EENT List of Most Commons for Physician Assistant Students

Most Commons in HEENT for Physician Assistants

HEENT (EENT) makes up 9% of the PANCE and is one of the most common “bread and butter” medicine topics you’ll come across. Below is a combination of “most commons”, “buzzwords”, and other clinical pearls I have come across since completing my didactic year. I compiled this in order to help myself prepare for the PANCE and for rotations. I hope it helps you in your studies as well.

1. Head
1. Bell’s Palsy - most common acute disease involving a single nerve and most common cause of acute facial nerve paralysis
1. Onset within 72 hours
2. Loss of taste sensation in anterior ⅔ tongue (chorda tympani)

2. Ears

Acute Otitis Media	Otitis Externa - Bacterial	Otitis Externa - Fungal
MC: viral (45-70%), S. pneumo (25-50%), H. Flu (15-30%), M. Cat (20%) MC (pediatric): S. pneumo	MC Path: Pseudomonas (50%), S. aureus/St. pneumo (40%), sterile (10%)	MC Path: Aspergillus-niger (black), -flavus (yellow), or -fumigatus (gray) Candida albicans (white)
Pain when supine or leaning forward, pulling on ear Fever, hearing loss, aural fullness, pressure PE: red TM, purulence, pre- or post-auricular LAD with cervical LAD, loss of cone of light Associated rhinitis Ruptured TM = drainage Tuning fork: BC > AC	Pain with movement of pinna or eating Conductive hearing loss PE: swollen, red, yellow/green discharge, foul smelling, pre- or post-auricular LAD +/- cellulitis of face Tuning fork: BC > AC	ITCHY Weeping, pain, hearing loss, aural fullness PE: swollen, hyphae +/- spores, moist/wet-appearance
TX: most resolve spontaneously Mild: no ABX, reevaluate 2-3 d Uncomplicated, previously untreated: HD (80-90 mg/kg/d) Amoxicillin or Augmentin x 10-14 d or IM ceftriaxone Switch ABX 48-72 h if no resp.   PCN allergy: Sulfonamide + Erythromycin or Clindamycin, FQ Do not use: antihistamines, decongestants	TX: hygiene, clean, otowick, topical analgesics Otic drops: Ciprodex, Floxin Contraindicated: irrigation or Gentamicin/Tobramycin with perforated TM	TX: hygiene, clean Topical antifungal powder + Antifungal otic drops: acetic acid, Vosol Prophy: 1:1 ETOH/white vinegar in each ear after showering Contraindicated: Lotrimin with perforated TM
Chronic Otitis Media (recurrent)	3+ AOM in 6 months OR 4+ AOM in 1 year Autophony - can hear your echo	SX: continued pressure or fullness after resolution of infection, hearing loss, tinnitus, increased sensitivity to loud noises, not painful PE: dull TM with  decreased movement, hearing loss, speech delay
Serous Otitis Media HX: recent viral URTI, sinus infection, flare of allergies, flying while congested, recent AOM, adenoid hypertrophy, nasopharyngeal mass TX: resolves slowly (up to 12 weeks), follow up 4-6 W, nasal steroid sprays, short course of PO steroids Do not use: antihistamines, decongestants	Fullness, hearing loss, pressure, popping/gurgling after a yawn or blowing nose, dizziness or swimming sensation Unilateral or bilateral PE: retracted TM, amber or “coca cola” colored fluid, displacement of cone of light, air bubbles behind TM, pneumatic otoscopy reveals decreased movement of TM Tuning fork: BC > AC
Cholesteatoma Chronic negative pressure thins the TM and retracts, adhering to middle ear -> squamous epithelium forms inside and expands	Worsening hearing loss Chronic discharge, fullness Not painful History of AOM or previous surgery PE: pearly white mass, squamous debris, discharge Conductive hearing loss
Necrotizing (Malignant) Otitis Externa MC: diabetics, immunocompromised MC pathogen: pseudomonas	Deep severe pain Drainage, swollen red canal Granulation tissue, osteomyelitis at skull-base, pain with talking/chewing CN 7 and 12 involvement TX: control DM, oral FQ
Mastoiditis MC pathogen: S. pneumo, S. aureus	Fever, malaise, hearing loss, +/- headache History of ABX use without improvement PE: swollen over mastoid, redness, tenderness, LAD, outward protrusion of pinna TX: IM ceftriaxone or IV ABX CT Scan, refer to ENT

Labyrinthitis (otitis interna), vestibular neuronitis, vestibular neuritis
Etiology: viral, head injury, stress, allergy	Rapid onset severe vertigo (3-5 days), nausea, vomiting, imbalance Preceding URTI +/- nystagmus (severe)	Symptoms regress over 3-6 weeks

Central Vertigo	Peripheral Vertigo
Gradual and continuous symptoms, mild to moderate Focal signs, nausea, vomiting, hearing loss (rare)	Acute and intermittent symptoms, but severe hearing loss, tinnitus, fullness Hearing loss, severe nausea and vomiting, diaphoresis
Etiology: MS, brain tumor, head injury, medications	TX: Valium, Meclizine

1. Acute otitis media - most common diagnosis for acute office visits in children
1. Most common complication: tympanic membrane perforation
2. Untreated complications - leads to facial nerve paralysis (Bell’s Palsy), cerebral venous sinus thrombosis, mastoiditis, short/long term hearing loss, speech delay, bacterial meningitis, intracranial abscess, TM perforation
3. Bagel ear - bulging TM
2. Most common cause of hearing loss: cerumen impaction
3. Most common cause of unilateral sensory hearing loss: viral neuritis
4. Presbycusis - Most common type of hearing loss in elderly
5. Most common neuropathy associated with acoustic neuroma: loss of corneal reflex due to trigeminal involvement
6. Bilateral nystagmus with cold caloric testing - signifies intact cortex, midbrain, and brainstem
7. Recurrent unilateral serous otitis media - consider oropharyngeal cancer
8. Drugs that cause nystagmus - MALES TIP
1. Methanol
2. Alcohol
3. Lithium
4. Ethylene glycol
5. Sedative hypnotics, Solvents
6. Thiamine depletion and Tegretol (carbamazepine)
7. Isopropanol
8. PCP, Phenytoin
9. Medications that cause hearing loss: aminoglycosides, antineoplastic agents, loop diuretics, salicylates
10. Meniere's Disease (endolymphatic hydrops) - excessive endolymph fluid in the cochlea overstimulates hairs causing vertigo and sudden hearing loss with aural fullness; most commonly unilateral and appears in adults
1. SX: sudden vertigo, aural fullness or pressure, tinnitus, fluctuating hearing loss, nausea/vomiting, lasts hours
2. TX: low salt, high water diet, diuretics, intratympanic steroids
1. Avoid ETOH, caffeine, tobacco
11. Dix-Hallpike Maneuver - diagnoses benign positional vertigo (eye twitching occurs), which is provoked by head movements or positioning
1. Nystagmus - always positional, brief, and fatigable
2. Rotatory nystagmus (posterior canal BPPV) - Epley maneuver
3. Lateral nystagmus (lateral canal BPPV)  - Lempert Maneuver
4. Vertical nystagmus (superior canal BPPV) - Deep head hanging maneuver
12. Weber Test - sound is louder in ear with conductive loss
13. Acoustic Neuroma (vestibular schwannoma) - tumor of 8th CN
1. SX: unilateral hearing loss, vertigo (late), unsteadiness, tinnitus
2. Bilateral acoustic neuroma - associated with Neurofibromatosis type II
3. Decreased corneal sensitivity, diplopia, headache, facial weakness
4. LP: elevated protein
5. TX: MRI
1. Eyes
1. Basic Anatomy of the Eye
1. Myopia - “nearsighted”; vision rays come into focus in FRONT of retina
2. Hyperopia - “Farsighted”; vision rays come into focus BEHIND retina
1. Presbyopia - farsightedness caused by old age
3. Strabismus (heterotropia) - eyes do not align (cross-eye)
2. Hordeolum vs. Chalazion
1. Hordeolum - occurs on upper or lower eyelid; red and painful; spontaneously resolves
1. Abscess of Meibomian gland (internal) - points toward conjunctiva
2. Glands of Zeis (external, stye) infection at eyelid margin, pointing outward
2. Chalazion - obstruction of meibomian gland (granuloma) or internal posterior hordeolum; painless, non-tender, non inflamed swelling (nodule) developing over the course of weeks (chronic)
1. TX: hot compress, oral doxycycline or tetracycline
3. Pterygium (Surfer’s Eye) - commonly grows from the nasal side of the conjunctiva
4. Eyelid Malposition
1. Entropion vs. Ectropion
5. Retinoblastoma - child with blurry vision and abnormal pupillary reflex with a white reflex upon fundoscopic exam
6. Subconjunctival hemorrhage - bleeding of the conjunctival or episcleral blood vessels into the subconjunctival space; painless; self limiting - lasts 2 weeks
7. Blepharitis - conjunctival and lid margin inflammation
1. Slit lamp exam: greasy appearance of lid margin with scaling around the base of the lashes
8. Hypopyon - accumulation of white inflammatory exudate in the anterior chamber
1. SX: painful, red eye
2. Slit lamp exam: localized, white, flocculent infiltrate in anterior chamber
9. Hyphema - blood in anterior chamber resulting from tears in ciliary body or iris root vessels; most common in children (70%)
1. RF for rebleeding: sickle cell disease or trait, black, ASA use, prior low visual acuity, hyphema > ⅓ anterior chamber, treated after 24 hours, elevated IOP
2. 4 S’s of Hyphema (Complications)
1. Staining of the cornea
2. Synechiae - iris adheres to cornea or lens
3. Secondary rebleeds on 2-5th day (20%)
4. Significantly increased IOP
3. TX: Rest, elevation of head, topical steroids, avoid ASA/NSAID
10. Welder’s Flash - severe eye pain and multiple pinpoint areas of fluorescein uptake representing ruptured corneal epithelial cells
1. Slit lamp exam: Diffuse Punctate Keratopathy
11. Most common pathogens of
1. Acute Dacryocystitis: Staph aureus and beta-hemolytic streptococci
2. Chronic Dacryocystitis: candida albicans, anaerobic streptococci, staphylococcus epidermidis
3. SX: painful erythema over the tear duct at nasal side of eye with small amount of pus draining from tear duct
12. Dacryoadenitis - acute inflammation of the lacrimal gland seen in sterile inflammatory disease
1. SX: abrupt onset swelling of upper eyelids, laterally;
2. Most due to gram positive bacteria, but EBV most common virus
13. Normal range of intraocular pressure (IOP): 10-23 mmHg

Central Retinal Artery Occlusion (cherry red spot, ischemic retina): flow through CRA occluded Associated: atherosclerotic thrombosis, embolus, giant cell arteritis SX: sudden painless loss of vision in one eye (unilateral) PE: pale-gray retina, APD, cherry dot Irreversible damage to retina after 90 minutes - IMMEDIATE CONSULT (decrease IOP & arterial dilation)
Central Retinal Vein Occlusion (Blood & Thunder Fundus): sudden, painless unilateral vision loss, 50+ PE: macular edema, cotton wool spot, massive superficial/deep hemorrhage with vitreous involvement MC Associated: HTN, POAG
Age Related Macular Degeneration (ARMD): loss of central vision clarity, long smoking history, metabolic syndrome, FH, female, white, age 50+ PE: drusen formations, retinal atrophy TX: Anti-VEGF intravitreal injections
Dry AMD (Nonexudative)	Wet AMD (Exudative)
Buildup of drusen Mild - asymptomatic Moderate - some vision loss Severe - central blind spots TX: vitamins to slow process	Choroidal neovascularization Early - mild distortion Late - central blind spot

Differential of Red Eye with Decreased Visual Acuity
Acute (Angle Closure) Glaucoma EMERGENT OPHTHALMOLOGY CONSULT “Halos around lights”  (bilateral) Dull or severe pain, blurry vision, frontal headache, lacrimation, +/- nausea and vomiting Pain more severe in dark RF: asians, eskimos, hyperopes, elderly IOP: 40-80 mmHg (sudden increase) TX: IV mannitol, pilocarpine, IV acetazolamide, iridectomy
Chronic (Primary Open Angle) Glaucoma (POAG) Visual changes begin peripherally Gradual, painless loss of vision More common than acute 4% of patients 40+ Most common cause: outflow obstruction through trabecular meshwork
Acute Iritis (anterior uveitis): inflammation of the ciliary body and iris SX: eye/periorbital pain, consensual photophobia, hypopyon, irregular pupil, Floaters, headaches, dilated ciliary vessels (ciliary injection or flush), “cells and flare” in anterior chamber, keratic precipitates (KP) on posterior surface of cornea TX: refer to ophthalmology +/- rheumatology, steroid and dilating drops
Corneal Abrasion Multiple vertical linear abrasions (ice rink sign) under upper eyelid suggests foreign body MC etiology: contact lenses TX: cycloplegic, topical NSAID, topical antibiotic, oral analgesics/sedatives Contraindicated: topical steroids, patching
Herpes Simplex (HSV) Keratitis EMERGENT OPHTHALMOLOGY CONSULT Etiology: HSV-1 SX: painful eye, blurred vision, conjunctivitis, photophobia, tearing Slit lamp exam: dendritic ulcer (branch-like) lesion Hutchinson’s sign: herpetic lesion on tip of nose (nose and cornea supplied by nasociliary nerve) TX: most spont. resolve in 3 weeks Contraindicated: topical steroids or patching
Bacterial (Microbial) Keratitis SX: rapid onset red, painful eye with discrete corneal infiltrate, photophobia, and decreased vision +/- hypopyon (+) Seidel sign/test Most common: pseudomonas (contact lens wearers), Enterobacter VISION THREATENING PROCESS - rapid progression (24-48 h), REFER If small, peripheral - FQ every 1-2 h
Conjunctival Injection Anterior vessels - produce more redness, move with conjunctiva and constrict with vasoconstrictors Posterior - stationary and less red
Viral Conjunctivitis (pink eye) Most common: adenovirus Associated symptoms: recent URTI, no resolution with eye drops SX: unilateral or bilateral, benign, self-limiting (2-4 weeks), preauricular adenopathy, epiphora, hyperemia, chemosis, follicular conjunctival injection, subconjunctival hemorrhage TX: supportive (cold compress, lubricants - artificial tears), hand hygiene
Bacterial Conjunctivitis Associated: steroid or OTC eye drops, contact lens wearers, age, sexual activity, immunodeficiency Segmental or diffuse injection, purulent discharge, “mattering” or lid margin, difficulty prying open lids after awakening Topical FQ and erythromycin
Seasonal Allergic Conjunctivitis (SAC) SX: Itching, history of rhinitis, clear discharge, conjunctival injection +/- chemosis, +/- eyelid edema Summer, Spring, Fall Usually symptom free in winter
Vernal Keratoconjunctivitis (VKC) Bilateral, chronic inflammation or “Spring catarrh” summer conjunctivitis Large cobblestone papillae Shield ulcer (pathognomonic) caused by inflammatory mediator release Onset in puberty Most common in males
Giant Papillary Conjunctivitis (GPC) RF: contact lens overuse, plastic prosthetic eye First: itching with mucoid discharge Large cobblestone papillae >0.3 mm TX: stop wearing contact lenses
Atopic Keratoconjunctivitis (AKC) Bilateral, inflammation of conjunctiva AND eyelids, eczematoid dermatitis of eyelid with dry, scaly, inflamed skin Associated with atopic dermatitis (eczema) TX: topical antihistamines, mast cell stabilizers, olopatadine, topical NSAID (ketorolac), topical steroid (prednisolone)
Gonococcal Conjunctivitis (neonatal = ophthalmia neonatorum) N. gonorrhoeae or C. trachomatis Pain, tenderness, hyperemia, chemosis Purulent, mucoid or mucopurulent May ulcerate, resulting in vision loss
Episcleritis: inflammation between conjunctiva and sclera (episcleral tissue) Mild, self-limiting, recurrent Vessels blanch with topical vasoconstrictors 2 Types Simple: intermittent (1-3 months), lasts 7-10 days, mod-severe inflammation, spontaneously resolves after 2-3 weeks Nodular (shown): prolonged, acute onset, mild-mod + systemic disease TX: none required +/- oral NSAID
Scleritis: inflammation of the sclera Diffuse or Nodular VISION THREATENING - REFER IMMEDIATELY SX: awakened from sleep due to deep boring pain, vessels will not blanch or move with topical vasoconstrictors

Hard Exudate: deep yellow with sharp margins; circinate	Leakage from pre-capillary arterioles Ex. von Hippel Lindau disease, radiation, HTN Most common cause: DM
Cotton Wool Spots (soft exudates): fluffy gray-white patches; near optic disc Due to ischemia of superficial retina (microvasculature)	Neural micro infarctions Ex. HIV, connective tissue disease, DM Most common cause: HTN Most common funduscopic exam finding in AIDS patients (CMV retinitis)
Retinal Drusen: clusters of yellow-orange spots, centered around fovea	Metabolic debris from retinal pigment epithelium Most common cause: ARMD
Diabetic Proliferative Retinopathy Prolonged hyperglycemia causes: 1. Basement membrane thickening 2. Decreased pericytes (hyperproliferation) 3. Microaneurysms 4. Neovascularization	Neovascularization breaks through ILM (inner limiting membrane) leading to tractional retinal detachment
Non-proliferative Retinopathy	Aneurysms Hard exudates Hemorrhage
Papilledema: optic disc swelling caused by increased intracranial pressure (ICP)	Bilateral, develops over hours to weeks Transient obscurations of vision (lasts seconds) ICP: most commonly occurs bilaterally
Optic Neuritis: optic nerve swelling causes destruction of myelin sheath Papillitis - head of optic nerve Retrobulbar neuritis - posterior nerve PAIN PRECEDES VISUAL LOSS	Most common cause: Multiple sclerosis Normal ICP Sudden unilateral loss of central vision MC symptom: blurry or “foggy” vision Pain with movement of affected eye (NOT RED) Central scotoma, central change in color perception PE: swollen disk, APD TX: IV/oral steroids
Cataracts Any opacity of the lens, whether visually significant or not Most common cause: age related nuclear sclerosis	SX: glare, myopic shift, multiple images due to refraction, blurry vision Complication: endophthalmitis
Retinal Hemorrhage	Causes: HTN, retinal vein occlusion, DM, shaken baby syndrome or severe head trauma
Vitreous Hemorrhage: extravasation (leakage) of blood into areas in and around vitreous humor Age 50+ 50-70% of acutely symptomatic patients have retinal detachment	Most common cause: proliferative diabetic retinopathy Others: trauma, retinal detachment “Flashing lights”, floaters Blurry vision, reddish tint, photopsia (brief flashes of light in periphery) Most asymptomatic
Retinal Detachment EMERGENT OPHTHALMOLOGY CONSULT Peripheral -> central vision loss TX: inferior - patient sits up superior - patient lies down	Preceded by posterior vitreous detachment: photopsia, floaters, feeling of heaviness in eye Painless vision loss “Curtain of darkness” with peripheral flashes or spider webs and floaters Gray detached retina
Amaurosis Fugax Etiology: atherosclerosis (retinal artery emboli), carotid stenosis	“Fleeting blindness” or “curtain coming down vertically into field of vision” Painless, transient (quickly returns), unilateral visual loss Lasts 2-20 minutes
Non-arteritic Anterior Ischemic Optic Neuropathy (NAION): damage to optic nerve head from microvascular occlusion RF: HTN, DM, hypercholesterolemia, smoking	Sudden upon awakening, non-painful, unilateral optic disc swelling Afferent pupillary defect (APD), most upper or lower half of visual field Age: 50-70 Visual loss does not progress or recover Resolves 4-8 weeks
Arteritic Anterior Ischemic Optic Neuropathy (AION): damage to optic nerve head from microvascular occlusion	Age: 70-90 (older) Severe visual loss, jaw claudication, temporal artery tenderness, temporal headache, unintentional weight loss, fatigue, myalgias, loss of appetite Significant APD DX: STAT ESR, temporal artery biopsy TX: high dose steroids to prevent blindness in contralateral eye
Hypertensive Retinopathy	Hallmark: Diffuse arteriolar narrowing (AV nicking)
Osteogenesis Imperfecta (brittle bone disease, Lobstein syndrome)	Blue-gray sclerae due to underlying choroidal veins showing through a thin sclera (defective Type 1 collagen) Most common type of OI: Type 1

14. Cellulitis
1. Most common cause of orbital cellulitis: Staphylococcus aureus
1. LIFE THREATENING - EMERGENT OPHTHALMOLOGY CONSULT
2. Most common cause of periorbital (preseptal) and orbital infections: Staph aureus, Strep pneumo, and H. flu

Orbital Cellulitis	Periorbital (preseptal) Cellulitis
Gross lid edema, chemosis Toxic, febrile Proptosis, limitation of ocular mobility +/- decreased vision	Lid edema, chemosis ONLY NO proptosis, limitation of motility, or decreased vision

15. Open Globe Injuries
1. SX: decreased visual acuity, IOP (“Squishy eye”), bloody chemosis, visible wound of cornea/sclera, change in anterior chamber depth, displacement of pupil or shape, prolapse of ocular tissue (brown)
2. Lateral canthotomy contraindicated if suspected ruptured globe!
16. Orbital Compartment Syndrome
1. SX: Pain, eccyhmosis, bloody chemosis, resistance to retropulsion
1. Afferent pupillary defect (APD)
2. Increased IOP
17. Most common pathogens causing bacterial conjunctivitis: Staph aureus, Strep pneumo, H. flu
18. Most common cause of vision loss in patients 24-70 - Diabetic retinopathy
19. Most common cause of vision loss in patients 65+ - Age related macular degeneration (ARMD)
1. Most common cause of drusen - ARMD
20. Most common cause of exudates: Diabetes
21. Viral conjunctivitis - most commonly caused by Adenovirus
22. Red-green color blindness - one of the most common genetic disorders, affecting 7% of all males
23. Most common findings associated with orbital floor fractures: diplopia, globe lowering, numbness over the cheek (V2)
24. Most common causes of preventable vision loss: amblyopia (lazy eye), diabetic retinopathy, glaucoma
25. Marcus Gunn Pupil (Afferent Pupillary Defect) - due to optic nerve damage or retinal detachment
1. DX: Swinging Flashlight Test - decreased bilateral pupillary constriction when light shown in affected eye
2. Most common conditions: ischemic optic neuropathy (ION), glaucoma, optic neuritis
26. Seidel Test - assesses the presence of anterior chamber leakage in cornea, including post-trauma, corneal perforation or degeneration
27. Tangential Light Test - determines the presence of narrow angle glaucoma or perforating corneal injury; if part of the iris is in the shadow, the angle is narrow
28. Cycloplegics vs. Sympathomimetics
1. Cycloplegics - inhibits parasympathetic stimulation which constricts the iris and inhibits the ciliary muscle, paralyzing the ciliary muscle and causing loss of accommodation (ex. atropine and cyclopentolate, scopolamine, tropicamide)
2. Sympathomimetics -  stimulates iris’ dilator muscle

Bilateral optic disk swelling	Unilateral optic disk swelling
Raised intracranial pressure, malignant hypertension	Optic neuritis, ION, central retinal vein occlusion, intracranial optic nerve compression, posterior scleritis

4. Nose

Acute Viral Rhinosinusitis (common cold, URI)	Influenza	Sinusitis
Etiology: adenovirus Incubation: 2-4 d (3 day shed) Direct contact, droplets	Influenza virus Incubation: 1-4 d (infectious day before to 5 days after onset)	MC Etiology: antecedent viral URI, allergies, tumors, FB, deviated septum or polyps MC sinus: maxillary (cheek pain), ethmoid (retro orbital pain), frontal (lower forehead) MC pathogens: S. pneumo, H. flu, M. Cat
Const SX: Fever, chills, malaise Rhinorrhea - clear, watery Nasal congestion, sneezing Sore throat, non-prod cough Myalgia, headache PE: low fever, nasal/throat erythema, congested turbinates/discharge, sinus tenderness, cervical LAD	Abrupt onset fever Sore throat, retro-orbital headache, myalgias, malaise, nonproductive cough PE: fever, clear nasal discharge, pharyngeal erythema, cervical LAD	Major Symptoms Facial pressure or pain worse with bending forward Nasal obstruction, discharge (purulent), hyposmia Minor Symptoms Fever, fatigue Headache, halitosis, dental pain, cough, ear pressure 2 Major OR 2 Minor + 1 Major PE: purulent discharge, PND, halitosis, sinus tenderness, transillumination of sinuses
Resolves 5-8 days Analgesics: ASA, Tylenol, NSAIDs Topical analgesics - Chloraseptic Nasal saline washes, humidifier Decongestants - Sudafed, Afrin Mucolytic - Mucinex Antihistamines - Benadryl, Claritin, Zyrtec, Allegra	Symptoms last 3 days to 2 weeks Antipyretics, bedrest Oseltamivir (Tamiflu) within 40 hours of symptom onset IM/ID Vaccine for anyone >6 months up to 5 years and >50 years old Nasal spray: non-preg 2-49	Acute: lasts <30 d with complete resolution Subacute: 30-90 d with complete resolution Chronic: >90 d with persistent symptoms Non-contrast CT Scan - first line (chronic, unresponsive) Sinus aspirate culture - gold standard First line: Amoxicillin, Cefdinir (Omnicef) 10-14 d Beyond 2 W: Augmentin, Cefuroxime Chronic: add inhaled steroids Severe: Levaquin, Bactrim PCN Allergy: Azithro, Clarithro
Hydration, humidifiers, saline sprays Decongestants: topical or PO Analgesics: NSAID, Tylenol If allergic: nasal steroids, antihistamines Refer to ENT immediately: changes in vision, mentation, or periorbital edema

1. Sinusitis - Maxillary most commonly affected, followed by ethmoid
1. Most common etiology for acute sinusitis: antecedent viral URI
2. Most common bacterial pathogens: strep. pneumo, H. flu, M. cat.
2. Orbital Cellulitis - associated with ethmoid sinus
1. SX: fever, eyelid edema, ptosis, proptosis, chemosis
3. Osteomyelitis - Frontal sinus most commonly affected
1. SX: fever, headache, doughy edema over bone, large forehead abscess
2. Pott’s puffy tumor
4. Allergic rhinitis (Type 1 Allergic RXN) - Boggy blue turbinates and nasal swab showing eosinophils
1. Initially IgE mediated, then recruits neutrophils, eosinophils, lymphocytes
2. SX:
1. Irritative: sneezing, itching, rhinorrhea
1. TX: antihistamines
2. Congestive: congestion, stuffiness
1. TX: decongestant (Sudafed, Afrin), anti-leukotriene
3. DX: RAST Test or Skin Allergy Test (more sens/spec)
4. First line: antihistamines, topical nasal steroids
5. Adjunctive: mast cell stabilizer
5. Vasomotor rhinitis - most common in anxious patients (non-allergic, unknown etiology), causes congestion & profuse rhinorrhea
1. TX: topical anticholinergics (ipratropium bromide)
6. Aspirin induced asthma (Samter's triad) - aspirin precipitates acute bronchospasm in patients with nasal polyps and asthma
1. Triad: nasal polyps, asthma, Aspirin-sensitivity
7. Nasal polyposis - usually bilateral; if unilateral, consider tumor; congestion & fullness
8. Rhinitis medicamentosa - rebound rhinitis following sudden cessation of topical decongestants (3-5 d)
1. SX: extreme nasal obstruction, pressure
2. “3 sprays, 3 times daily, for 3 days”
9. Squamous cell carcinoma - most common form of nasopharyngeal cancer
10. Most common cause of Septal Hematoma: nasal trauma
1. Saddle nose deformity - complication if untreated
11. Toxic Shock Syndrome (TSS) - previous nasal packing for anterior nosebleed
1. Etiology: toxin releasing S. aureus
2. SX: fever, nausea, vomiting, and hypotension
12. Most common cause of Epistaxis: digital trauma
1. “Colder, older, males” - most commonly occurs in colder months, older population, and males
2. Most common type of epistaxis: anterior epistaxis

Anterior epistaxis	Posterior epistaxis
Origin: Kiesselbach plexus Visualized easily TX: anterior nasal pressure	Origin: sphenopalatine artery’s lateral nasal branch Unable to visualize bleeding site, blood trickles down oropharynx and both sides of nose, unable to control with pressure TX: posterior-anterior packing or balloon tamponade device

5. Mouth/Throat
1. Centor Criteria for diagnosis of Strep Throat - Fever > 38 C, lack of cough, tonsillar exudate, tender anterior cervical LAD (3 out of 4 present, sensitive)

Bacterial Pharyngitis	Viral Pharyngitis	Infectious Mononucleosis
Etiology: Strep (GAS), Staph Incubation: 12 h - 4 d	Etiology: Coxsackie A&B, adenovirus, rhinovirus, echovirus, HSV	EBV or CMV Prodromal: 2-5 d (infectious)
SX > 1 week Odynophagia, dysphagia,  cough, hoarseness Rhinorrhea Fever, anterior cervical LAD (60%) +/- Purulence PE: tonsillar exudates	SX < 1 week Odynophagia, dysphagia, cough, hoarseness Rhinorrhea LAD, myalgia, malaise, fever	Exudate - think EBV Posterior cervical LAD Splenomegaly, hepatomegaly Sore throat Fever, malaise “hairy leukoplakia” - lateral tongue; will not scrape off
Rapid strep test (specific, less sensitive) - not required		CBC - lymphocytosis Mono-spot test (specific, not sensitive), reveals previous infection IgM & IgG titer to VCA, EA, EBNA (2-3 d for results)
Hydration 1: Benzathine PCN, Pen-V K 2: Clinda, Amox, Cefuroxime 3: Levaquin, Cipro Do not treat with Ampicillin: causes measles-like rash & type 3 immune-complex GN	Supportive: hydration, Tylenol HSV: acyclovir	Supportive Ampicillin Avoid contact sports & being hit in abdomen

Peritonsillar abscess	Adolescents or adults Incubation: 2-3 d Hot potato voice (dysarthria) Drooling, sore throat, low fever, trismus (lock jaw), odynophagia Ipsilateral otalgia Unilateral swelling of soft palate, uvula deviation Tonsillitis		IV hydration IV Clindamycin or PCN Intraoral drainage Elective tonsillectomy
Retropharyngeal Abscess	Etiology: B-hemolytic Strep Common 6 M to 3 y/o Prefer supine position Dysphagia, muffled voice, stridor, drooling Fever, dyspnea, stiff neck Cervical LAD	Lateral XR: wide retropharyngeal space at C4, air/fluid level PE: Uvula/tonsil displaced away from abscess	ABCs IV antibiotics ICU admission
Diphtheria	Corynebacterium diphtheriae (gram + rod) - exotoxins MC: first decade of life Sore throat, dysphagia, fever, tachycardia Gray-black membrane - do NOT try to remove		Antitoxin (CDC)
Gonococcal Pharyngitis	N. gonorrhoeae Asymptomatic or presents like bacterial/viral pharyngitis Tonsillar hypertrophy LAD		IM Ceftriaxone Treat for Chlamydia - Azithromycin
Oral Candidiasis (Thrush)	MCC: Candida albicans Cheesy, creamy mucosal plaques	Gram stain Budding yeast with pseudohyphae Can be scraped off	Oral Nystatin (swish & swallow) PO Fluconazole
Oral Cancer	Age: 50-60 with PMH of ETOH or smoking SX: weight loss, localized pain Odynophagia, dysphagia, oral mass, LAD, CN involvement		Refer
Parotitis	Non-suppurative: paramyxovirus (mumps), influenza A, Coxsackie A, CMV, echovirus, Sjogren’s Suppurative: Staph, strep SX: Pain, swelling, pus from Stensen's duct (parotid)	CT	1. Clindamycin 2. Cefuroxime, Amox Hydration, warm compress, lemon drops

2. Infectious Mononucleosis (EBV, CMV) - infects B-lymphocytes
3. First line treatment for Group A beta-hemolytic strep: PCN
1. PCN Allergy: Clindamycin or Erythromycin
2. Most common sequelae: post-strep GN, rheumatic heart disease
4. Dental abscess treatment - Clindamycin or Augmentin
5. Dental caries - most common chronic disease in children
6. Most common cause of xerostomia: medications (antihistamines and antidepressants)
7. Most common form of glossitis: vitamin B12 deficiency
8. Nutritional deficiencies leading to aphthous ulcers: B12, Folate, Iron
9. Sialadenitis - most commonly affects the submandibular gland due to stasis of flow of saliva
1. Infectious (children, post-op) - most commonly S. aureus, Strep pneumo, E. coli, H. flu
2. Obstructive (more common form) - most common in middle-aged men
10. Sialolithiasis (mealtime syndrome) - pain and swelling of submandibular gland worse with thought, smell, sight or taste of food
11. Ludwig’s Angina - abscess of the submandibular, submental, or sublingual space
1. Most common origin: lower second and third molar
2. Most common agents: hemolytic strep, staph, mixed anaerobic/aerobic bacteria
12. Alveolar osteitis (dry socket) - severe pain, foul mouth odor, and taste several days after tooth extraction
13. Most common site affected in oral cancer: lateral ventral tongue
14. Oropharyngeal thrush - most common oral manifestation of AIDS
15. Epiglottitis - most common in 2-4 year old boys
16. Viral pharyngitis - most common cause of pharyngitis
1. Most commonly caused by Coxsackie A & B
17. Most common viral agents of laryngotracheitis - parainfluenza virus I, II, III
1. Most common bacterial agents: S. aureus, Strep. pneumo
18. Herpangina - caused by Coxsackievirus group A
19. Sjogren syndrome - most common in women 50+
1. SX: diminished lacrimal and salivary gland secretion (dry mouth and eyes), salivary gland enlargement, arthritis
2. Etiology: lymphatic infiltration of lacrimal/salivary glands

Epiglottitis	MC: 2-4 y/o boys Etiology: HIB (children) Child: fever, irritable, dysphonia, dysphagia Drooling, inspiratory stridor Adults: recent viral URI, severe pain, dysphagia, drooling, muffled voice	Clinical DX High WBC, neutrophils Lateral view: “Thumb print sign”	ABCs ABX: 3rd Gen Cephalosporin, Unasyn
Acute Laryngitis	Etiology: M. Cat, H. flu, N. gonorrhoeae Non-infectious: reflux Sudden onset hoarseness, rhinorrhea, cough, sore throat		Self-limiting: 2 weeks Voice rest, hydration Cough suppression - no antihistamines
Chronic Laryngitis		> 2 weeks	Refer