ENT PRACTICE QUESTIONS WITH VERIFIED
ANSWERS
An 18-month-old boy is brought to his pediatrician's office by his father because of fever
and ear tugging for the past 3 days. His father reports a temperature of 37.8°C
(100.0°F) this morning and a decreased appetite. The boy's temperature is 38.6°C
(101.4°F), pulse is 110/min, respirations are 22/min, and blood pressure is 90/60 mm
Hg. Otoscopic examination shows a bulging and erythematous right tympanic
membrane with decreased mobility of the right tympanic membrane. Oral amoxicillin is
initiated. Four days later, the child returns to the office with no improvement in
symptoms. Repeat physical examination shows a bulging tympanic membrane
bilaterally with a meniscus of fluid within the middle ear. Which of the following is the
most appropriate next step in management?
A. Amoxicillin/clavulanate
B. Azithromycin
C. Ceftriaxone injection
D. Continue amoxicillin
E. Vancomycin - Answers - A. Amoxicillin/clavulanate
Major takeaway
Acute otitis media is a middle ear infection which commonly occurs in children. Initial
therapy of choice is oral amoxicillin. Switch therapy to amoxicillin and clavulanate if no
clinical improvement is noted.
Main explanation
Acute otitis media is a middle ear infection which most commonly affects children <2-
years-old. Risk factors include day care, pure formula feeding, second-hand tobacco
smoke, and pacifiers. The most common causes of bacterial acute otitis media include
Streptococcus pneumoniae, Hemophilus influenza (non-typeable), and Moraxella
catarrhalis. Symptoms of acute otitis media are otalgia (ear pain), decreased appetite,
fever, and increased fussiness. Diagnosis is done on otoscopio examination showing
decreased mobility of an erythematous and bulging tympanic membrane. First-line
therapy for acute otitis media is oral amoxicillin. In cases where the microbes are
resistant (e.g. no improvement in symptoms), the next best step in management is to
switch therapy to amoxicillin/clavulanic acid. Clavulanic acid is a ß-lactamase inhibitor
and potentiates the efficacy of amoxicillin.
A 3-year-old boy is brought to the pediatrician's office by his mother because of left ear
pain for the past 4 days. Physical examination shows a bulging and erythematous left
tympanic membrane. The use of pneumatic pressure otoscope shows no movement of
the tympanic membrane. Which of the following organisms is the most likely cause of
this patient's symptoms?
A. Bacillus anthracis
B. Chlamydia trachomatis
,C. Haemophilus influenzae
D. Staphlococcus aureus
E. Streptococcus agalactiae - Answers - C. Haemophilus influenzae
Major takeaway
Acute otitis media (AOM) is most commonly caused by Streptococcus pneumoniae,
Moraxella catarrhalis, or Haemophilus influenzae (non-typeable strain). Initial treatment
of choice is amoxicillin.
Main explanation
Acute otitis media is an infection of the middle ear which is common in children.
Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae ^non-
typeable strains) are the most common causes of bacterial otitis media. Patients with
acute otitis media will have otalgia (ear pain), fever, increased fussiness, and loss of
appetite. Physical examination using an otoscope will show a red, bulging, and non-
mobile tympanic membrane. Once diagnosed, treatment should be initiated with
antibiotics in order to prevent hearing loss. First line treatment of choice for acute otitis
media is amoxicillin. If the bacteria are resistant or symptoms do not improve, then
amoxicillin-clavulanate should be utilized.
A 2-year-old boy is brought to the office by his mother because of complaints of fever
and ear pain. He began tugging on his ear and complaining of pain three days ago. The
mother reports a temperature of 37.8°C (100.0°F) this morning, with decreased
appetite. Current temperature is 38.6ºC (101.4ºF). ENT examination shows erythema
and decreased mobility of the right tympanic membrane. Which is the most appropriate
pharmacological management?
A. Amoxicillin
B. Azithromycin
C. Ceftriaxone
D. Ciprofloxacin
E. Piperacillin - Answers - A. Amoxicillin
Major takeaway
For uncomplicated acute otitis media, the first line pharmacological therapy is
amoxicillin. If amoxicillin does not resolve the symptoms, then the patient should be
switched to amoxicillin-clavulanate.
Main explanation
Acute otitis media is a bacterial or viral infection of the middle ear and is common in the
pediatric population. Risk factors include a recent upper respiratory infection, second-
hand tobacco smoke, and formula feeding. Symptoms of acute otitis media are otalgia
(ear pain), fever, fussiness, and fever. Ear discharge signifies perforation of the
tympanic membrane. A diagnosis is made using pneumatic otoscopy. First line
pharmacological therapy is amoxicillin. Amoxicillin will cover most typical organisms.
Flowever, there is increasing resistance to amoxicillin. If symptoms do not improve, then
amoxicillin-clavulanate should be given. Clavulanate is a ß-lactamase inhibitor and
potentiates the efficacy of amoxicillin.
,A 4-year-old boy is brought to the emergency department by his mother because of
fever and constant tugging of his left ear. Physical examination shows a swollen and
erythematous left ear canal that is tender to the touch. An opaque serum-like exudate is
seen oozing through the left tympanic membrane. An audiometry test shows bilateral
conductive hearing loss. Which of the following is the most likely causative microbe?
A. Proteus mirabilis
B. Pseudomonas aeruginosa
C. Staphylococcus aureus
D. Streptococcus pneumonia
E. Streptococcus pyogenes - Answers - D. Streptococcus pneumonia
Major takeaway
Streptococcus pneumoniae is the most common bacteria associated with acute otitis
media. Diagnosis is made using pneumatic otoscopy. Amoxicillin is the initial treatment
choice.
Main explanation
Acute otitis media is an infection common in children of the middle ear. Symptoms
include fussiness, fever, loss of appetite, tugging of the ear, and bilateral conductive
hearing loss. Breast milk has been shown to be protective against acute otitis media.
Second hand tobacco smoke is a major risk factor. Diagnosis of acute otitis media is
done using pneumatic otoscopy. Other characteristic symptoms include bulging of the
posterior quadrants of the tympanic membrane, scalded appearance of the superficial
epithelial layer, and a perforated tympanic membrane. The most commonly associated
bacteria with acute otitis media is Streptococcus pneumoniae. Other microbes include
Hemophilus influenza and Moraxella catarrhalis. Initial treatment of choice is amoxicillin.
However, if the patient's symptoms do not improve, then amoxicillin-clavulanate should
be given.
There is considerable debate about the use of tympanostomy tubes in the management
of recurrent otitis media in children. Tympanostomy tube placement has been proven to
A. improve hearing
B. prevent mastoiditis
C. prevent recurrence of effusion
D. prevent delayed language development - Answers - A. improve hearing
Hearing is improved with tympanostomy tubes by eliminating middle ear effusion when
the tubes are functioning properly.
The most reliable sign of acute otitis media (AOM) is
A. bulging of the tympanic membrane
B. loss of tympanic membrane mobility
C. reddening of the tympanic membrane
D. air bubbles behind the tympanic membrane - Answers - B. loss of tympanic
membrane mobility
Loss of tympanic membrane mobility during pneumoinsufflation is the most reliable sign
for diagnosing acute otitis media.
, A patient with Type 1 diabetes mellitus was treated for otitis externa of the right ear for 2
weeks with topical ear drops. The patient presents today with persistent, foul aural
discharge, granulations in the ear canal, and deep ear pain. Which of the following is
the proper treatment at this time?
A. ciprofloxacin (Cipro) IV
B. cefuroxime (Zinacef) IV
C. ampicillin-sulbactam (Unasyn) PO
D. azithromycin (Zithromax) PO - Answers - IV antibiotics directed against
Pseudomonas, the most likely etiology, is needed for the treatment of malignant otitis
media.
Which of the following is the most likely organism in a 2 year-old child with acute otitis
media?
A. Staphylococcus aureus
B. Moraxella catarrhalis
C. Pseudomonas aeruginosa
D. Streptococcus pneumoniae - Answers - The most common pathogens in children
with acute otitis media are Streptococcus pneumoniae, Haemophilus influenzae, and
Streptococcus pyogenes.
A 3 year-old patient is brought in with a 10 day history of clear nasal drainage and
cough which has now developed into otalgia and fever exceeding 101 degrees F for the
last 5 days. Mom denies other chronic medical problems. The patient has had similar
complaints three times in her life. Which of the following is the most likely causative
organism?
A. Mycoplasma pneumoniae
B. Pneumocystis jiroveci
C. Pseudomonas aeruginosa
D. Streptococcus pneumoniae - Answers - Acute otitis media is a bacterial infection of
the mucous lined air-containing spaces of the temporal bone most commonly caused by
Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes.
---SNAPSHOT--- A 9-month-old boy presents to your urgent care clinic for increased
irritability. One week prior to presentation, the patient had an upper respiratory infection,
which has since improved. Over the last day, the mother has noticed that the child has
been tugging at his right ear, refuses to lie down on it, and has had a fever. There is
right tympanic membrane erythema that is bulging and minimally mobile with pneumatic
otoscopy. - Answers - Acute Otitis Media
A 3-year-old boy presents to the pediatrician crying with ear pain and his temperature
has been 101°F (38.3°C) for several days. His mother states that other children at his
daycare center have been having similar symptoms. She further describes that he was
fed formula and was not breastfed. The mother admits that she smokes cigarettes daily.
On exam, the boy is irritable and crying, and frequently tugs on his left ear. Both
tympanic membranes appear erythematous, and the left appears opaque and bulging
ANSWERS
An 18-month-old boy is brought to his pediatrician's office by his father because of fever
and ear tugging for the past 3 days. His father reports a temperature of 37.8°C
(100.0°F) this morning and a decreased appetite. The boy's temperature is 38.6°C
(101.4°F), pulse is 110/min, respirations are 22/min, and blood pressure is 90/60 mm
Hg. Otoscopic examination shows a bulging and erythematous right tympanic
membrane with decreased mobility of the right tympanic membrane. Oral amoxicillin is
initiated. Four days later, the child returns to the office with no improvement in
symptoms. Repeat physical examination shows a bulging tympanic membrane
bilaterally with a meniscus of fluid within the middle ear. Which of the following is the
most appropriate next step in management?
A. Amoxicillin/clavulanate
B. Azithromycin
C. Ceftriaxone injection
D. Continue amoxicillin
E. Vancomycin - Answers - A. Amoxicillin/clavulanate
Major takeaway
Acute otitis media is a middle ear infection which commonly occurs in children. Initial
therapy of choice is oral amoxicillin. Switch therapy to amoxicillin and clavulanate if no
clinical improvement is noted.
Main explanation
Acute otitis media is a middle ear infection which most commonly affects children <2-
years-old. Risk factors include day care, pure formula feeding, second-hand tobacco
smoke, and pacifiers. The most common causes of bacterial acute otitis media include
Streptococcus pneumoniae, Hemophilus influenza (non-typeable), and Moraxella
catarrhalis. Symptoms of acute otitis media are otalgia (ear pain), decreased appetite,
fever, and increased fussiness. Diagnosis is done on otoscopio examination showing
decreased mobility of an erythematous and bulging tympanic membrane. First-line
therapy for acute otitis media is oral amoxicillin. In cases where the microbes are
resistant (e.g. no improvement in symptoms), the next best step in management is to
switch therapy to amoxicillin/clavulanic acid. Clavulanic acid is a ß-lactamase inhibitor
and potentiates the efficacy of amoxicillin.
A 3-year-old boy is brought to the pediatrician's office by his mother because of left ear
pain for the past 4 days. Physical examination shows a bulging and erythematous left
tympanic membrane. The use of pneumatic pressure otoscope shows no movement of
the tympanic membrane. Which of the following organisms is the most likely cause of
this patient's symptoms?
A. Bacillus anthracis
B. Chlamydia trachomatis
,C. Haemophilus influenzae
D. Staphlococcus aureus
E. Streptococcus agalactiae - Answers - C. Haemophilus influenzae
Major takeaway
Acute otitis media (AOM) is most commonly caused by Streptococcus pneumoniae,
Moraxella catarrhalis, or Haemophilus influenzae (non-typeable strain). Initial treatment
of choice is amoxicillin.
Main explanation
Acute otitis media is an infection of the middle ear which is common in children.
Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae ^non-
typeable strains) are the most common causes of bacterial otitis media. Patients with
acute otitis media will have otalgia (ear pain), fever, increased fussiness, and loss of
appetite. Physical examination using an otoscope will show a red, bulging, and non-
mobile tympanic membrane. Once diagnosed, treatment should be initiated with
antibiotics in order to prevent hearing loss. First line treatment of choice for acute otitis
media is amoxicillin. If the bacteria are resistant or symptoms do not improve, then
amoxicillin-clavulanate should be utilized.
A 2-year-old boy is brought to the office by his mother because of complaints of fever
and ear pain. He began tugging on his ear and complaining of pain three days ago. The
mother reports a temperature of 37.8°C (100.0°F) this morning, with decreased
appetite. Current temperature is 38.6ºC (101.4ºF). ENT examination shows erythema
and decreased mobility of the right tympanic membrane. Which is the most appropriate
pharmacological management?
A. Amoxicillin
B. Azithromycin
C. Ceftriaxone
D. Ciprofloxacin
E. Piperacillin - Answers - A. Amoxicillin
Major takeaway
For uncomplicated acute otitis media, the first line pharmacological therapy is
amoxicillin. If amoxicillin does not resolve the symptoms, then the patient should be
switched to amoxicillin-clavulanate.
Main explanation
Acute otitis media is a bacterial or viral infection of the middle ear and is common in the
pediatric population. Risk factors include a recent upper respiratory infection, second-
hand tobacco smoke, and formula feeding. Symptoms of acute otitis media are otalgia
(ear pain), fever, fussiness, and fever. Ear discharge signifies perforation of the
tympanic membrane. A diagnosis is made using pneumatic otoscopy. First line
pharmacological therapy is amoxicillin. Amoxicillin will cover most typical organisms.
Flowever, there is increasing resistance to amoxicillin. If symptoms do not improve, then
amoxicillin-clavulanate should be given. Clavulanate is a ß-lactamase inhibitor and
potentiates the efficacy of amoxicillin.
,A 4-year-old boy is brought to the emergency department by his mother because of
fever and constant tugging of his left ear. Physical examination shows a swollen and
erythematous left ear canal that is tender to the touch. An opaque serum-like exudate is
seen oozing through the left tympanic membrane. An audiometry test shows bilateral
conductive hearing loss. Which of the following is the most likely causative microbe?
A. Proteus mirabilis
B. Pseudomonas aeruginosa
C. Staphylococcus aureus
D. Streptococcus pneumonia
E. Streptococcus pyogenes - Answers - D. Streptococcus pneumonia
Major takeaway
Streptococcus pneumoniae is the most common bacteria associated with acute otitis
media. Diagnosis is made using pneumatic otoscopy. Amoxicillin is the initial treatment
choice.
Main explanation
Acute otitis media is an infection common in children of the middle ear. Symptoms
include fussiness, fever, loss of appetite, tugging of the ear, and bilateral conductive
hearing loss. Breast milk has been shown to be protective against acute otitis media.
Second hand tobacco smoke is a major risk factor. Diagnosis of acute otitis media is
done using pneumatic otoscopy. Other characteristic symptoms include bulging of the
posterior quadrants of the tympanic membrane, scalded appearance of the superficial
epithelial layer, and a perforated tympanic membrane. The most commonly associated
bacteria with acute otitis media is Streptococcus pneumoniae. Other microbes include
Hemophilus influenza and Moraxella catarrhalis. Initial treatment of choice is amoxicillin.
However, if the patient's symptoms do not improve, then amoxicillin-clavulanate should
be given.
There is considerable debate about the use of tympanostomy tubes in the management
of recurrent otitis media in children. Tympanostomy tube placement has been proven to
A. improve hearing
B. prevent mastoiditis
C. prevent recurrence of effusion
D. prevent delayed language development - Answers - A. improve hearing
Hearing is improved with tympanostomy tubes by eliminating middle ear effusion when
the tubes are functioning properly.
The most reliable sign of acute otitis media (AOM) is
A. bulging of the tympanic membrane
B. loss of tympanic membrane mobility
C. reddening of the tympanic membrane
D. air bubbles behind the tympanic membrane - Answers - B. loss of tympanic
membrane mobility
Loss of tympanic membrane mobility during pneumoinsufflation is the most reliable sign
for diagnosing acute otitis media.
, A patient with Type 1 diabetes mellitus was treated for otitis externa of the right ear for 2
weeks with topical ear drops. The patient presents today with persistent, foul aural
discharge, granulations in the ear canal, and deep ear pain. Which of the following is
the proper treatment at this time?
A. ciprofloxacin (Cipro) IV
B. cefuroxime (Zinacef) IV
C. ampicillin-sulbactam (Unasyn) PO
D. azithromycin (Zithromax) PO - Answers - IV antibiotics directed against
Pseudomonas, the most likely etiology, is needed for the treatment of malignant otitis
media.
Which of the following is the most likely organism in a 2 year-old child with acute otitis
media?
A. Staphylococcus aureus
B. Moraxella catarrhalis
C. Pseudomonas aeruginosa
D. Streptococcus pneumoniae - Answers - The most common pathogens in children
with acute otitis media are Streptococcus pneumoniae, Haemophilus influenzae, and
Streptococcus pyogenes.
A 3 year-old patient is brought in with a 10 day history of clear nasal drainage and
cough which has now developed into otalgia and fever exceeding 101 degrees F for the
last 5 days. Mom denies other chronic medical problems. The patient has had similar
complaints three times in her life. Which of the following is the most likely causative
organism?
A. Mycoplasma pneumoniae
B. Pneumocystis jiroveci
C. Pseudomonas aeruginosa
D. Streptococcus pneumoniae - Answers - Acute otitis media is a bacterial infection of
the mucous lined air-containing spaces of the temporal bone most commonly caused by
Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes.
---SNAPSHOT--- A 9-month-old boy presents to your urgent care clinic for increased
irritability. One week prior to presentation, the patient had an upper respiratory infection,
which has since improved. Over the last day, the mother has noticed that the child has
been tugging at his right ear, refuses to lie down on it, and has had a fever. There is
right tympanic membrane erythema that is bulging and minimally mobile with pneumatic
otoscopy. - Answers - Acute Otitis Media
A 3-year-old boy presents to the pediatrician crying with ear pain and his temperature
has been 101°F (38.3°C) for several days. His mother states that other children at his
daycare center have been having similar symptoms. She further describes that he was
fed formula and was not breastfed. The mother admits that she smokes cigarettes daily.
On exam, the boy is irritable and crying, and frequently tugs on his left ear. Both
tympanic membranes appear erythematous, and the left appears opaque and bulging
