Chapter 20: Otolaryngology

A 2-year-old is brought to your office by her mother who is concerned that she has been pulling at her left ear since late last night and has a fever of 101.3°F. She has had recurrent bouts of these symptoms, the last of which was 9 months ago. Each time, the symptoms resolved with one "shot." She is alert and interactive. She has some evidence of mucoid discharge from her nares bilaterally.

Question 20.1.1 Each of the following findings is diagnostic of acute otitis media (AOM) EXCEPT:

A) Profuse, purulent ear discharge without other evidence of otitis externa.

B) Air–fluid level behind the tympanic membrane (TM) with marked redness of the TM and poor movement with pneumatic otoscopy.

C) Bulging, thickened yellow and red TM that does not move well with pneumatic otoscopy.

D) Bubbles in fluid behind the TM with impaired mobility of the TM on pneumatic otoscopy.

E) Yellow, opaque TM, poor movement with pneumatic otoscopy, and substantial ear pain.

Answer 20.1.1 The correct answer is "D." Suspected ear infections drive many parents to bring their children to a family physician. There may be fluid in the middle ear that is not infected (otitis media with effusion [OME]). In order to diagnose AOM, you need evidence of fluid in the middle ear and inflammation, and the symptoms should be acute (starting in the last few days). Middle ear effusion is diagnosed by (1) bubbles and/or air–fluid level behind the TM or (2) two or more of the following: decreased or absent TM movement with pneumatic otoscopy, opacification of the TM, and discoloration of the TM (yellow, white, blue). These findings get you to OME but not AOM. To diagnose AOM, you will need to have OME with evidence of acute inflammation, such as marked pain, thickened and/or bulging TM, and reddened TM. For these reasons, "B," "C," and "E" are examples of AOM. "A," purulent otorrhea without evidence of otitis externa, would be the one exception where you can diagnose AOM without even seeing the TM. "D" describes OME without inflammation.

Your patient's left TM is opaque, red, and immobile upon pneumatic otoscopy.

Question 20.1.2 Each of the following factors increases her risk for developing otitis media EXCEPT:

A) She attends day care

B) Her mother smokes inside the house

C) The patient is a female

D) Patient still uses a pacifier

Answer 20.1.2 The correct answer is "C." The following are known risk factors for the development of AOM: day care attendance, smoking inside the home, male gender, pacifier use, children in developing countries, age between 6 and 18 months, lack of breastfeeding, and going to bed with a bottle.

Question 20.1.3 Which of the following findings is reliably found in patients with AOM?

A) Fever

B) Ear pulling

C) Irritability

D) Rhinitis

E) None of the above

Answer 20.1.3 The correct answer is "E." None of the above is reliably found in patients with AOM. Other unreliable factors include vomiting, diarrhea, and cough. The presence or absence of any of these findings is not helpful in making the diagnosis of otitis media. Note that while ear pain is a symptom of inflammation, it is a relatively weak predictor of AOM and must be accompanied by other findings as listed above. However, pneumatic otoscopy or otoscopy plus tympanometry is the way to make the diagnosis, but always make sure that you have a good seal or you run the risk of a "false-positive" finding.

This patient has not had any problems with otitis media for at least 9 months, has not been on antibiotics during that time, is not in day care, and has no allergies. You opt to treat her with an antibiotic.

Question 20.1.4 What is the most appropriate treatment for this patient?

A) Amoxicillin 40 mg/kg/day divided TID

B) Amoxicillin 80 to 90 mg/kg/day divided BID

C) Ceftriaxone 50 mg/kg IM once

D) Azithromycin 10 mg/kg for 1 day then 5 mg/kg for days 2 to 5

E) Amoxicillin/clavulanate 40 to 80 mg/kg/day divided BID

Answer 20.1.4 The correct answer is "B." Amoxicillin is the first-line treatment of AOM. The dose is 80 to 90 mg/kg/day in all patients whether antibiotic-naive or not. More broad-spectrum drugs such as ceftriaxone and amoxicillin/clavulanate should be reserved for patients who fail initial therapy with a first-line drug or have a penicillin allergy.

Question 20.1.5 Which of the following statements best characterizes the role of antibiotics in the treatment of AOM?

A) Antibiotics have been shown to reduce suppurative complications of AOM, such as mastoiditis, in developed countries.

B) The majority of patients with AOM benefit from the use of antibiotics.

C) The use of antibiotics for AOM reduces hearing loss and benefits language development.

D) With or without antibiotics, about 75% of children have resolution of AOM symptoms after 7 days.

E) All of the above are true.

Answer 20.1.5 The correct answer is "D." The benefit of antibiotics for most children with AOM is marginal and the number needed to treat (NNT) is about 12; thus, the option exists to observe and not even give antibiotics in children ≥2 years who have mild symptoms, are immunocompetent, and have good follow-up. The rest of the statements are incorrect. Antibiotics do not reduce suppurative complications in developed countries, but they do seem to prevent suppurative complications in developing countries where sanitation and healthcare access are not optimal. "B" is incorrect. The benefit is limited to a 5% absolute reduction in those who have pain at days 2 to 3 (11.6% without antibiotics vs. 15.9% with antibiotics). "C" is incorrect as well, since treating with antibiotics does not impact these outcomes in any way.

You prescribe amoxicillin for 10 days and suggest acetaminophen for comfort. A few days later, the patient's mother calls to say that she is no better. You ask her to come in to clinic for evaluation.

Question 20.1.6 When treating AOM, which of these individuals should be considered a treatment failure and switched to another antibiotic?

A) A patient with a fever that continues at 24 hours after starting an oral antibiotic

B) A child who is still tugging at his ear 5 days into a course of antibiotics

C) A symptomatic child who still has a bulging, red, immobile TM 3 days after starting antibiotics

D) A child who continues to have rhinorrhea 1 week after starting antibiotics

E) All of the above

Answer 20.1.6 The correct answer is "C." You should consider switching to a different antibiotic in patients who remain symptomatic at 3 days and who continue to have positive findings on pneumatic otoscopy. Symptoms are not enough: they are unreliable. Remember, since most of these are viral infections, you are not doing a whole lot of good with your antibiotics anyway. "A" is incorrect because 24 hours is not sufficient to determine if a particular antibiotic will be effective. "B" is incorrect because children pull at their ears for a number of reasons besides AOM (such as "Ha! I just discovered I have ears!"). "D" is incorrect. If you chose this one, back to Microbiology 101 for you! Rhinorrhea does not respond to antibiotics and is most likely not bacterial in origin.

She returns with persistent pain and fever after taking amoxicillin for 3 days. On examination, you find evidence of persistent AOM. You switch the patient to your favorite second-line antibiotic. You see her back in 2 weeks for an ear check and find complete resolution. The mother asks what she could do to avoid these troublesome infections in the future.

Question 20.1.7 All of the following have been shown to reduce the incidence of recurrent otitis media EXCEPT:

A) Antibiotic prophylaxis

B) Conjugate pneumococcal vaccine

C) Tympanostomy tubes

D) Tonsillectomy

E) Influenza vaccine

Answer 20.1.7 The correct answer is "D." Primary tonsillectomy has not been shown to reduce the recurrence of otitis media. However, adenoidectomy with or without tonsillectomy will reduce the rate of recurrent otitis media in patients who already have tympanostomy tubes. "A," the use of antibiotic prophylaxis, will reduce recurrent otitis media. Antibiotic prophylaxis should be considered in the patient who has had ≥3 episodes of otitis media in 6 months or ≥4 episodes in 12 months. Reasonable choices for antibiotics include amoxicillin and trimethoprim/sulfamethoxazole. Give half of the usual daily dose. This is generally given at bedtime. Often, antibiotics can be stopped during the summer since an upper respiratory infection (URI) is the precipitant of most cases of otitis media. Pneumococcal vaccine (e.g., Prevnar) will reduce the risk of recurrence in children with severe and recurrent AOM. The same is true of influenza vaccine. Also recommended to reduce the frequency of AOM: avoid pacifier use, avoid bottle propping at night, avoid smoke exposure, and encourage breast feeding for at least the first 6 months of life.

The patient returns 4 weeks later with the mother saying, "She is still pulling at her left ear." There are no other complaints. On examination, you find the left TM is without redness or opacity but there is still a fluid level. The right ear examination is unremarkable.

Question 20.1.8 What is your next diagnostic step?

A) Pneumatic otoscopy

B) Hearing test

C) Tympanostomy

D) No further diagnosis needed—treat with antibiotic

Answer 20.1.8 The correct answer is "A." Even though we all think we can do it well, the diagnosis of otitis media is fraught with problems. Pneumatic otoscopy should be done in essentially all patients but especially in those in whom long-term therapy is being considered. Remember that fluid can persist for a month or more after an otitis media.

On your examination, the TM does not move with insufflation. The patient's mother asks you if the child should have tubes placed.

Question 20.1.9 Which of the following is NOT a criterion for tympanostomy tubes?

A) Chronic bilateral effusions for more than 3 months with unilateral hearing loss

B) Failure of antibiotic therapy to prevent recurrent otitis media

C) Language delay secondary to otitis media

D) Greater than 20 dB hearing loss bilaterally

Answer 20.1.9 The correct answer is "A." Patients should meet the criteria listed above before being considered for tympanostomy tubes. Note that this requires that patients also meet the criteria for prophylactic antibiotic therapy (≥3 episodes of AOM in 6 months or ≥4 episodes in 12 months). A modification of "A" is also a criterion: chronic bilateral effusions for more than 3 months with bilateral hearing loss. Although included as a criterion, there is no evidence that tympanostomy tubes improve language development in the short or long term.

If fluid persists in the middle ear after AOM, it is termed OME.

Question 20.1.10 Which of the following interventions has proven benefit in patients with OME?

A) Oral decongestants

B) Oral antihistamines

C) Prolonged treatment (≥1 month) with oral antibiotics

D) Oral corticosteroids

E) None of the above

Answer 20.1.10 The correct answer is "E." For persistent OME, there are no useful medical interventions (although there is some data that amoxicillin-clavulanate leads to normal tympanometry 2 weeks before it is achieved with placebo [JAMA Pediatr. 2014 May 5]). Autoinflation ("eustachian tube exercises" or forced exhalation with closed nose and mouth) is often recommended but has not shown a benefit (and try explaining how to do this to a 6-month-old). Patients may benefit from surgical intervention (see the question about tympanostomy tubes above).

Objectives: Did you learn to…

• Diagnose otitis media appropriately?

• Initiate treatment in a patient with otitis media?

• Recognize failed antibiotic therapy and choose a new antibiotic for otitis media?

• Describe prevention strategies for recurrent otitis media?

• Recognize indications for tympanostomy tube placement?

Which of the following can cause ear pain?

A) Temporomandibular joint (TMJ) syndrome

B) Cervical spine degenerative arthritis

C) Cranial nerve lesions (5, 7, 9, or 10)

D) Bell palsy

E) All of the above can cause ear pain

The correct answer is "E." All of the above can cause ear pain. A more complete list is given in Table 20-1. The main point here is that not all ear pain is otitis media.

A 23-year-old female college student presents to your clinic complaining of ear pain. She is on the swimming team and notes that this pain occurs during swimming season. The pain is increased by motion of the pinnae. The external auditory canal is erythematous, edematous, and exquisitely tender when you try to use the otoscope to examine her TM. There is whitish debris in the external auditory canal.

Question 20.2.1 The most likely organism involved in this patient's disease is:

A) Streptococcus

B) Haemophilus

C) Moraxella

D) Pseudomonas

E) Parainfluenza

Answer 20.2.1 The correct answer is "D." This patient likely has otitis externa. The most common pathogenic organism isolated in cases of otitis externa is Pseudomonas (guess those flagellated bacteria sure can cause swimmer's ear!) followed closely by Staphylococcus aureus. However, up to one-third of cases of otitis externa are polymicrobial.

Question 20.2.2 Which of the following is/are considered first-line treatment for otitis externa?

A) Oral ciprofloxacin

B) Acetic acid ear drops

C) Polymyxin and neomycin combination ear drops

D) A and C

E) B and C

Answer 20.2.2 The correct answer is "E." Otitis externa can be treated with a wide array of topical agents. One option is to acidify the external ear canal. Neither Pseudomonas nor Staphylococcus species can thrive at an acidic pH. Thus, acetic acid drops (e.g., VoSol^®) can be used: they are cheap and effective. Another approach is to use a topical antibiotic. Polymyxin/neomycin combinations (e.g., Polysporin) are safe and effective. A number of other antibiotic preparations are available as well. Alcohol-based solutions are another alternative. "A" is incorrect because oral treatment is not indicated for simple otitis externa. However, topical ciprofloxacin may be used.

Question 20.2.3 This patient is concerned about recurrences of her otitis externa. What advice can you give her?

A) Avoid exposure by putting a petroleum jelly (e.g., Vaseline) impregnated cotton plug in her ear before swimming

B) Use a blow dryer on her ear after swimming

C) Instill a 50/50 mixture of alcohol and vinegar in her ears after swimming

D) Avoid swimming when she has active disease

E) All of the above

Answer 20.2.3 The correct answer is "E." All of the above can be used to minimize disease recurrence. The benefit of "C" is less certain.

You treat the patient with neomycin/polymyxin drops, and the symptoms persist and possibly worsen a little after 5 days. The patient has no fever and no signs of cellulitis around the ear.

Question 20.2.4 Of the following possibilities, which is the LEAST likely to explain her persistent symptoms?

A) Resistant organisms

B) Noncompliance with medical recommendations

C) Misdiagnosis of otomycosis

D) Development of contact dermatitis

Answer 20.2.4 The correct answer is "A." Several things could explain her persistent symptoms. First, the patient should be questioned regarding compliance. Is she still swimming despite advice to the contrary? Is she using the drops at least TID and letting them soak into her ear? Another issue is the development of an allergic reaction, especially in response to neomycin (up to 35% of patients treated chronically with topical neomycin develop a dermatitis). Patients may also "fail" treatment for otitis externa due to misdiagnosis. Otomycosis, a fungal infection of the auditory canal, causes redness, discharge, itching, and sometimes pain. With respect to "A," treatment failures due to antibiotic resistance are uncommon, and as noted above, antibiotics are not even necessary in the treatment of most cases of otitis externa.

On examination, you notice fine, white, cotton-like fibers filling the ear canal along with the other debris. The examination is otherwise unchanged.

Question 20.2.5 What is your next step?

A) Admit for intravenous (IV) antibiotic and antifungal therapy

B) Clean the ear canal under direct otoscopy and add oral amoxicillin/clavulanate to her medication regimen

C) Clean the ear canal under direct otoscopy and add topical clotrimazole 1% to her medication regimen

D) Order CT or MRI of the head and neck to rule out abscess

E) Refer to an otolaryngologist

Answer 20.2.5 The correct answer is "C." On examination, you have identified signs of otomycosis. It could be that the otomycosis was present initially or developed in the interval with antibiotic administration. Otomycosis is usually due to Aspergillosis; Candida only represents 10% to 20% of cases. Thorough cleaning of the ear canal is an important part of therapy. A topical antifungal that is active against Aspergillosis is recommended (e.g., clotrimazole, miconazole, and nystatin).

Objectives: Did you learn to…

• Identify bacterial pathogens implicated in otitis externa?

• Diagnose and treat a patient with otitis externa?

• Recommend prevention strategies for otitis externa?

• Determine why treatment for otitis externa may fail?

A 59-year-old male presents with a 3-week history of hoarseness. He denies sore throat or heartburn. He has had no fevers, night sweats, or weight loss. When he initially presented a week ago, your partner treated him empirically for postnasal drainage. He smokes 2 packs of cigarettes per day and drinks alcohol daily. On examination, his vital signs are normal. His voice sounds husky. You find no other abnormalities (besides the burn holes in his shirt and the pint of whisky in his back pocket).

Question 20.3.1 The best next step in the management of this patient is:

A) Empiric antibiotic treatment

B) Empiric proton pump inhibitor treatment

C) Direct laryngoscopy

D) Esophagogastroduodenoscopy (EGD)

E) Neck MRI

Answer 20.3.1 The correct answer is "C." The first concern is to rule out malignancy, so the larynx should be visualized. Direct laryngoscopy is a straightforward office procedure and takes only a few minutes. If the equipment and expertise are not available in your office, referral to an otolaryngologist is appropriate. Although there are no firm guidelines, some authors recommend direct laryngoscopy after 2 weeks of hoarseness in patients who are at risk (older patients and those who have a history of tobacco and alcohol use). Since laryngoscopy is such an available, low-cost, low-risk procedure, it is hard to justify postponing it for any patient at risk for malignancy. Therefore, "A" and "B" are incorrect, as further empiric medication trials will only delay laryngoscopy. Besides, antibiotics are not indicated for the lone symptom of hoarseness. In other instances (e.g., low-risk patient with heartburn and hoarseness), empiric proton pump inhibitor therapy may be more practical, since gastroesophageal reflux is a common cause of hoarseness. "D" is incorrect. In this case, direct laryngoscopy is preferred to EGD. Finally, "E" is incorrect. Neck MRI is not indicated in the initial evaluation of hoarseness, but it might be used for follow-up after laryngoscopy or to investigate a neck mass.

Question 20.3.2 All of the following are potential causes of hoarseness EXCEPT:

A) Vocal cord mass

B) Infectious laryngitis

C) Hypothyroidism

D) Lung malignancy

E) A vow of silence

Answer 20.3.2 The correct answer is "E." Far from being a cause of hoarseness, voice rest is often recommended for patients with hoarseness due to overuse (e.g., singers). All of the other options are known to cause hoarseness. Of particular note is "C": hypothyroidism can result in an accumulation of connective tissue elements, basically myxedema, in the vocal cords. Intrathoracic processes such as lung cancer can present with hoarseness (see "Helpful Tip" below).

Characterizing the nature of the patient's hoarseness can be helpful in narrowing the differential diagnosis. The voice changes may be further characterized as breathy, low-pitched, strained, tremulous, or hoarse. A "breathy" voice may be seen with vocal cord paralysis, abductor spasm, or functional dysphonia. A "low-pitched" hoarseness might be due to edema (seen in smokers), vocal abuse, reflux laryngitis, vocal cord paralysis, or muscle tension dysphonia. A "strained" voice may occur with adductor spasm, muscle tension dysphonia, or reflux laryngitis. A "tremulous" voice occurs in parkinsonism, essential tremor, spasmodic dysphonia, or muscle tension dysphonia. A "hoarse" voice may be due to vocal cord lesions, muscle tension dysphonia, and reflux laryngitis. Vocal fatigue (loss of volume over time) may also be noted (especially during presidential campaigns) and is often caused by muscle tension dysphonia, vocal cord paralysis, reflux laryngitis, or vocal abuse. However, one cannot eliminate a cause of hoarseness based on these characteristics.

On direct laryngoscopy, you notice a mass lesion on the right vocal cord. You refer the patient to an otolaryngologist. The patient asks if you think that the mass is cancer. Because you are compassionate and also not entirely certain, you avoid saying, "Oh, heck yeah. That's cancer all right." You try to be more optimistic.

Question 20.3.3 However, you want to remind him of risk factors for laryngeal cancer, which include all of the following EXCEPT:

A) Tobacco smoking

B) Alcohol use

C) Epstein–Barr virus (EBV)

D) Family history of head and neck cancers

E) Male sex

Answer 20.3.3 The correct answer is "C." EBV infection is associated with the development of nasopharyngeal cancer, not laryngeal cancer. Additionally, EBV infection has been associated with Burkitt lymphoma (children in Africa), Hodgkin disease, and non-Hodgkin lymphoma. Tobacco and alcohol use are independent risk factors for the development of most types of head and neck cancers (oral, laryngeal, etc.), and the two substances may act synergistically in the promotion of these cancers. A family history of head and neck cancer has a weaker association, but the association is still present. Males are two to four times more likely to have head and neck cancers compared with females. These risk factors sound a lot like our patient.

Question 20.3.4 If this patient is found to have cancer, what pathologic variant is most likely?

A) Adenocarcinoma

B) Squamous cell carcinoma

C) Schneiderian papilloma

D) Neuroblastoma

Answer 20.3.4 The correct answer is "B." Upon pathologic examination, the great majority of head and neck cancers are found to be squamous cell carcinomas. Adenocarcinoma may arise from the gastrointestinal tract and could be seen on laryngoscopy but would rarely occur on the vocal cords. Schneiderian papillomas ("C") are polyps that arise from the nasal and sinus mucosae, are associated with HPV, and may transform into carcinomas. Neuroblastomas ("D"), which arise from the sympathetic nervous system, rarely occur in the head and neck region.

During your examination of the oropharynx, you also encountered a small, white, indurated plaque on the underside of the tongue. When you scraped the plaque with a tongue blade, nothing happened (see Fig. 20-1).

FIGURE 20-1. From Usatine RP et al., eds. Color Atlas of Family Medicine. 2nd ed. New York: McGraw-Hill; 2013. Courtesy of Richard P. Usatine, MD.

Question 20.3.5 This lesion is most appropriately described as:

A) Squamous cell carcinoma

B) Candida albicans

C) Leukoplakia

D) Geographic tongue

E) Aphthous ulcer

Answer 20.3.5 The correct answer is "C." Leukoplakia is a premalignant lesion of the oropharynx (about 5% will progress to cancer over 10 years). It occurs in response to trauma and/or exposure to irritants and carcinogens, having an especially strong association with smokeless tobacco (e.g., "snuff," "chew") use. In fact, the lesion could be squamous cell carcinoma ("A"), and it should be biopsied. However, it would be premature to diagnose the patient with squamous cell carcinoma, and the lesion is more accurately described as leukoplakia. "B," C. albicans lesions, may look just like leukoplakia (white plaques on oropharyngeal mucosa), but you should be able to scrape some of the plaques off with a tongue blade (although thrush can be remarkably adherent and may cause some bleeding). A trial of antifungal therapy may be appropriate if the lesion is low-risk and you suspect thrush but cannot scrape it off—but follow the patient closely and re-examine him. "D," geographic tongue, is so named because of the meandering white-bordered patches that occur on the dorsum of the tongue. It is most often asymptomatic, and the lesions vary in shape (or completely resolve) over time. Finally, "E," an aphthous ulcer, is just that—an ulcer, not a plaque. You should not confuse leukoplakia for an aphthous ulcer.

You receive a letter from the otolaryngologist stating the patient does indeed have squamous cell carcinoma of the larynx. The patient will be seen in consultation with an oncologist and presented at tumor board. His treatment may consist of surgery, chemotherapy, and/or radiation. Unfortunately, he lost the roll of the cosmic dice.

Objectives: Did you learn to…

• Generate a differential diagnosis for hoarseness of voice?

• Evaluate a patient with a voice complaint?

• Identify oral lesions, particularly leukoplakia?

• Recognize important issues in the prevention and treatment of head and neck cancers?

A 61-year-old man presents to your office complaining that over the last few months he cannot seem to understand what people are saying when they are standing to his left side. He also has episodes of "dizziness," especially when he changes position from sitting to lying and vice versa. He denies nausea and vomiting. He worked for 30 years in a factory and has had bilateral tinnitus for the last 10 years. He has had no previous hearing problems or evaluation. His past medical history is significant for CAD and hypertension. He takes atenolol, chlorthalidone, and aspirin. There is no family history of ear disease. On examination, both ears are normal in appearance. Weber test is best heard by the patient on his right side. Rinne test on both sides was negative (air conduction was greater than bone conduction).

Question 20.4.1 These findings are consistent with which type of hearing loss on the left?

A) Conductive

B) Sensorineural

C) Mixed

D) Selective

E) Unable to tell

Answer 20.4.1 The correct answer is "B." Hearing can be assessed in the office using the Weber and Rinne tests. The Weber test is performed by putting the tuning fork on the forehead and seeing if the sound lateralizes to one side or the other. In conductive hearing loss ("A"), the sound will be louder (i.e., the test will lateralize) to the "bad" side (e.g., the side with wax occluding the canal, otosclerosis). However, in sensorineural hearing loss, the sound will lateralize to the "good" side (e.g., the side not affected by a hearing problem).

The Rinne test is performed by comparing bone conduction (on the mastoid) to air conduction. Patients will notice poor air conduction versus bone conduction if there is a conductive hearing loss. Normal Rinne tests in both ears suggest that neither ear has conductive loss. Our patient, (or more likely his family) complains about decreased hearing on the left and the Weber test lateralizes to the right, and these findings point to a problem with sensorineural hearing loss in the left ear.

Question 20.4.2 Which of the following is LEAST likely to be responsible for this patient's hearing loss?

A) Ménière disease

B) Acoustic neuroma

C) Presbycusis

D) Otosclerosis

E) Noise exposure

Answer 20.4.2 The correct answer is "D." Otosclerosis is a bony overgrowth that involves the stapes and leads to conductive loss. Your patient has a sensorineural hearing loss. Ménière disease ("A") presents with the classic triad of hearing loss, tinnitus, and vertigo. These manifestations may be temporally separated with hearing loss, tinnitus, and vertigo occurring at different times. Patients with Ménière disease will note fullness in their ear, which resolves with the onset of vertigo. Typically, the vertigo will last for several hours. "B" is true. Sensorineural hearing loss can also be caused by an acoustic neuroma, a benign tumor that arises from cranial nerve VIII (acoustic nerve), and symptoms include unilateral hearing loss, vertigo, tinnitus, and disequilibrium. "C," presbycusis, is one of the most common causes of sensorineural hearing loss and is often thought of as the "normal" hearing loss that is associated with aging. Presbycusis manifests as an inability to hear high frequencies. This leads to problems with speech discrimination, especially in noisy environments (e.g., parties). It is typically symmetrical and may be associated with tinnitus. However, it may be unilateral, especially in those who have one ear turned toward noisy equipment in their job (e.g., farmers driving tractors and looking behind them—remember, this is being written in Iowa). See Table 20-2 for some causes of conductive and sensorineural hearing loss.

Question 20.4.3 What is the next step in the evaluation of this patient?

A) Audiogram

B) Brainstem evoked responses

C) MRI

D) Tympanogram

Answer 20.4.3 The correct answer is "A." An audiogram can further define the air versus bone conductance relationship, check speech discrimination, and define the frequency of hearing loss. Brainstem-evoked responses evaluate the neural pathways of hearing and, along with MRI, could be useful if tumor were higher on the differential. A tympanogram, which evaluates movement of the TM, might be useful if conductive hearing loss were suspected.

The audiogram confirms sensorineural hearing loss in the left ear. Because of the associated symptoms of vertigo, you order an MRI of the posterior fossa to rule out acoustic neuroma, and the results are negative. The patient continues to have episodes of vertigo, and the hearing loss on his left side persists. When probed further, he does in fact have an increase in tinnitus during his vertiginous episodes.

Question 20.4.4 You should consider all of the following treatments for this condition EXCEPT:

A) Salt, caffeine, and tobacco restriction

B) Diuretics (e.g., hydrochlorothiazide)

C) Intracochlear injection of gentamicin

D) Labyrinthectomy or endolymphatic sac shunt

E) H₂-blockers (e.g., cimetidine)

Answer 20.4.4 The correct answer is "E." The clinical picture now looks most like Ménière disease—a disease for which there is no cure. Luckily not all patients with Ménière disease will experience worsening of their condition over time, and up to 90% are able to maintain normal daily activities with optimal medical management. Few patients progress to debilitating disease. The mainstays of therapy include diet/lifestyle modification and diuretics. Outside the United States, betahistine, an H₁-blocker, is commonly used (to theoretically reduce endolymphatic hydrops), but H₂-blockers have no role in therapy. A more aggressive approach is indicated in patients with more severe disease, and this might include surgery, intracochlear gentamicin (to kill the nerve and reduce vertigo), labyrinthectomy, or endolymphatic sac shunt.

Objectives: Did you learn to…

• Evaluate a patient with hearing loss?

• Describe differences between conductive and sensorineural hearing loss?

• Generate a differential diagnosis for hearing loss?

• Diagnose and treat a patient with Ménière disease?

A 7-year-old female is brought to your office by her concerned parents. Over the last 24 hours, the patient has developed pain in her mouth, drooling, and fever. She refuses to eat. On examination, she is febrile and slightly tachycardic. The sublingual space is swollen and tender bilaterally. The tongue is elevated in the mouth. There are no ulcerations. There is well-demarcated erythema, brawny edema, tenderness, and warmth in the submandibular area. Her respirations are normal, and her lung sounds are clear.

What is the next step in the evaluation and management of this patient?

A) Reassurance, oral rehydration, and analgesics

B) Oral antibiotics

C) MRI of the head and neck

D) IV antibiotics

E) Intubation and mechanical ventilation

The correct answer is "D." This patient is presenting with classic signs and symptoms of Ludwig angina (related neither to angina nor to Ludwig von Beethoven). These include brawny edema, tenderness and warmth in the submandibular region along with elevation of the tongue. The term Ludwig angina is reserved for infection of the submandibular and sublingual areas. The status of the patient's airway must be addressed, of course. This patient is stable and her airway appears patent; therefore, "E" is incorrect. "A" and "B" are incorrect because patients with Ludwig angina may experience rapid progression of symptoms and should be treated with IV antibiotics and observed in the hospital. Finally, "C" is incorrect because the diagnosis of Ludwig angina is clinical. Also, MRI may delay antibiotic treatment and is unlikely to be of any value, unless you suspect the presence of an abscess. Even then CT would be the examination of choice. Surgical intervention may be necessary.

A 30-year-old man comes to your office complaining of a swollen neck. He noticed it 3 weeks ago when he was stung by a bee on the right side of his anterior neck. The area has continued to enlarge. It is no longer tender. It was erythematous after the sting, but the redness has resolved. He notes no other symptoms. On examination, you find a 2-cm firm, somewhat tender, enlarged lymph node in the right anterior cervical chain. The node is mobile, nonfluctuant, with no surrounding erythema. There are also shotty anterior and posterior cervical nodes in addition to the larger node described. You find neither splenomegaly nor lymphadenopathy of the supraclavicular, axillary, and inguinal regions.

Question 20.5.1 What elements of the presentation make malignancy LESS likely?

A) The node is freely mobile

B) The node is only 2 cm

C) The node is associated with trauma (bee sting)

D) The node is tender

E) All of these help to rule out malignancy

Answer 20.5.1 The correct answer is "A." Nonmalignant nodes are generally less than 1 cm in size, freely mobile, and rubbery in constancy. Malignant nodes tend to be larger, rock-hard, and fixed. They become immobile secondary to tumor invasion into the surrounding tissues and/or inflammation. Remember that pain in a node is not always indicative of an inflammatory or benign process. Hemorrhage into, or necrosis of, a malignant node can cause capsular distention leading to pain. "C" is of particular note. This patient's bee sting was quite a while ago and is unlikely to be a useful part of the history unless there is ongoing inflammation. Patients will often attribute a physical malady to something in their lives whether or not it makes sense from a biological and medical perspective (one of us had a patient who swore that his purulent sputum was because his lungs were connected to his gallbladder). Of course, lymphadenopathy is not the only source of neck masses. See Table 20-3 for the differential diagnosis of neck masses in adults.

Question 20.5.2 What is the most appropriate next step in the management of this patient?

A) Empiric antibiotics

B) Observation for 4 weeks

C) Open biopsy of the node

D) Fine needle aspiration of the node

E) Incision and drainage

Answer 20.5.2 The correct answer is "B." Patients with lymphadenopathy can be observed for 3 to 4 weeks unless there is a suggestion of malignancy (e.g., fever, night sweats, and weight loss). Note that a 3- to 4-week delay makes no difference in patient outcome if the node does turn out to be malignant. If adenopathy does not resolve, further evaluation including biopsy can be done. Open biopsy and fine needle aspiration each have advantages and disadvantages, but either could be used to obtain tissue. "A," empiric therapy with antibiotics, is possibly correct if you suspect a lymphadenitis or a bacterial infection causing secondary lymphadenopathy. However, in our patient, there is no tenderness or other signs of infection, arguing against lymphadenitis.

Question 20.5.3 Which of the following tests is NOT helpful in arriving at a diagnosis in a patient with GENERALIZED lymphadenopathy?

A) CBC

B) Chest radiograph

C) Glucose, BUN, creatinine

D) HIV

E) Heterophile antibody

Answer 20.5.3 The correct answer is "C." Glucose, BUN, and creatinine are not likely to help you with the diagnosis of generalized lymphadenopathy. Lymphadenopathy in primary care is malignant approximately 1% of the time. After a period of observation, the workup should proceed in stages. First step: CBC, chest radiograph. Second step: PPD, HIV, syphilis test (RPR or other), ANA, heterophile antibody. Final step: biopsy. Use your clinical judgment to determine the extent of testing necessary in any individual case.

Objectives: Did you learn to…

• Describe features of malignant and nonmalignant lymph nodes?

• Evaluate a patient with lymphadenopathy?

A 42-year-old businesswoman presents to your office with the chief complaint of 2 days of headache, sore throat, and nasal congestion productive of green mucus. She denies any fever, contact with ill persons, and gastrointestinal symptoms, but she does have a history of seasonal allergies. On examination, she has completely normal vital signs. Her posterior oropharynx has mild erythema and postnasal drainage but no exudates. There is nasal mucosal erythema and swelling with clear rhinorrhea. Her neck is supple with no adenopathy. Respirations are clear.

Question 20.6.1 The most likely agent causing her symptoms and the most common cause of acute rhinosinusitis is:

A) Rhinovirus

B) S. pneumoniae

C) H. influenzae

D) M. catarrhalis

E) Norwalk virus

Answer 20.6.1 The correct answer is "A." Viruses are the most common cause of URIs (or colds or rhinosinusitis). Up to 50% of colds are caused by the 100 different serotypes of rhinoviruses. Other viruses that commonly cause colds include coronaviruses, RSV, parainfluenza, and influenza. Norwalk virus typically causes an intestinal illness. The bacteria listed ("B"–"D") are also associated with infections of the upper respiratory tract, particularly otitis, and sinusitis, but are much less common than viruses.

Question 20.6.2 Initial treatment for this patient includes:

A) Oral decongestants

B) NSAIDs

C) Oral antibiotics

D) A and B

E) A and C

Answer 20.6.2 The correct answer is "D." Most cases of rhinosinusitis are viral and need only symptomatic treatment. Analgesics and systemic and nasal decongestants are reasonable options. Other treatment options include ipratropium nasal spray (which will also help to decrease mucus production), nasal steroids (at least one well-done randomized trial proved mometasone is superior to placebo … but it takes a while), and first-generation antihistamines with anticholinergic activity (e.g., diphenhydramine).

Question 20.6.3 Which of the following does NOT increase the likelihood that a patient has a bacterial sinusitis?

A) Persistence of symptoms for greater than 7 days

B) Thickened nasal mucosa or effusion on CT scan

C) Maxillary tooth pain

D) Unilateral maxillary sinus pain

Answer 20.6.3 The correct answer is "B." Radiography is particularly poor at differentiating bacterial sinusitis from a simple URI. Thickened nasal mucosa is only 40% to 50% specific for sinusitis (flip a coin, it's cheaper). The other problem with imaging is that essentially all patients with a URI will have fluid in the sinuses. Clinical criteria are more helpful in predicting the presence of bacterial sinusitis; thus, "A," "C," and "D" are correct. Additionally, a biphasic course, sometimes referred to as "double sickening," is a helpful predictor of bacterial sinusitis: if the patient initially improves and then gets worse, consider a secondary infection. The color of snot is meaningless. Thick, green, nasal drainage does not necessarily mean that bacteria are present. Secretions will turn green with a viral illness, as with anything else that concentrates protein in the mucous (e.g., anticholinergics).

The patient is initially convinced that only antibiotics will make her better. Through skillful negotiation (and a hefty dose of haloperidol), you manage to avoid prescribing antibiotics for what you strongly suspect is a viral infection. Two weeks later, the patient returns. Initially, she improved, but then she developed subjective fever, face pressure, maxillary tooth pain, and copious green nasal drainage. You now suspect that a bacterial sinusitis has developed. The look on her face says, "I told you so … and I am not taking any more of that haloperidol stuff." She has no drug allergies.

Question 20.6.4 Which of the following treatments do you offer as first-line therapy?

A) Azithromycin

B) Trimethoprim/sulfamethoxazole

C) Prednisone

D) Ceftriaxone

E) Amoxicillin/clavulanate

Answer 20.6.4 The correct answer is "E." According to 2012 Infectious Diseases Society of America guidelines addressing the treatment of acute bacterial sinusitis, amoxicillin/clavulanate should be used as first-line treatment for adults and children— although the evidence is weak. Previously trimethoprim/sulfamethoxazole ("B") would have been the best choice but there is increasing resistance. Azithromycin ("A") is not recommended due to resistance patterns and poor penetration into the sinuses (Got that … No Z-Pack). "C" is incorrect. There is no reason to prescribe steroids here. "D," ceftriaxone, might be considered in cases of treatment failure, but oral antibiotics are generally preferred. Per 2012 guidelines, doxycycline is recommended as second-line therapy, followed by respiratory fluoroquinolones. Of course, you should continue to recommend that the patient use decongestants and other symptom-oriented therapies.

Objectives: Did you learn to…

• Describe the most common pathogens involved in rhinosinusitis?

• Recognize clinical signs and symptoms that are more consistent with bacterial sinusitis than viral rhinosinusitis?

• Prescribe treatment for viral and bacterial sinusitis?

A 65-year-old male presents with dizziness that started a few days ago. He reports that he is otherwise healthy and takes no medications.

Question 20.7.1 Which of the following is the best question to ask him in order to elicit a better characterization of his dizziness complaint?

A) "Is the room spinning round and round?"

B) "Do you feel that you are going to faint?"

C) "Can you describe the dizziness using any other words?"

D) "Do you feel as though you are drunk?"

E) "Are you really just drunk right now?"

Answer 20.7.1 The correct answer is "C." When exploring a complaint of dizziness, insist that the patient characterizes the nature of the dizziness further without putting words into his mouth. This is a good time for that old technique learned in medical school but rarely used in practice: the open-ended question. There are essentially four types of dizziness: vertigo, presyncope, imbalance (disequilibrium), and undifferentiated dizziness. Patients will usually come up with their own terminology that will allow you to categorize their dizziness into one of these four types.

The patient describes a sensation of the room spinning, usually lasting less than a minute. Further, this sensation comes on in different positions and has led to a fall, which resulted in minor injuries. He denies any upper respiratory symptoms, fevers, hearing loss, or tinnitus. He sometimes feels nauseated with the dizziness but has not vomited. He first noticed the dizziness while in bed and rolling over, but it now occurs more frequently and in various positions. Sudden turning of the head definitely exacerbates his symptoms. It tends to be worse in the morning and better in the evening. You are comfortable calling this type of dizziness vertigo.

Question 20.7.2 Which of the following is LEAST likely to cause vertigo (in a general sense … not in this particular patient)?

A) Labyrinthitis

B) Ménière disease

C) Migraine aura

D) Otitis media

E) Perilymphatic fistula

Answer 20.7.2 The correct answer is "D." There are many causes of vertigo, but otitis media should not generally be thought of as one of them (or at least should be a diagnosis of exclusion). Labyrinthitis is usually caused by viral infection and results in severe vertigo that lasts for days. Ménière disease results in episodic vertigo that lasts for minutes to hours. Migraine aura can present with vertigo as well as many other symptoms (e.g., scotoma, diplopia, blindness, and paresthesias). Perilymphatic fistula occurs when perilymph leaks through a tear in the oval window (secondary to a fall or barotrauma—including sneezing). It typically resolves on its own. Although a perilymphatic fistula often results in vertigo, it is a relatively uncommon cause of vertigo.

Question 20.7.3 Which of the following is the best next step in the diagnosis of this patient?

A) Dix–Hallpike maneuvers

B) Obtain blood for CBC, electrolytes, BUN, and creatinine

C) MRI brain and brainstem

D) CT brain

E) Audiometry

Answer 20.7.3 The correct answer is "A." A complete evaluation of the patient with vertigo includes examination of the neurological and cardiovascular systems as well as the ears, eyes, nose, and throat. The Dix–Hallpike maneuver is designed to differentiate central from peripheral vertigo, can be a useful tool (more on this later …). In order to perform the maneuver, rapidly move the patient from a seated to a supine position, turning the head to the left or right, and observe for nystagmus. The patient is helped into a seated position, and the maneuver is repeated, turning the head to the other side. If nystagmus occurs within 30 seconds of performing the maneuver, it is considered a positive test. "B" is incorrect. Laboratory tests are rarely helpful. "C" and "D" are not correct because neuroimaging should only be performed if the history and/or examination indicate the need for it. In this case, the examination is not even complete yet! Likewise, audiometry (although helpful in the diagnosis of Ménière disease) is premature.

Dix–Hallpike maneuver is positive with rotation of the head to the left. The rest of the physical examination is unremarkable. The patient gets vertiginous and then it resolves in less than 1 minute.

Question 20.7.4 Given the history and examination, the most likely diagnosis in this patient is:

A) Labyrinthitis

B) Benign paroxysmal positional vertigo (BPPV)

C) Vertebrobasilar stroke

D) Motion sickness

E) Cerebellar stroke

Answer 20.7.4 The correct answer is "B." The history of episodic, positional vertigo and the positive Dix–Hallpike maneuver make BPPV the most likely diagnosis. Note that the Dix–Hallpike maneuver is not specific for BPPV. The Dix–Hallpike maneuver is designed to differentiate central from peripheral vertigo. In this case, the history is probably the most important aspect in making the diagnosis. BPPV is more common in older patients but can occur at any age. Women are more commonly affected than men. BPPV is caused by calcium stone deposition in the posterior semicircular canal. BPPV tends to be worse in the morning and better toward evening because, being of peripheral origin, the vertigo response fatigues as the day goes on (see Table 20-4). The other diagnoses listed are less likely. However, "C" and "E" deserve special mention. Stroke should be considered in any patient presenting with sudden onset, persistent vertigo, and risk factors (e.g., hypertension and atrial fibrillation). In general, there should be other findings such as diplopia, dysmetria, and ataxia. However, not every elderly patient with vertigo needs an MRI. If the history is consistent with BPPV, then neuroimaging is not necessary.

Question 20.7.5 For this patient with BPPV, the LEAST appropriate treatment at this time is:

A) Prednisone

B) Lorazepam

C) Meclizine (Antivert)

D) Rehabilitation exercises

E) Dimenhydrinate (Dramamine)

Answer 20.7.5 The correct answer is "A." Steroids are not likely to improve symptoms in BPPV. Benzodiazepines, anticholinergics, and antihistamines have all been employed in treating the symptoms of BPPV, but should all be second-line therapies after rehabilitation and repositioning exercises. Cawthorne rehabilitation exercises, physical therapy, and physician-directed head positioning (AKA Epley maneuvers to move stones out of the posterior semicircular canal) may be successful. Most patients will improve with time, although many will have relapses.

Objectives: Did you learn to…

• Describe types of dizziness?

• Generate a differential diagnosis for vertigo?

• Diagnose and treat a patient with BPPV?

A 15-year-old male wrestler presents to the ED with a nosebleed and a swollen ear. He clearly did not win this round. Prior to coming to the ED, he held pressure to his nose for 30 minutes. He has had nosebleeds before, but none were this bad. When asked how much blood he lost, his father shrugs and says it was "all over the mat." On examination, you see blood oozing slowly from the anterior nasal septum.

Question 20.8.1 Which of the following is a source of anterior epistaxis?

A) Ethmoid artery

B) Sphenopalatine artery

C) Kiesselbach arterial plexus

D) Palpatine artery

Answer 20.8.1 The correct answer is "C." Kiesselbach plexus is a collection system involving several terminal arteries (anterior ethmoidal, greater palatine, and superior labial arteries) in the anterior nose. It is the most common site of nasal bleeding. As one of your editors learned to his embarrassment, the Kiesselbach plexus lies very anterior and can be missed when using a speculum to inspect the nares. Don gloves, retract the patient's nasal tip, shine a light, and you will see it. The ethmoid and sphenopalatine arteries supply the posterior area of the nose, and bleeding from these sites is more difficult to control. Of special note is "D." Emperor Palpatine, also known as "Darth Sidious," converted Anakin Skywalker to the Dark Side using hatred, anger and lies—not epistaxis caused by an eponymous artery. Also, don't confuse the Kiesslebach plexus with the Kessel Run, which the Millennium Falcon allegedly completed in under 12 parsecs.

Question 20.8.2 What is the best next step in managing this patient's nosebleed?

A) Continue to hold pressure against the septum

B) Pack the anterior naris with gauze

C) Spray the mucosal surface with phenylephrine

D) Chemical cautery with silver nitrate

E) Any of the above can be used

Answer 20.8.2 The correct answer is "E." Any of the options listed could be used alone or in combination to try to stop the bleeding. If these methods are not successful, consider electrocautery, laboratory evaluation for signs of bleeding disorders (e.g., CBC, PT/PTT), and otolaryngology consultation. Laboratory studies will rarely be helpful, though.

With silver nitrate cautery and direct pressure, you were able to stop the bleeding. You now turn your attention to his left ear. You find a purplish, tender, fluctuant swelling at the left pinna.

Question 20.8.3 The best treatment for this condition is:

A) Analgesics, protection, and observation

B) Compressive dressing, using a headband (preferably that sweatband in your gym bag)

C) Oral antibiotics

D) Incision and drainage, leaving the wound open to drain and heal by secondary intention

E) Needle drainage followed by compressive dressing sutured into the pinna

Answer 20.8.3 The correct answer is "E." With traumatic auricular hematoma/seroma, fluid collects between the perichondrium and underlying cartilage, predisposing the cartilage to loss of vascular supply and necrosis. In order to avoid "cauliflower ear" deformity, the hematoma or seroma must be evacuated via incision or needle drainage. However, you cannot stop there: a compressive dressing must then be sutured into the pinna, or the fluid is likely to re-accumulate. "B" is incorrect because compressive dressing alone is insufficient. "D" is incorrect only because it does not include compressive dressing. "A" and "C" are incorrect because taking these actions will delay definitive treatment—and antibiotics are not needed anyway. If the patient were to present late (10 days or more after the injury), he will not benefit from incision or needle drainage, and instead should be referred for otoplasty.

Objectives: Did you learn to…

• Evaluate and treat a patient with epistaxis?

• Treat a patient with auricular trauma?

A 20-year-old female presents with three painful ulcerations on her inner lip and tongue. She has no other symptoms. Although she has never had such sores before, everyone else in her family has had similar mouth sores. She only smokes when drinking cheap wine coolers, which occurs about once per week. She is afebrile, and her examination is otherwise unremarkable.

The most likely diagnosis is:

A) Aphthous ulcers

B) Behcet disease

C) Crohn disease

D) Gluten enteropathy

E) Squamous cell carcinoma

The correct answer is "A." This otherwise healthy young woman with a family history of "similar sores" most likely has aphthous ulcers or "canker sores." The etiology of aphthous ulcers is not well understood, and they are alternatively explained as viral, autoimmune, genetic, traumatic, or due to chemical irritants or other processes (also, karmic retribution, divine punishment for sin, etc.). "B," Behcet disease, is uncommon in the United States. It is thought to be an autoimmune disease, and it presents with recurrent oral and genital ulcerations and skin and eye lesions among other findings. "C" and "D" can both present with isolated oral ulcers but are less common than idiopathic aphthous ulcers: there should also be other GI symptoms. "E" is incorrect because it is highly unlikely that this young, healthy person has developed cancer … in three places … simultaneously. Finally, lupus pemphigoid, pemphigus, and multiple infections (e.g., Hand-Foot-Mouth, HIV, herpes, and syphilis) may present with oral ulcers.

A 34-year-old male dentist presents to your office with a 1-week history of right facial weakness and a bit of tongue numbness. He states that he "just woke up this way one morning." He would have come in sooner, but he was busy with his practice and he has felt fine. He has not noticed any other neurological symptoms. He denies pain, fever, or upper respiratory symptoms. He reports being healthy and taking no medications. On examination, his vital signs are normal. You note that his right eyebrow sags, as does the right corner of his mouth. He cannot close the right eye completely or raise his right eyebrow, and the right nasolabial fold is less prominent than the left. The remainder of the neurological examination is normal.

Question 20.9.1 The neurological finding in this patient that most suggests a cranial nerve process (as opposed to a central brain lesion) is:

A) Normal strength in the upper extremities

B) Inability to smile on the right

C) Inability to wrinkle the forehead

D) Normal blood pressure

E) Normal speech rate and rhythm

Answer 20.9.1 The correct answer is "C." Partial sparing of the forehead muscles suggests a brain lesion because innervation of the forehead contains crossed fibers from both sides of the brain; a bilateral brain lesion is possible but unlikely. Thus, a dense paralysis is more likely to be peripheral (CN7) since all innervation is knocked out when this is involved. This patient's entire right face, including the forehead, is paralyzed, which suggests a lower motor neuron (CN7) process. While "A" and "E" are found in a normal neurologic examination and are reassuring, they are not as helpful in isolating the location of the lesion to a lower motor neuron source. "B," lower facial muscle weakness or paralysis, can occur with upper or lower motor neuron disease. "D," normal blood pressure, is not helpful.

You tell the patient that you suspect he has Bell palsy. He asks what causes this problem.

Question 20.9.2 Which of the following is the most likely cause of this patient's Bell palsy?

A) Herpes virus

B) Tick-borne illness

C) Diabetes

D) Adenovirus

E) The dark side of the force

Answer 20.9.2 The correct answer is "A." It seems that many cases of Bell palsy are due to reactivation of herpes simplex virus (HSV). Other viral etiologies have been implicated as well, including EBV, CMV, coxsackievirus, and adenovirus ("D"), but all are much less commonly isolated compared with HSV. While "B," tick-borne illnesses such as Lyme disease cause Bell palsy, these represent a minority of cases. "C," diabetes, may put a patient at increased risk of contracting Bell palsy, but it does not cause the disease.

Question 20.9.3 Which of the following treatments is most likely to benefit this patient?

A) Acyclovir

B) Prednisone

C) Artificial tears and eye patching at night

D) A and B

E) None of the above

Answer 20.9.3 The correct answer is "C." In a patient with Bell palsy and weakness to eye closure, good eye care, and protection from trauma must be employed to prevent corneal damage (remember that this patient cannot close his right eye). The evidence for antiviral therapy is negative; acyclovir likely doesn't work, and it is no longer recommended. There may be some slight benefit to corticosteroids. Steroids are most likely to provide a benefit if started within the first 3 days after the onset of symptoms. Our patient is now a full week out, so steroids are unlikely to produce a benefit.

You recommend eye care but not other medications. Knowing that patients with Bell palsy generally require a lot of reassurance, you discuss the diagnosis in detail, including prognosis.

Question 20.9.4 The patient can expect which of the following?

A) Complete resolution (∼100% likelihood) with nearly zero risk of recurrence

B) Likely resolution (>50% likelihood) with nearly zero risk of recurrence

C) Likely resolution (>50% likelihood) with about 10% risk of recurrence

D) High probability (∼95% likelihood) of persistent paralysis

Answer 20.9.4 The correct answer is "C." Most patients will recover (71% complete, 13% minor impairment with the rest having significant sequelae), but it may take months. If a patient with suspected Bell palsy has no improvement in symptoms after a few months, reconsider the diagnosis. Patients with complete paralysis are more likely to have persistent symptoms, whereas those with partial paralysis usually recover more quickly and completely. Other treatments such as surgical nerve decompression and nerve stimulation have little or no evidence supporting them.

Objectives: Did you learn to…

• Differentiate Bell palsy from a central lesion?

• Describe causes of Bell palsy?

• Manage a patient with hemifacial paresis?

A 30-year-old female presents with several months of pain and stiffness in her jaw. When asked to localize the pain, she points to the temporomandibular joints (TMJ) bilaterally. She notes that the pain is worse with stressful situations, driving, and chewing. Her husband complains that she grinds her teeth at night. She is otherwise healthy. On physical examination, you find palpable popping in the TMJs bilaterally, and the remainder of her examination is unremarkable.

You make all of the following recommendations EXCEPT:

A) Start chewing gum daily

B) Use ibuprofen as needed

C) Use a bite block at night

D) Learn relaxation techniques

The correct answer is "A." This patient's history is consistent with TMJ syndrome. In addition to those described in the case, symptoms of TMJ may include ear pain, headache, "sinus" headache, limited jaw mobility, and crepitus and tenderness on palpation of the joint. TMJ syndrome may occur unilaterally or bilaterally. No single therapy appears to have greater efficacy than any other, and many different interventions have been tried, although poorly studied. "A," increased use of the joint by chewing gum, is the exact opposite of what the patient should be doing. Jaw rest is important. All of the other interventions are reasonable. Also, you might recommend a softer diet, hot packs, and TMJ massage.

A 22-year-old female presents to your office complaining of severe facial pain for the past 3 days. She has poor dentition and you find that on examination, there is mandibular swelling and tenderness.

Question 20.10.1 All of the following are causes of mandibular area swelling EXCEPT:

A) Submandibular duct stone

B) Dental abscess

C) Retropharyngeal abscess

D) Ludwig angina

E) Branchial cleft cyst

Answer 20.10.1 The correct answer is "C." Retropharyngeal abscesses are generally not visible but present with fever, throat pain, and symptoms due to swelling of the retropharyngeal space (dysphagia, drooling, odynophagia, and airway obstruction). All of the other options can cause swelling around the mandible.

Question 20.10.2 One of the diagnoses you are considering is parotitis. Which of the following is true regarding parotitis?

A) You will only see mumps in science-denying, anti-vaccine, whack jobs

B) Mumps can be associated with pain and inflammation of the meninges, pancreas, and gonads as well as the parotid glands

C) Bacterial parotitis is mostly caused by pan-sensitive streptococcus and can be treated with penicillin

D) Mumps is usually treated with IVIG

Answer 20.10.2 The correct answer is "B." Mumps can lead to inflammation of other tissues including the meninges, pancreas, and gonads (possibly leading to decreased fertility in males, not in females), and will occasionally require hospitalization. Thankfully, most people recover spontaneously with good supportive care, including NSAIDs and warm compresses. IVIG would be reserved for those with severe complications as mentioned above. "A" is incorrect. While the MMR vaccine is about 88% effective after 2 doses, this still leaves over 10% of the population susceptible to outbreaks. Therefore, you may see mumps in immunosuppressed patients as well as anyone who is more than 10 years out from their last vaccination. Bacterial parotitis ("C") is usually caused by Staphylococcus aureus and anaerobes. In the hospital setting, approximately 40% of the Staphylococcus aureus is methicillin resistant, so first-line therapy is usually IV vancomycin pending culture results. Parotitis secondary to stones is often treated with cephalexin, dicloxacillin, or amoxicillin/sulbactam. Use clinical judgment and assure good follow-up.

Question 20.10.3 Which of the following is NOT typical of sialolithiasis (salivary duct stones)?

A) Intermittent swelling of the salivary gland

B) More than 80% of stones involve the parotid gland

C) The majority resolve with conservative, nonoperative treatment

D) Anti-staphylococcal antibiotics should be used in their treatment

E) Sialogogues (e.g., lemon drops) should be used as part of the treatment

Answer 20.10.3 The correct answer is "B." In actuality, more than 80% of cases of sialolithiasis involve the submandibular gland. "A" is true. Swelling tends to occur when patients eat and tends to resolve between meals as saliva slowly makes its way through the duct. "C" is true. Most salivary duct stones pass spontaneously. "D" is true. Think of this as an abscess. If there is any sign of infection, anti-staphylococcal antibiotics should be used until the stone passes. Finally, sialogogues such as lemon drops promote saliva formation. The effectiveness is questionable, but it is worth a try and it gives the patient something to do.

Question 20.10.4 Which of the following is considered good practice with regard to salivary duct stones?

A) Patients should be followed up within 72 hours if the stone does not pass

B) Stones can be removed using sialolithotomy (using a probe and/or scalpel to nick the outlet)

C) Patients should be referred for lithotripsy if stones do not pass within 4 days

D) Surgical excision of the duct should be done if the stone does not pass

E) Tricyclic antidepressant prophylaxis if stones occur frequently

Answer 20.10.4 The correct answer is "B." A probe can be used to "dilate" the duct. Occasionally, the outlet needs to be nicked using a scalpel blade to allow the stone to egress. The rest are incorrect. With regard to "A," patients should be followed up in 24 hours if the stone does not pass. "C" is also incorrect. Lithotripsy has actually been used with some good results but is definitely third line. Finally, "D" is incorrect. Excising the duct seems a little dramatic. "E" is very wrong. Anticholinergics reduce salivary flow and thus contribute to stone formation.

You check the patient's mouth and decide that there is likely a dental abscess, not a salivary duct stone. She needs to have her tooth extracted, but the dentist will not be able to see the patient until the morning. She requires antibiotics but is penicillin-allergic.

Question 20.10.5 The antibiotic of choice for this patient is:

A) Erythromycin

B) Clindamycin

C) Azithromycin

D) Levofloxacin

E) Trimethoprim/sulfamethoxazole

Answer 20.10.5 The correct answer is "B." Clindamycin is the drug of choice as an alternative to penicillin. The drug used for a dental abscess should cover anaerobes. There is resistance to erythromycin and azithromycin. Neither levofloxacin nor trimethoprim/sulfamethoxazole covers anaerobes.

During your examination, you also noticed a firm nodule in the submental area in the midline. (It is definitely not this patient's day!) It moves up and down when she swallows. She says that it has been there for years—as long as she can remember.

Question 20.10.6 The most likely cause of this midline nodule is:

A) Submandibular gland infection

B) Thyroglossal duct cyst

C) Infected frenulum

D) Branchial cleft cyst

E) An accumulation of midi-chlorians

Answer 20.10.6 The correct answer is "B." This is likely a thyroglossal duct cyst. The rest are not likely. Submandibular glands ("A") and branchial cleft cysts ("D") are lateral to the midline. "C" is incorrect. The frenulum is under the tongue. As for "E," another Star Wars reference. Maybe there will be a Wookie at the end of the chapter. Keep reading.

You start the patient on clindamycin, but she returns in the morning with severe submandibular swelling. The tongue is elevated in the mouth and there is brawny edema; she is having trouble talking. You make the diagnosis of Ludwig angina. ("Didn't we just do this?" you ask. "Yes, we are going to do it again," we reply.)

Question 20.10.7 At this time, the most appropriate treatment for this patient is:

A) Continue PO clindamycin and add saltwater gargles

B) Continue PO clindamycin and add PO metronidazole

C) Incise and drain the swollen area under the tongue

D) Refer immediately for surgical evaluation for possible tracheostomy

E) Administer IV fluids and ceftriaxone in the office and follow up tomorrow

Answer 20.10.7 The correct answer is "D." This patient's situation has become fairly desperate overnight even while on an appropriate antibiotic. Securing an airway should be your first concern. Unfortunately, these patients do not respond to local incision and drainage, as the swelling is usually diffuse, quickly spreading, and does not result in discrete pus pocket formation until late in the course. She should be admitted for IV fluids, appropriate IV antibiotics (not levofloxacin), and possible tracheostomy. Patients with advancing Ludwig angina do not tolerate endotracheal intubation; thus, an alternative airway is often provided with tracheostomy.

Objectives: Did you learn to…

• Diagnose salivary stones?

• Treat salivary stones?

• Recognize the presentation of submandibular masses?

A 21-year-old male presents for a sore throat. His symptoms started 3 days ago. He has had subjective fevers, sweats, fatigue, and mild nausea. He has no cough or rhinorrhea. His temperature is 38.3°C. His vital signs are normal otherwise. He has symmetrically enlarged tonsils with exudates present and tender anterior cervical lymphadenopathy.

Question 20.11.1 At this point, you:

A) Reassure and recommend saltwater gargles

B) Obtain a routine aerobic culture of the oropharynx

C) Prescribe penicillin 500 mg BID for 10 days

D) Prescribe levofloxacin 500 mg daily for 7 days

Answer 20.11.1 The correct answer is "C." This patient has 4 of 4 signs/symptoms suggestive of streptococcal (group A strep or Streptococcus pyogenes) pharyngitis. These are the "Centor criteria": (1) fever, (2) tender cervical adenopathy, (3) exudative pharyngitis, and (4) lack of other URI symptoms. In this case, the most appropriate step would be empiric antimicrobial treatment. "B," performing a culture, will take a few days and does not add much, given the strength of the clinical argument for strep throat. Furthermore, the oropharynx is colonized by many kinds of flora that do not cause disease, and we only really care about group A streptococcus, so a routine aerobic culture is of no value. Alternatively, a rapid assay or a specific "rule out" culture for group A strep could be done rather than treating based on clinical grounds (the rapid strep has a 5% false negative rate). While saltwater gargles seem to help reduce the pain of pharyngitis, "A" is incorrect because you would want to do more than that for this patient who likely has strep throat. "D" is incorrect because levofloxacin and other fluoroquinolones are not indicated for treatment of strep throat.

Here are three strategies for the patient you think might have strep throat:

Strategy 1: No testing (or minimal testing)

In this strategy, one treats based on clinical symptoms. You are looking for four things: fever, exudate, absence of other URI symptoms, and tender anterior cervical adenopathy. Treat patients with 3 or 4 criteria, and do not treat others. Another approach is to treat patients with 4 criteria, do a rapid strep test on those with 3 (and maybe 2) criteria, and avoid treatment and testing of others. The CDC has recommended this for nonimmunosuppressed patients in the absence of an outbreak of rheumatic fever in the community.

Strategy 2: Testing

Test all patients and treat those with a positive strep screen. Do not culture others.

Strategy 3: For Children

The majority of group A strep pharyngitis occurs in children between ages 5 and 15 years. In this age group, 15% to 30% of acute pharyngitis is caused by group A strep. In children, doing a rapid strep test is considered the standard (although many argue convincingly that it is not even necessary here in the older child). Cultures are again optional depending on the reliability of your rapid antigen test. Many would culture all rapid strep test negative patients and this is certainly an acceptable strategy as well.

So, now you are quite confused. So is everyone else …

Question 20.11.2 Which of the following is true about antibiotic therapy of streptococcal pharyngitis?

A) Azithromycin is the drug of choice because of resistant streptococci

B) There is no significant resistance seen in Group A β-hemolytic streptococci, and penicillin is still the drug of choice

C) Cephalexin is the preferred drug because it covers H. influenzae, which is a frequent coinfector with streptococci

D) Amoxicillin is preferred for strep throat because it does not cause a rash if the patient happens to have mononucleosis

Answer 20.11.2 The correct answer is "B." There is no significant resistance among group A β-hemolytic streptococci to penicillin. Thus, penicillin remains the drug of choice despite drug detailing. There is no reason to use anything else, except in the case of allergy where erythromycin or cephalexin can be used. Remember that there is now resistance to erythromycin, azithromycin, and clarithromycin. "D" is important. Amoxicillin can cause an uncomfortable rash should your patient turn out to have mononucleiosis rather than strep throat.

Question 20.11.3 Antibiotics should be started within what time period to reduce the risk of rheumatic fever from streptococcal pharyngitis?

A) 2 days after presentation

B) 2 to 4 days after presentation

C) 4 to 6 days after presentation

D) 6 to 8 days after presentation

E) 8 to 10 days after presentation

Answer 20.11.3 The correct answer is "E." Antibiotics should be started within 9 days after presentation in order to prevent rheumatic fever, which is really our goal when we treat streptococcal pharyngitis. Thus, there really is no reason to hurry treatment.

Your patient is a student teacher and wants to know how long to stay out of the classroom.

Question 20.11.4 A patient with streptococcal pharyngitis should be considered infectious and kept out of school for what period after beginning antibiotics?

A) 12 hours

B) 24 hours

C) 36 hours

D) 48 hours

Answer 20.11.4 The correct answer is "B." Patients should be considered infectious for 24 hours after the initiation of therapy for streptococcal pharyngitis. The risk of transmission goes down markedly after this point. Unfortunately, the patient is actually infectious for the 3 to 5 days before they become symptomatic, so removing the patient for 24 hours after treatment is closing the barn door after the horses have left. Of course, since this is being written in Iowa, so we are closing the pen after the hogs have left. There is some preliminary data that it is OK to return to work/school 12 hours after starting treatment but this is not yet the standard of care (Pediatr Infect Dis J. 2015 Aug 20).

You see the same patient 3 weeks later. He took all of his penicillin even though he felt fine a few days after he left your office. (Wow! A compliant patient!) However, he now has the same symptoms, starting 2 days ago. His examination is the same.

Question 20.11.5 Which of the following is the most likely cause for his current symptoms?

A) Gonococcal pharyngitis

B) Infection with a resistant streptococcal organism

C) Mononucleosis

D) Staphylococcal pharyngitis

E) None of the above

Answer 20.11.5 The correct answer is "E." Since his symptoms resolved, you either got the diagnosis and treatment right or he had some other self-limited infection. Therefore, it would be unlikely that he had gonococcal pharyngitis or resistant streptococcal organisms. Nonetheless, sexual history is important—even when confronted with pharyngitis; if a patient with exudative pharyngitis is not improving, think about gonococcal disease. Remember that gonococcal disease will be missed for two reasons in this scenario: the history is never obtained regarding oral sex and gonococcus requires Thayer-Martin agar to grow, so it will not show up on routine culture, and there are a lot of false negative cultures; consider PCR if thinking about gonococcal pharyngitis. "B," penicillin-resistant Streptococcus organisms causing pharyngitis, like the Tooth Fairy, are nonexistent. "C" is unlikely in this case because his symptoms resolved, but mononucleosis can cause prolonged symptoms of sore throat and fatigue and can be confused with strep throat. In this case, recurrent strep throat is most likely and he should be advised appropriately: retreat with penicillin, not a more broad-spectrum antibiotic; consider testing and/or treating cohabitants; have the patient replace his toothbrush.

It's a "two for Tuesday" at your clinic. The next patient comes in for a sore throat and tender anterior and posterior cervical adenopathy. He is febrile and relatively stoic. He has been sick for 2 weeks with significant fatigue and just isn't getting better. In addition to the adenopathy, you notice left-sided abdominal tenderness with minimal guarding but no rebound tenderness. You believe that you feel a spleen edge. However, the patient's heterophile antibody (monospot) is negative. You decide to get anti-EBV (Epstein–Barr virus) antibodies. The results of the anti-EBV antibody test are as follows (VCA is against the capsid): IgM-VCA positive, IgG-VCA negative, anti-EBV nuclear antigen antibody negative.

Question 20.11.6 How do you interpret these results?

A) The patient has acute EBV infection

B) The patient has had EBV at least 6 weeks ago

C) The absence of anti-EBV nuclear antigen antibody makes acute infection highly unlikely

D) The patient has never been infected with EBV

Answer 20.11.6 The correct answer is "A." The patient has an EBV infection, starting in the last few weeks. Here is why. IgM-VCA is produced acutely and is elevated in the acute infection for 2 to 4 weeks. Since this patient's IgM-VCA is positive, he has had an acute EBV infection within the past month. IgG-VCA is measurable 3 to 4 weeks after acute infection and persists for life. Thus, it gives no information about when infection occurred. The absence of IgG-VCA means either (1) the patient has no history of EBV infection or (2) the patient has had a recent EBV infection. Antibodies against the EBV nuclear antigen show up at 6 to 12 weeks after infection. If this antibody is present in the blood, it suggests that there has not been an acute infection; the infection had to have been at least 6 weeks ago.

Question 20.11.7 Of the following, which DOES NOT cause a mononucleosis-like syndrome?

A) Human immunodeficiency virus (HIV)

B) Cytomegalovirus (CMV)

C) Toxoplasmosis

D) West Nile virus (WNV)

E) Leptospirosis

Answer 20.11.7 The correct answer is "D." WNV is characterized by fever, headache, myalgias, back pain, and anorexia lasting 3 to 6 days. Much less common manifestations are nausea, vomiting, diarrhea, encephalitis, etc. Thus, WNV does not cause a mononucleosis-like syndrome because it does not last as long and rarely includes pharyngitis. One thing to note is that WNV may include lymphadenopathy. All the other answers can cause a mononucleosis-like syndrome. Other causes of mononucleosis-like syndromes include adenovirus, parvovirus B19 (erythema infectiosum), herpes virus 6 (roseola infantum), and ehrlichiosis (Asian form only). Remember these diagnoses in heterophile negative mono-like illness.

Question 20.11.8 There is some concern of splenic rupture in patients with mono who have splenomegaly. If splenomegaly were confirmed in this patient, what would be the generally accepted recommendation with regard to athletic participation (e.g., cage fighting)?

A) No participation until negative acute titers for EBV

B) No participation for 2 week after the diagnosis is made, assuming complete resolution of symptoms and then full participation

C) No participation until 3 weeks after the diagnosis is made, assuming complete resolution of symptoms and then only noncontact training for another week

D) Full practice and competition allowed immediately unless abdominal pain occurs