ENT Clinical Reference Guide
Condensed Comprehensive PANCE Review | All Conditions & High-Yield Pearls
1. EXTERNAL EAR DISORDERS
Acute Otitis Externa (AOE) Swimmer's Ear
Overview & Patho: Disruption of cerumen/skin barrier leading to infection of ear canal.
Etiology: Pseudomonas aeruginosa (41%, MCC overall), Staph aureus (15%), anaerobes, fungal.
Risk Factors: Swimming/water exposure, excess cleaning/Q-tips, trauma, hearing aids, eczema/psoriasis.
Clinical Presentation: Severe otalgia, pruritus, otorrhea, muffled hearing. Classic sign: Tragus/pinna movement causes severe pain.
Canal is edematous with yellow/white debris.
Treatment:
• TM Intact: Cortisporin drops (Neomycin/Polymyxin B/Hydrocortisone) or Fluoroquinolones (Cipro/Ofloxacin otic). Ear wicks if severe
edema.
• TM Perforated / Non-visualized: Topical Fluoroquinolones ONLY (Cipro, Ofloxacin). Avoid aminoglycosides/neomycin/alcohol
(ototoxic!).
• Severe/Immunocompromised: Combined topical + systemic antibiotics + ear culture.
PANCE Pearl: Pull pinna UP & BACK in adults, DOWN & BACK in kids. Keep ear dry for 7-10 days.
Otomycosis (Fungal Otitis Externa)
Etiology: Aspergillus (black spores) and Candida (white cottage-cheese exudate). Often follows recent topical/oral ABX use.
Presentation: Severe pruritus (more prominent than pain), minimal swelling/erythema.
Treatment: ENT referral for meticulous microscopic debridement + topical Clotrimazole 1% BID x 10-14 days. If TM perforated, use PO
antifungals (Fluconazole for Candida, Voriconazole for Aspergillus).
External Ear Dermatologic Conditions & EAC Malignancy
• Contact Dermatitis: Irritant/allergen exposure (e.g. poison ivy, earrings). Avoid agent, topical steroids.
• Atopic Dermatitis: Red, itchy canal. Managed with topical steroids.
• EAC Cancer: Squamous Cell Carcinoma is MCC of EAC malignancy. Persistent pain/otorrhea non-responsive to ABX. Urgent ENT
referral.
Malignant (Necrotizing) Otitis Externa (MOE)
Pathophysiology: Invasive necrotizing osteomyelitis of skull base spreading from EAC. 98% caused by Pseudomonas aeruginosa.
Risk Population: Elderly patients with Diabetes Mellitus (90%) or immunocompromised (HIV/chemo).
Clinical Presentation: Severe deep otalgia out of proportion to exam, foul otorrhea, non-responsive to topical ear drops.
Pathognomonic Exam: Granulation tissue at the bony-cartilaginous junction of EAC floor. May cause CN VII (Facial) palsy or lower
CN deficits.
Diagnosis: CT Head/Temporal Bone w/ contrast (bony erosion). ESR/CRP markedly elevated. Ear cultures.
Treatment: Admission + ENT/ID consult + IV Ciprofloxacin x 6-8 weeks (PO step-down once stable).
Black Box Warning: Ciprofloxacin risks include Achilles tendon rupture, C. diff, and QT prolongation.
Cerumen Impaction
Presentation: Conductive hearing loss ("underwater feeling"), fullness, pruritus, reflex cough (Vagus nerve stimulation).
Management:
• Warm Water Irrigation: Contraindicated if TM perforated, AOM, or history of ear tubes.
• Cerumenolytics: Carbamide peroxide (Debrox) 5-10 drops BID x 4 days.
• Manual Extraction: Curette under direct visualization. Avoid ear candling.
PANCE ENT High-Yield Clinical Summary Page 1 of 6
, Foreign Bodies (Auditory Canal & Auricle)
Auditory Canal: Common in children < 6 y/o.
• Insects: Kill/immobilize with 1% Lidocaine, mineral oil, or ethanol BEFORE removal.
• Button Batteries: EMERGENCY! Do NOT irrigate (causes tissue necrosis/corrosion). Immediate ENT removal.
• Vegetable Matter (Beans/Rice): Do NOT irrigate (swells with water). Manual removal.
Auricle / Embedded Earrings: Contact dermatitis or local infection. Earlobe infection = Keflex/Bactrim (Staph/Strep). Cartilage infection =
Cipro (Pseudomonas). Urgent removal required to avoid chondritis.
Perichondritis & Auricular Hematoma
Feature Auricular Hematoma Perichondritis
Definition Blood collection in subperichondrial space Infection of perichondrium surrounding ear cartilage
Etiology Blunt trauma (wrestlers, boxers, martial arts) High cartilage piercings, trauma, burns, surgery
Organism Non-infectious (initially) Pseudomonas aeruginosa (MCC), Staph aureus
Tender, fluctuant, violaceous collection on anterior pinna. Erythematous, swollen, warm, painful pinna. Earlobe
Key Exam
Earlobe spared. SPARED.
Complication Cartilage necrosis → Cauliflower Ear deformity Cartilage necrosis, abscess, severe deformity
Urgent I&D + compression dressing + 7d oral Cipro Oral Cipro (mild). If fluctuant/abscess: Admit + IV ABX +
Treatment
(Pseudomonas cover) Surgical I&D
2. MIDDLE EAR DISORDERS
Eustachian Tube Dysfunction (ETD)
Overview: Failure of ET to equalize pressure / clear secretions. Obstructive (MCC) or Patulous (fails to close). Common in children
(horizontal, short tube).
Triggers: URI, allergic rhinitis, altitude changes, adenoid hypertrophy.
Presentation: Ear fullness, popping/crackling, conductive hearing loss, autophony. Otoscopy: Retracted TM, decreased mobility on
pneumatic otoscopy.
Treatment: Treat underlying allergy/URI (nasal steroids, antihistamines). Modified Valsalva/swallowing. Short-term Afrin (<72h to avoid
rhinitis medicamentosa) for flight changes. Refractory: Tympanostomy tubes.
Acute Otitis Media (AOM) vs. Otitis Media with Effusion (OME)
Feature Acute Otitis Media (AOM) Otitis Media with Effusion (OME)
Infection Status Acute suppurative bacterial/viral infection Non-infectious sterile fluid collection
Etiology H. influenzae (MCC overall), S. pneumoniae, M. catarrhalis Residual fluid post-AOM or ETD
Systemic
Fever, otalgia, irritability, ear pulling No fever, no acute ear pain
Symptoms
Otoscopy Bulging TM with cloudy/erythematous appearance, Amber/cloudy fluid, air-fluid levels/bubbles, neutral or
Findings decreased mobility retracted TM
High-dose Amoxicillin 1st-line (80-90 mg/kg/day x 10d). See Watchful waiting (spontaneous resolution). Antibiotics/
Management
table below for details. steroids NOT indicated.
PANCE ENT High-Yield Clinical Summary Page 2 of 6
Condensed Comprehensive PANCE Review | All Conditions & High-Yield Pearls
1. EXTERNAL EAR DISORDERS
Acute Otitis Externa (AOE) Swimmer's Ear
Overview & Patho: Disruption of cerumen/skin barrier leading to infection of ear canal.
Etiology: Pseudomonas aeruginosa (41%, MCC overall), Staph aureus (15%), anaerobes, fungal.
Risk Factors: Swimming/water exposure, excess cleaning/Q-tips, trauma, hearing aids, eczema/psoriasis.
Clinical Presentation: Severe otalgia, pruritus, otorrhea, muffled hearing. Classic sign: Tragus/pinna movement causes severe pain.
Canal is edematous with yellow/white debris.
Treatment:
• TM Intact: Cortisporin drops (Neomycin/Polymyxin B/Hydrocortisone) or Fluoroquinolones (Cipro/Ofloxacin otic). Ear wicks if severe
edema.
• TM Perforated / Non-visualized: Topical Fluoroquinolones ONLY (Cipro, Ofloxacin). Avoid aminoglycosides/neomycin/alcohol
(ototoxic!).
• Severe/Immunocompromised: Combined topical + systemic antibiotics + ear culture.
PANCE Pearl: Pull pinna UP & BACK in adults, DOWN & BACK in kids. Keep ear dry for 7-10 days.
Otomycosis (Fungal Otitis Externa)
Etiology: Aspergillus (black spores) and Candida (white cottage-cheese exudate). Often follows recent topical/oral ABX use.
Presentation: Severe pruritus (more prominent than pain), minimal swelling/erythema.
Treatment: ENT referral for meticulous microscopic debridement + topical Clotrimazole 1% BID x 10-14 days. If TM perforated, use PO
antifungals (Fluconazole for Candida, Voriconazole for Aspergillus).
External Ear Dermatologic Conditions & EAC Malignancy
• Contact Dermatitis: Irritant/allergen exposure (e.g. poison ivy, earrings). Avoid agent, topical steroids.
• Atopic Dermatitis: Red, itchy canal. Managed with topical steroids.
• EAC Cancer: Squamous Cell Carcinoma is MCC of EAC malignancy. Persistent pain/otorrhea non-responsive to ABX. Urgent ENT
referral.
Malignant (Necrotizing) Otitis Externa (MOE)
Pathophysiology: Invasive necrotizing osteomyelitis of skull base spreading from EAC. 98% caused by Pseudomonas aeruginosa.
Risk Population: Elderly patients with Diabetes Mellitus (90%) or immunocompromised (HIV/chemo).
Clinical Presentation: Severe deep otalgia out of proportion to exam, foul otorrhea, non-responsive to topical ear drops.
Pathognomonic Exam: Granulation tissue at the bony-cartilaginous junction of EAC floor. May cause CN VII (Facial) palsy or lower
CN deficits.
Diagnosis: CT Head/Temporal Bone w/ contrast (bony erosion). ESR/CRP markedly elevated. Ear cultures.
Treatment: Admission + ENT/ID consult + IV Ciprofloxacin x 6-8 weeks (PO step-down once stable).
Black Box Warning: Ciprofloxacin risks include Achilles tendon rupture, C. diff, and QT prolongation.
Cerumen Impaction
Presentation: Conductive hearing loss ("underwater feeling"), fullness, pruritus, reflex cough (Vagus nerve stimulation).
Management:
• Warm Water Irrigation: Contraindicated if TM perforated, AOM, or history of ear tubes.
• Cerumenolytics: Carbamide peroxide (Debrox) 5-10 drops BID x 4 days.
• Manual Extraction: Curette under direct visualization. Avoid ear candling.
PANCE ENT High-Yield Clinical Summary Page 1 of 6
, Foreign Bodies (Auditory Canal & Auricle)
Auditory Canal: Common in children < 6 y/o.
• Insects: Kill/immobilize with 1% Lidocaine, mineral oil, or ethanol BEFORE removal.
• Button Batteries: EMERGENCY! Do NOT irrigate (causes tissue necrosis/corrosion). Immediate ENT removal.
• Vegetable Matter (Beans/Rice): Do NOT irrigate (swells with water). Manual removal.
Auricle / Embedded Earrings: Contact dermatitis or local infection. Earlobe infection = Keflex/Bactrim (Staph/Strep). Cartilage infection =
Cipro (Pseudomonas). Urgent removal required to avoid chondritis.
Perichondritis & Auricular Hematoma
Feature Auricular Hematoma Perichondritis
Definition Blood collection in subperichondrial space Infection of perichondrium surrounding ear cartilage
Etiology Blunt trauma (wrestlers, boxers, martial arts) High cartilage piercings, trauma, burns, surgery
Organism Non-infectious (initially) Pseudomonas aeruginosa (MCC), Staph aureus
Tender, fluctuant, violaceous collection on anterior pinna. Erythematous, swollen, warm, painful pinna. Earlobe
Key Exam
Earlobe spared. SPARED.
Complication Cartilage necrosis → Cauliflower Ear deformity Cartilage necrosis, abscess, severe deformity
Urgent I&D + compression dressing + 7d oral Cipro Oral Cipro (mild). If fluctuant/abscess: Admit + IV ABX +
Treatment
(Pseudomonas cover) Surgical I&D
2. MIDDLE EAR DISORDERS
Eustachian Tube Dysfunction (ETD)
Overview: Failure of ET to equalize pressure / clear secretions. Obstructive (MCC) or Patulous (fails to close). Common in children
(horizontal, short tube).
Triggers: URI, allergic rhinitis, altitude changes, adenoid hypertrophy.
Presentation: Ear fullness, popping/crackling, conductive hearing loss, autophony. Otoscopy: Retracted TM, decreased mobility on
pneumatic otoscopy.
Treatment: Treat underlying allergy/URI (nasal steroids, antihistamines). Modified Valsalva/swallowing. Short-term Afrin (<72h to avoid
rhinitis medicamentosa) for flight changes. Refractory: Tympanostomy tubes.
Acute Otitis Media (AOM) vs. Otitis Media with Effusion (OME)
Feature Acute Otitis Media (AOM) Otitis Media with Effusion (OME)
Infection Status Acute suppurative bacterial/viral infection Non-infectious sterile fluid collection
Etiology H. influenzae (MCC overall), S. pneumoniae, M. catarrhalis Residual fluid post-AOM or ETD
Systemic
Fever, otalgia, irritability, ear pulling No fever, no acute ear pain
Symptoms
Otoscopy Bulging TM with cloudy/erythematous appearance, Amber/cloudy fluid, air-fluid levels/bubbles, neutral or
Findings decreased mobility retracted TM
High-dose Amoxicillin 1st-line (80-90 mg/kg/day x 10d). See Watchful waiting (spontaneous resolution). Antibiotics/
Management
table below for details. steroids NOT indicated.
PANCE ENT High-Yield Clinical Summary Page 2 of 6
