up within a few days in the office to examine for any re-accumulation of the nasal septal hematoma.

The correct answer is B. The dermatomal distribution of a vesicular rash should lead you to the diagnosis of herpes zoster. Herpes zoster ophthalmicus is zoster in the V1 distribution presenting with ocular involvement. Oral acyclovir therapy was found in randomized clinical trials to reduce viral shedding from vesicular skin lesions, decrease systemic dissemination of the virus, and ameliorate the incidence and severity of the most common ocular complications (dendritic keratitis, uveitis, and stromal keratitis).

Herpes simplex antigen detection studies (choice A) would not be helpful for herpes zoster.

Oral antibacterial therapy (choice C) would be inappropriate for the management of herpes zoster, which is a viral infection.

Topical antiviral drops (choice D) have not been found to be effective for the treatment of herpes zoster ophthalmicus.

A topical antibiotic (choice E) may be used on the skin or in the eye to prevent secondary bacterial infection, but this is not the most appropriate next step in management.

The correct answer is B. The coronal CT scan of the orbits clearly demonstrates an orbital floor fracture. The patient’s exam finding of restricted upward gaze also suggests injury to the inferior rectus muscle. Orbital wall fractures most often occur in the orbital floor and sometimes in the medial wall of the orbit, because these are the weakest regions of the bony orbit. The proximity of the paranasal sinuses, nerves, vessels, extraocular muscles, globe, and other orbital structures predispose them to a wide variety of possible damage from injuries producing orbital fractures. The most common extraocular muscle entrapped in orbital floor fractures is the inferior rectus muscle, which limits upward gaze.

Blindness (choice A) is not a complication of orbital floor fractures. Blindness can occur if there is direct injury to the globe itself or if there is injury to the optic nerve. There are no signs of globe or optic nerve injury in this patient’s physical examination or in the CT scan.

Entrapment of the medial rectus muscle (choice C) is a complication of fractures of the medial orbital wall. Entrapment of this extraocular muscle is manifested by limited abduction of the eye.

An orbital pseudotumor (choice D) is not associated with orbital injury. It is an idiopathic granulomatous inflammation of the orbit that often presents with chemosis, proptosis, and pain. The most common structure in the orbit to be involved is the lacrimal duct.

Sinusitis (choice E) is not associated with orbital injury. Sinusitis is often due to underlying allergies. Orbital floor fractures or other fractures of the orbit do not predispose patients to the development of sinus disease.

The correct answer is C. This patient most likely has pharyngitis caused by the group A beta-hemolytic streptococcus. His signs and symptoms are classic for presentation with an infection caused by this bacteria. This is the only form of acute pharyngitis for which antibiotics are definitively indicated. Antibiotic treatment prevents well-defined suppurative complications such as peritonsillar abscess and nonsuppurative complications such as rheumatic fever. Although the gold standard diagnostic test is the throat swab and culture (choice E), this test is only useful when follow up is available. In a college student, the rapid strep test, which is an ELISA test looking for the bacterial antigen is the most practical test because the results are available within 1 hour.

Since this patient has no risk factors for HIV, testing for HIV serum RNA levels (choice A) is not indicated.

The Monospot test (choice B) is a test for heterophile antibody in blood, which indicates infection with Epstein-Barr virus (infectious mononucleosis). This typically presents with a few-week history of fatigue, malaise, and a sore throat. Examination often shows pharyngeal edema, erythema, and palatal petechiae, lymphadenopathy, and splenomegaly. Hepatomegaly may also occur.

A throat culture on Thayer-Martin medium (choice D) would be used to test for gonococcal disease, which this patient is not suspected of having.

The correct answer is B. The condition described in this girl is a cholesteatoma. A cholesteatoma occurs when the middle ear is lined with stratified squamous epithelium. The squamous epithelium desquamates in a closed space, which cannot be cleared and hence accumulates serving as a culture medium for the organisms. Cholesteatomas have the ability to destroy bone, including ossicles. Those arising in association with a perforation in the pars flaccida are called primary acquired cholesteatoma, while those arising in association with marginal perforations are called secondary acquired cholesteatoma. The presence of cholesteatoma greatly increases the probability of the development of serious complications, such as purulent labyrinthitis, facial paralysis, or intracranial suppurations like meningitis, brain abscess, subdural empyema, or epidural abscess. They are usually recognized by the small bits of amorphous white debris in the middle ear, and by the destruction of the bone of the external auditory canal superior to the perforation. A CT scan of the temporal bone is helpful in determining destruction of the bone. Cholesteatoma requires surgical treatment. The primary goal of the operation is to make the ear safe and the secondary goal is to maintain, or improve the hearing. The objective of the therapy is to remove the cholesteatoma or exteriorize it. A mastoidectomy, sparing the tympanic membrane, is the appropriate form of therapy for a cholesteatoma. In a radical mastoidectomy, the middle ear including the attic, the antrum, and the mastoid antrum are converted into one cavity that is in communication to the exterior, through the ear canal. The modified radical mastoidectomy spares the tympanic membrane remnants and ossicles to preserve the hearing.

Antibiotic eardrops and decongestants are not sufficient forms of therapy in treating a cholesteatoma (choice A). Delay in the treatment without a mastoidectomy, usually results in the progression of the disease.

Oral antibiotics (choice C) are not a sufficient form of therapy in treating a cholesteatoma. Although after a mastoidectomy, this condition can be treated with antibiotics, initially surgical treatment is the option.

Reassurance and follow-up in 3 weeks to see if the perforation closes spontaneously (choice D) is not optimal treatment. Cholesteatoma usually progresses, with the destruction of the bone and becomes a culture medium for the bacteria, unless a surgical debridement is carried out.

Tympanoplasty (choice E) is not a safe option, as this will not treat the primary pathology in a cholesteatoma.

The correct answer is B. Strabismus is an important diagnosis to make. Resultant amblyopia is treatable and reversible if the child is referred to an ophthalmologist promptly. Treatment with spectacles or patching is very effective in the first 5 years of life, and often later depending on the degree of amblyopia and its cause.

Neuroimaging is considered for selected cases of atypical ocular misalignment or with any suspicion of cranial nerve palsies, but routine imaging for all children with strabismus is not necessary based on ocular findings alone (choice A).

Visual acuity loss from amblyopia will improve with treatment and so any loss of visual acuity that is present now will not be permanent (choice C) is incorrect. However, stereo vision loss is harder to treat. Many patients with amblyopia will note subtle subjective visual loss in their amblyopic eyes that may not show up on visual acuity measurements

Children do not grow out of strabismus and you should never wait for the child to “outgrow” ocular misalignment (choice D). Delay in referral to an ophthalmologist will make the treatment of amblyopia longer and more difficult.

This patient does not have a 4th cranial nerve palsy (choice E). The patient has full extraocular movements and a forth cranial nerve palsy will produce an exotropia (outward deviation) and hypertropia (upward deviation) of the affected eye.

The correct answer is A. This patient most likely has a retropharyngeal abscess. The next step in evaluating this is a lateral radiograph of the neck. This will also allow for assessment of a foreign body in the epiglottis. A throat culture is necessary to guide antibiotic therapy. A retropharyngeal abscess is a disease of children under the age of 5 years. Tissue in the back of the throat of young children allow a purulent collection to form. However, this does not happen in adults, as the potential space does not exist. Clinical signs of a retropharyngeal abscess include stridor, severe sore throat, difficulty swallowing, and drooling. There will be an elevated white blood cell count. On plain film there will be widening of the retropharyngeal soft tissues with a possible impingement on the airway. The abscess can dissect into the mediastinum causing mediastinitis. Further complications include pneumonia and osteomyelitis. The treatment involves intravenous antibiotics, possible airway protection and surgical drainage.

A CT of the chest (choice B) will not detect the retropharyngeal abscess in the neck.

A CT of the chest and a neck x-ray (choice C) is a complete radiographic evaluation for retropharyngeal abscess with mediastinitis. A throat culture, however, is necessary to direct antibiotic therapy in this case. Broad spectrum antibiotics should be fine tuned with cultures whenever possible.

A CT of the chest and a throat culture (choice D) will not detect the retropharyngeal abscess in the neck. The pneumomediastinum is a secondary finding of retropharyngeal abscess. A throat culture is indeed necessary to direct antibiotic therapy in this case.

A direct laryngoscopy and a throat culture (choice E) would not be the way to approach this scenario. The next step in evaluating this is a lateral radiograph of the neck. This will also allow for assessment of a foreign body in the epiglottis and an evaluation for a retropharyngeal abscess.

The correct answer is C. This patient has Meniere’s disease, which is characterized by tinnitus, vertigo, and progressive hearing loss. It is thought to be related to a degeneration of the vestibular and cochlear hair cells. The treatment includes bed rest, a low-salt diet, dimenhydrinate, cyclizine or meclizine.

Benign positional vertigo (choice A) is characterized by paroxysmal vertigo and nystagmus. It is brought on by certain changes in position. Hearing loss is not present. The cause is idiopathic.

Benign recurrent vertigo (choice B) and vestibular neuronitis (choice E) are two names for the same syndrome, which is characterized by the sudden onset of vertigo, nausea, and vomiting. There is no change in hearing.

Toxic labyrinthitis (choice D) presents with vertigo. It is due to medications and alcohol. Aminoglycosides are among the most common culprits. This patient does not take any medications and denies any alcohol.

The correct answer is C. The approach to the patient with a headache is difficult because often, at times the complete evaluation is normal. A physical examination, including a neurologic and funduscopic exam, should almost always be performed. Neuroimaging is generally not indicated if the physical exam is normal. Chronic pain can be due to typical headaches, such as tension headaches and cluster headaches, a brain tumor, temporal arteritis, pseudotumor cerebri, or other miscellaneous causes like disorders of the teeth, jaws, or related structures. Dental caries that progress to infection of the dental pulp, the alveolar bone, and the soft tissues may cause a severe unilateral headache that can be confused with any of the above causes. Before you do “a million dollar” work-up for a headache with a completely normal physical examination, especially when the usual migraine, tension, and cluster headache treatments are not helpful, a trip to the dentist may easily solve the problem.

While depression has been associated with chronic headaches, it seems that this patient should go to the dentist for an evaluation before you advise her to see a psychiatrist (choice A). You should first try to seek an organic cause of disease before you blame the chronic pain on depression.

Immediate corticosteroids (choice B) would be appropriate if you suspected temporal arteritis with ocular complications. She would probably have a tender temporal artery, scalp pain, and other systemic symptoms such as malaise, morning stiffness, shoulder, and hip pain. This patient only complains of a headache.

Chronic pain may be managed by a pain management specialist (choice D). However, this patient should first see a dentist before you recommend this treatment. You must understand that dental pain commonly causes a headache.

A temporal artery biopsy (choice E) is inappropriate at this time because it is very possible that this patient’s pain comes from the teeth or jaw. Temporal arteritis typically affects elderly individuals and is associated with a tender temporal artery, ocular, and systemic symptoms. This patient does not have any of these symptoms.

The correct answer is D. This patient has an acute third cranial nerve palsy. Patients with third nerve palsies will have extraocular muscle abnormalities, a dilated pupil, and ptosis. The eye is typically deviated “down and out” due to the unopposed actions of the lateral rectus and superior oblique muscles. Some patients do not have diplopia simply because their ptosis is pronounced enough to occlude the vision out of the paretic eye. The pupil exam is critical in the evaluation of a third nerve palsy. Patients with a dilated pupil have a compressive lesion on the third nerve until proven otherwise. The third nerve passes between the posterior cerebral artery and the superior cerebellar artery, and then parallels the posterior communicating artery. An aneurysm of any of these arteries (most commonly the posterior communicating artery), can cause a compressive lesion of the third nerve. An emergent MRI/MRA is the best test to evaluate compression of the third nerve, as it shows aneurysms greater than 4 mm as well as subtle neoplastic or inflammatory processes that could be causing compression.

A migraine headache (choice A) would be an unlikely cause of this presentation. The best first step is neuroimaging, and if this is negative then other causes such as migraines could be considered.

A “diabetic” third nerve palsy (choice B) presents as a “pupil-sparing” third nerve palsy. The etiology is presumably microvascular infarction of the third nerve. The fibers of the third nerve that control pupillary responses run on the outside of the nerve and thus are less likely to be affected by microvascular ischemia. This anatomic relationship also explains why compressive lesions of the third nerve will almost always show pupillary deficits.

Control of the patient’s hypertension (choice C) is not of primary concern and referral to a neurologist will delay appropriate neuroimaging.

Referral to an ophthalmologist (choice E) will also delay appropriate triage of this patient. Later, after the etiology of the third nerve palsy has been addressed, ophthalmology referral may be helpful in dealing with issues of diplopia.

The correct answer is E. The positive rapid test for group A streptococcus (S. pyogenes) confirms the diagnosis of streptococcal pharyngitis, and antibiotic therapy is essential for the prevention of suppurative complications (e.g., adenitis, peritonsillar abscess) as well as rheumatic fever. Penicillin remains the treatment of choice for streptococcal pharyngitis in non-allergic patients, as treatment failures are extremely rare.

Infectious mononucleosis is another potential cause of fever, pharyngitis, and rash in children. Associated findings would be generalized lymphadenopathy and splenomegaly on physical examination. The lack of these makes the diagnosis unlikely in this case. A complete blood count and monospot (choice A) can help confirm this diagnosis when it is suspected.

The rapid antigen detection tests have excellent specificity (>95%) and thus a positive test does not need to be confirmed by repetition (choice B).

Most practitioners choose to send a swab for bacterial culture (choice C) in the setting of a negative rapid test in order to increase sensitivity because of the potentially devastating sequelae of a missed case of streptococcal pharyngitis, but this is unnecessary with a positive test.

Amoxicillin-clavulanate (choice D) is a combination of a beta-lactam antibiotic and a beta-lactamase inhibitor. It is useful in the treatment of infections due to organisms that have developed resistance via the production of a beta-lactamase enzyme. Group A streptococcus does not produce a beta-lactamase. Thus, this combination is unnecessary in this case.

The correct answer is B. This patient most likely has conjunctivitis due to a bacterial infection. Conjunctivitis is a common condition in children that is usually bacterial or viral. Bacterial infections are usually purulent, while viral infections are not. Topical antibiotic therapy is typically given for bacterial infections. Conjunctivitis is contagious and it usually spreads by direct contact. Respiratory spread may occur. Children should be excluded from childcare settings until they are examined, given treatment if indicated, and approved for readmission.

It is incorrect to tell the mother that careful hand washing does not affect the spread of this condition (choice A) because the spread of infection is minimized by hand washing.

It is inappropriate to tell the mother that she should take her daughter for a CT scan before the appointment to rule out orbital cellulitis (choice C). A CT scan is used to evaluate a patient with suspected orbital cellulitis, which presents with proptosis, decreased visual acuity, and pain with movement. It is unlikely that the patient in this case has orbital cellulitis, and if the symptoms that the mother reported were consistent with orbital cellulitis, you would want to evaluate her before sending her for diagnostic studies.

Since the condition is most likely due to a self-limited virus, the appointment is for reassurance and not to administer therapy (choice D) is incorrect. The “thick yellow discharge” that the mother described is consistent with a bacterial infection, not a viral infection. The appointment is for evaluation and the administration of antibiotic therapy if indicated.

Topical corticosteroids are indicated if the patient has a herpetic dendritic ulcer (choice E) is incorrect. Corticosteroids are contraindicated in patients with a herpetic dendritic ulcer because they can worsen the condition. Individuals with a dendritic ulcer often have a painful, red eye, with visual blurring. Discharge may be present.

The correct answer is D. This patient has allergic rhinitis (AR). AR may be seasonal or perennial with significant overlap. For seasonal rhinitis there are well identified triggers in spring and summer. Perennial is characterized by more chronic symptoms with occasional flares. The diagnosis is solely based upon the history and physical examination. For this patient who appears to have a significant overlap between the two and has no clear allergen identified, medical treatment is indicated. Medical therapy has been shown to improve symptoms and is associated with an overall improved quality of life. Topical intranasal steroids are superior to prescription non-sedating antihistamines for overall symptom control and for fewer side effects. For this reason, they are now considered first-line pharmacotherapy for allergic rhinitis.

Since the patient has no clear allergen identifiable, it will likely not benefit him to have weekly home cleaning (choice A). For patients with such triggers identified, this maneuver often dramatically improves symptoms.

Over-the-counter antihistamine therapy (choice B) are so-called “sedating” or “traditional” antihistamines. These are not good agents for this patient because of his necessity to drive each day. In fact, studies have documented the driving performance of patients on these drugs are similar to those with alcohol intoxication.

Prescription strength intranasal (choice E) or oral (choice C) antihistamines are so called “non-drowsy” formulations. These are superior to the standard first generation agents but are not first-line therapy any longer. Steroids are now considered more efficacious and should be tried first. The intranasal formulations offer no added benefit when compared to oral formulations and are therefore not recommended.

The correct answer is D. This patient most likely has an alkaline eye burn, which is extremely destructive, and the process of destruction continues as long as the substance is in contact with the tissues. Immediate removal is essential, and the best method is massive irrigation. In the emergency room, sterile saline would be used, but at home, tap water will do. This irrigation is important even before going to the hospital (because the alkaline fluid will remain in the eye if you leave the irrigation to the emergency room physicians).

It is extremely dangerous to call an ambulance to bring him to the hospital, and place a patch over the affected eye (choice A). The alkaline chemical will begin to destroy the eye if you do not begin immediate irrigation while waiting for help.

Alkaline eye burns are emergencies that require immediate irrigation and medical attention. Calling the ophthalmologist and scheduling an appointment for the next available time (choice B) will leave too much time for the chemical to destroy the eye.

It would be inappropriate to tell her to flush his eye with a substance that she can find in her cabinet with a pH of 6.9 or lower (choice C). Irrigation with cold tap water is the treatment while waiting for additional medical help (in the ambulance or at the hospital).

While it is necessary to try to remove as much of the chemical as possible, telling her to pry his eye open and vigorously rub the entire eye, especially under the upper and lower lids (choice E) is incorrect. Massive irrigation is used to dilute the chemical and wash away any particles remaining in the eye. Gentle swiping may be appropriate later on in the treatment to wipe away any little remaining particulate matter, however, this may be done after irrigation.