ENT FINAL EXAMS QUESIONS AND ANSWERS 2022 COMPLETE SOLUTION

ENT FINAL EXAMS QUESIONS AND ANSWERS 2022 COMPLETE SOLUTION 1. A 63-year-old male presents with an asymptomatic lesion in his mouth that was discovered by his dentist at a check-up. It is ill marginated with pigment ranging from medium brown to black. Parts of the lesion are raised. What is the next appropriate step in management? A. Have the patient return in 30 days to see if the lesion resolves on its own. B. KOH prep of the lesion C. Biopsy D. Call your supervising physician Expl: pt has oral melanoma 2. Which of the following areas is the most common site for epistaxis to occur? A. Arterioles off the external carotid artery B. Arterioles off the internal carotid artery C. Stensen's Plexus D. Kiesselbach's Plexus 3. Which of the following is the most common cause for hearing loss? A. Acoustic Neuroma B. Presbycusis C. Cerumen impaction D. Vestibular Neuritis 4. A 37-year-old woman comes to your office for assessment of hearing loss. She has had problems intermittently for the past 12 months. On examination, the Weber tuning fork test lateralizes to the right ear, and the Rinne tuning fork test is negative in the right ear (bone conduction is greater than air conduction [BC > AC]). This suggests which of the following? A. a right-sided conductive hearing loss B. a left-sided conductive hearing loss C. a right-sided sensorineural hearing loss D. a left-sided sensorineural hearing loss Expl: Lateralization indicates the bad ear 5. Your patient is a 63 year old female that has a history of HTN and CAD. She has had a 3 month history of recurrent episodes of vertigo. These episodes tend to occur when she lays back in bed with her head not propped up. Her ENT exam is unremarkable. She has had an MRI of her brain that was negative as well as carotid dopplers. Which of the following is the most likely diagnosis? A. Meniere's Disease B. Benign Paroxysmal Positional Vertigo (BPPV ) C. Vestibular Neuritis D. Cerebellar Infarct 6. Which of the following disorders is characterized by a "thumb sign" on a soft tissue neck xray? A. Laryngitis B. Croup C. Epiglottitis D. Foreign Body 7. Your patient is a 23 year old female that presents with white plaques on tongue. She has no history of chemotherapy, dentures, oral inhaled glucocorticoids, or radiation therapy. She is not a diabetic. Which of the following is the most likely etiology of her symptoms? A. HIV (oral thrush) B. Smokeless tobacco C. Aphthous ulcers D. HSV 8. Which of the following is the most appropriate management for an auricular hematoma? A. Observation (can lead to cauliflower ear) B. Incision and drainage C. Ice for 20 minutes 4 times per day. D. Start cephalexin 9. Which of the following is not an etiology of tinnitus? A. ASA B. Congenital AV Malformations C. Cerumen Impaction D. Vascular Pathology 10. Which of the following bacteria is the most common cause of bacterial tonsillitis? A. Group A Streptococcus B. Neisseria Gonorrhea C. Mycoplasma D. Proteus 11. Which of the following conditions are not associated with allergic rhinitis? A. Atopic Dermatitis B. Urticaria C. Sinusitis D. Asthma 12. A 37-year-old woman comes to your office for assessment of hearing loss. She has had problems intermittently for the past 12 months. On examination, the Weber tuning fork test lateralizes to the right ear, and the Rinne tuning fork test is negative in the right ear (bone conduction is greater than air conduction [BC > AC]). This suggests which of the following? A. a right-sided conductive hearing loss B. a left-sided conductive hearing loss C. a right-sided sensorineural hearing loss D. a left-sided sensorineural hearing loss 13. First-line intervention for anterior epistaxis includes: A. Nasal packing B. Application of topical thrombin C. Firm pressure to the area superior to the nasal alar cartilage D. Chemical cauterization 14. A 45-year-old man presents with otitis externa. Likely causative pathogens include all of the following except: A. Fungal agents B. P. aeruginosa C. S. aureus D. M. catarrhalis 15. Physical exam findings in otitis externa include: A. Tympanic membrane immobility B. Increased ear pain with tragus palpation C. Tympanic membrane erythema D. Tympanic membrane bullae 16. A risk factor for malignant external otitis includes: A. The presence of an immunocompromised condition B. Age younger than 21 years C. A history of a recent URI D. A complicated course of otitis media with effusion 17. Expected findings in AOM include: A. Prominent bony landmarks B. Tympanic membrane immobility C. Itchiness and crackling in the affected ear (otitis externa) D. Submental lymphadenopathy 18. Which of the following is absent in otitis media with effusion? A. Fluid in the middle ear B. Hearing loss C. Fever D. Retracted TM 19. An 18-year-old woman has a chief complaint of a "sore throat and swollen glands" for the past 3 days. Her physical exam includes a temp of 101F, exudative pharyngitis, and tender anterior cervical lymphadenopathy. Right and left upper quadrant abdominal tenderness is absent. The most likely diagnosis is: A. Streptococcus pyogenes pharyngitis B. Infectious mononucleosis (posterior lymphadenopathy) C. Viral pharyngitis D. Vincent angina 20. Treatment options for streptococcal pharyngitis for a patient with PCN allergies include all of the following except: A. Azithromycin B. Trimethoprim-sulfamethoxazole C. Clarithromycin D. Erythromycin 21. Clinical presentation of peritonsillar abscesses includes A. Occipital lymphadenopathy B. Congested cough C. Muffled "hot potato" voice D. Abdominal pain 22. You prescribe nasal corticosteroid spray for a patient with allergic rhinitis. What is the anticipated onset of symptom relief with its use? A. Immediately with the first spray B. 1-2 days C. A few days to a week D. 2 or more weeks 23. Which of the following findings is most consistent with the diagnosis of acute bacterial rhinosinusitis (ABRS)? A. URIs persisting beyond 10 days B. Mild midfacial fullness and tenderness C. Preauricular lymphadenopathy D. Marked eyelid edema 24. The most common causative bacterial pathogen in ABRS is: A. M. pneumoniae B. S. pneumoniae C. M. catarrhalis D. H. influenzae 25. Which of the following is inconsistent with the clinical presentation of ABRS? A. Nasal congestion responsive to decongestant use B. Maxillary toothache C. Colored nasal discharge D. Antecedent event such as acute respiratory tract infection or allergic rhinitis 26. Which of the following is a first-line therapy for the treatment of ABRS in an adult with no recent antimicrobial use? A. Amoxicillin B. Trimethoprim-sulfamethoxazole C. Clarithromycin D. Levofloxacin 27. Which of the following represents a therapeutic option for ABRS in a patient with no recent antimicrobial care with treatment failure after 72 hours of appropriate-dose first-line antimicrobial therapy? (Amoxicillin) A. Clindamycin B. Clarithromycin C. Ofloxacin D. High-dose amoxicillin with clavulanate 28. Which of the following best describes hearing loss associated with presbycusis? A. Rapidly progressive, often asymmetric, and in all frequencies B. Slowly progressive, usually symmetric and predominantly high frequencies C. Variable in progression, usually unilateral, and in the midrange frequencies D. Primarily conductive and bilateral with slow progress 29. Allergies present in the nose as what? A. Red, swollen nasal mucosa with clear, watery discharge B. Pale, swollen nasal mucosa with clear, watery discharge C. Unilateral nasal discharge D. Bleeding 30. Which of the following conditions is described as rhinorrhea, itching of nose and eyes, lacrimation, nasal congestion, and sneezing. Turbinates appear pale or violet in color, and their surface is smooth and glistening. A. Sinusitis B. Acute rhinitis C. Allergic rhinitis 31. Anterior epistaxis is usually caused by: A. hypertension B. bleeding disorders C. localized nasal mucosa trauma D. a foreign body 32. A 25-year-old woman has a 3-day-history of left ear pain that began after 1 week of URI symptoms. On physical examination, you find that she has AOM. She is allergic to penicillin (use results in a hive-form reaction). The most appropriate antimicrobial option for this patient is: A. ciprofloxacin B. clarithromycin C. amoxicillin D. cephalexin 33. The best and most reproducible sign of acute inflammation of the middle ear is: A. Erythema of the TM B. Bulging of the TM C. Opaque TM D. Immobility of the TM 34. A 22-month-old female patient is brought to you crying and in obvious acute distress from right ear pain. She has a fever of 103.6oF, and has an immobile, bulging erythematous right TM. The best treatment option would be: A. Start antibiotics immediately B. Do not use antibiotics because this is probably a viral illness C. Have the parents observe for 24-48 hours and treat with antibiotics if the child does not improve D. Treat with anesthetic ear drops alone 35. 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. A. Otosclerosis B. Malignant otitis externa C. Acute otitis externa D. Acute otitis media E. Otitis media with effusion ANS: OTITIS MEDIA Expl: Symptoms: o fever o irritability o headache o poor oral intake and nausea o otalgia (most common complaint) - best predictor of acute otitis media 36 .A 56-year-old man presents to your office for excessive fatigue. He complains of falling asleep all the time at work, which is “very distressing" as it has been affecting his work. He denies sudden loss of muscle tone or hallucinations before or after falling asleep. His wife reports that he snores at night. A physical examination demonstrates an obese, lethargic man with unremarkable findings. A. Chronic fatigue syndrome B. Circadian rhythm sleep wake disorder C. Hypothyroidism D. Narcolepsy E. Obstructive sleep apnea ANS: Obstructive sleep apnea Expl: Obstructive sleep apnea (OSA) is common in obese individuals with large neck circumference and presents with nighttime awakenings, choking sensation and/or snoring, excessive daytime sleepiness, and (potentially) tachycardia and hypertension. Vs. Narcolepsy presents with excessive sleepiness and falling asleep inappropriately, as in this patient. However, other common symptoms of cataplexy, hypnagogic/hypnopompic hallucinations and sleep paralysis are not seen in this patient. Given the patient’s obesity, large neck circumference, multiple nighttime awakenings, headaches, tachycardia and hypertension, OSA is more likely. 37. A 8-year-old boy presents to the pediatric emergency department for a nose bleed. His symptoms began after he was hit in the face with a basketball. He denies any shortness of breath, hemoptysis, or hematemesis. Family history is unremarkable. On physical examination, there is small volume bleeding. He is asked to bend at the waist and press on his nasal alae. Hemostasis is eventually achieved. ANS: Anterior epistaxis Expl: Bleeding from the nose: • Anterior epistaxis (anterior nose bleed) o small volume bleed o damage to Kiesselbach plexus which results in bleeding • posterior epistaxis (posterior nose bleed) o large volume bleed o damage to the posterolateral branches of sphenopalatine artery 38. A 14-year-old boy presents with recurrent nasal congestion and left suborbital pain of 2 weeks duration. 1 week prior to the onset of these symptoms, he described having a "cold." On physical exam, there is pain over the left maxillary sinus. A CT of the head is shown. A.Acute viral rhinosinusitis B.Acute bacterial rhinosinusitis C.Subacute bacterial rhinosinusitis D.Allergic rhinitis E.Chronic rhinosinusitis Ans: Acute Bacterial sinusitis 39. A 29-year-old man presents with unresolved left ear pain for the past 5 months. He also states to having a relative hearing loss of the left ear with occasional tinnitus. Medical history is significant for otitis media that was treated with appropriate antibiotics. He reports completing the course of antibiotics. On physical examination, there is an amorphous, white debri in the left middle ear. Preparations are made to undergo a non-contrast computer tomography (CT) scan of the temporal bone. A. Acute otitis externa B. Cholesteatoma C. Foreign body D. Schwannoma E. Tympanosclerosis 40. A 26-year-old woman presents to her primary care physician for severe dizziness spells. Her dizziness is described as the room is spinning, and it typically lasts a few minutes. Her symptoms are associated with nausea and "ear ringing." At times she feels like her left ear has decreased hearing. She denies any lightheadedness or palpitations. Physical examination is unremarkable. She is referred for audiometry testing and was urged to decrease her salt and caffeine intake. She is prescribed meclizine for symptomatic improvement. A. Benign paroxysmal positional vertigo B. Meniere disease C. Migraine D. Transient ischemic attack E. Vestibular neuritis 41. a 7 year old girl presents to peds for headache and sore throat. Sx began a few days prior and fever 101 F, mild abdominal pain, cough, and poor oral intake. No history of hoarseness, conjunctivitis, or coryza (viral pharyngitis). (I THINK IT SAID SHE HAD CERVICAL LYMPHADENOPATHY ON PHYSICAL) o Bacterial pharyngitis 42. First-line therapy for angular cheilitis therapy includes the use of: A. metronidazole gel B. hydrocortisone cream C. topical nystatin D. oral ketoconazole 43. Your patient is a 54 year old male that presents with a runny nose and cough. The patent is also complaining of vertigo, tinnitus, and right sided hearing loss. Which of the following is the most likely diagnosis? A. Labyrinthitis B. Acute Vestibular Neuritis C. Cerumen impaction D. Benign Postural Positional Vertigo 44. Which of the following has NOT been identified as a risk factor for barotrauma to the tympanic membrane? A. Diving B. Flying C. Allergic Rhinitis D. Blast Injuries 45. All of the following are causes of otitis externa except? A. Trauma (Q-tips or scratch) B. Infection C. Allergic contact dermatitis D. Cerumen impaction 46. Which of the following is the most common organism causing mastoiditis? A. H. Influenzae B. S. Aureus C. S. Pneumoniae D. Group B Hemolytic Strep 47. Your patient is a 45 year old male that presents with episodic vertigo, hearing loss, and tinnitus over the last year. His Brain MRI was unremarkable. He has had no preceding viral syndrome. Which of the following is the most likely diagnosis? A. Benign Postural Peripheral Vertigo B. Vestibular Neuritis C. Labyrinthitis D. Meniere's Disease 48. A 54 year old male presents with fever, trismus, dysphagia, and a sore throat. Which of the following is the most likely diagnosis? A. Parotitis B. Sialadenitis C. Peritonsillar abscess D. GERD 49. Your patient is a 3 year-old male that presents with a bulging right tympanic membrane and a fever of 103.0. He has just finished a course of amoxicillin 14 days ago. Which of the following is the most appropriate treatment? A. High-dose amoxicillin B. Augmentin C. Keflex D. Cipro 50. Your patient is a 45 year old male that is not immunized. He presents with a fever of 102, dysphagia, drooling, and shortness of breath. Lungs are clear. O2 Sat 100%. Pulse 102. RR-24. Soft tissue neck reveals a thumb sign. All of the following are acceptable management plans except: A. Give a Racemic Epinephrine aerosol treatment and discharge the patient home on steroids B. Begin Ceftriaxone C. Intubate the patient in the operation room D. Consult anesthesia or ENT 51. Which of the following is NOT true about peritonsillar abscess? A. Group A Streptococcus is the most common organism B. MRI of the soft tissue neck is the imaging study of choice for confirmation C. Appropriate empiric antibiotic therapy includes clindamycin D. Abscess may be confirmed by aspirating pus from the peritonsillar fold 52. All of the following are potential etiologies for parotitis except? A. Stensen's Duct obstructed with a stone B. Retrograde salivary stasis and seeding in Stensen's Duct C. Staphylococcus aureus D. Streptococcus Virdans 53. A 23-year-old woman comes to your office with a 6-month history of dizziness. She "feels dizzy" when she stands up (as if she is going to faint). The sensation disappears within a minute. She has a history of major depression. She started taking doxepin 6 months ago, and her depression has improved much since that time. The patient's blood pressure is 140/ 90 mm Hg sitting and decreases to 90/ 70 mm Hg when she stands. There is no ataxia, nystagmus, or other symptoms. What is the most likely diagnosis in this patient? A. vestibular neuronitis B. acute labyrinthitis C. benign positional paroxysmal vertigo D. orthostatic hypotension 54. You inspect the oral cavity of a 69-year-old man who has a 100-pack-year cigarette smoking history. You find a lesion suspicious for malignancy and describe it as: A. Raised, red and painful B. A denuded patch with a removable white coating C. An ulcerated lesion with indurated margins D. A vesicular-form lesion with macerated margins 55. A firm, painless, relatively fixed submandibular node would most likely be seen in the diagnosis of: A. Herpes simplex B. Acute otitis media C. Bacterial pharyngitis D. Oral cancer 56. A 25-year-old woman who has seasonal allergic rhinitis likes to spend time outdoors. She asks you when the pollen count is likely to be the lowest. You respond: A. Early in the morning B. During breezy times of the day C. After a rain shower D. When the sky is overcast 57. A 57-year-old female patient of yours presents with dizziness and a sensation that she is spinning. It occurs when she turns in bed or lifts her head to look in an upper cabinet. Episodes are brief but are becoming more frequent. She has no tinnitus or hearing loss. The most likely diagnosis would be: A. Meniere's Disease B. Benign paroxysmal positional vertigo (BPPV) C. Vestibular neuronitis D. Acoustic neuroma 58. A 26-year-old female presents with a whitish coating on her tongue and lips. When you attempt to rub the plaque with a tongue depressor, a small amount of bleeding is noted from the oral mucosa. Her past medical history includes asthma. What diagnostic test would you perform to confirm your diagnosis? A. A culture and sensitivity B. A wet mount potassium hydroxide preparation C. A gram stain D. A rapid strep test 59. A 60-year-old male presents with complaints of irritation and a white plaque on his tongue. He denies pain. During physical exam you are unable to remove the white plaque from the mucosa with a tongue depressor. What is the most likely diagnosis, represented as follows? A. Glossitis B. Geographic tongue C. Lichen Planus D. Oral leukoplakia 60. A 45-year-old male presents with purulent discharge from his right ear for three weeks. He states that despite being treated by his family doctor for an ear infection one month ago, the problem continues to get worse. Upon exam, you note purulent discharge in the ear canal, an erythemic tympanic membrane, and a possible perforation. What are the pathogens most likely to culture positive? A. Strep pneumoniae B. Pseudomonas C. E. coli D. Candida albicans E. mycoplasma 61. A 38-year-old woman comes to your office with a 1-year history of episodic dizziness, ringing in both ears, a feeling of aural fullness, and hearing loss. The symptoms come on every 1 or 2 weeks and usually last for 12 hours. Nausea and vomiting are present. When asked to describe the dizziness, the patient says, “The world is spinning around me.” On physical examination, the patient has horizontal nystagmus. The slow phase of the nystagmus is to the left, and the rapid phase is to the right. Audiograms reveal bilateral sensorineural hearing loss in the low frequencies. What is the most likely diagnosis in this patient? A. vestibular neuronitis B. acute labyrinthitis C. positional paroxysmal vertigo D. orthostatic hypotension E. Meniere disease 62. Your patient is a 34-year-old male that has had maxillary sinus pressure and purulent drainage for 3 weeks. The patient has had a history of anaphylaxis with penicillin. Which of the following is the most appropriate antibiotic choice? A. Augmentin B. Cephalexin C. Amoxicillin D. Bactrim 63. Your patient is a 54 year-old male that presents with headaches, decreased hearing out of the right ear, right side facial paresthesias. The MRI of brain reveals a 2 x 3 cm right sided acoustic neuroma. Which of the following is not true regarding acoustic neuromas? A. Chemotherapy is the cornerstone of therapy B. Bilateral acoustic neuromas should increase a suspicion for neurofibromatosis C. Bilateral acoustic neuromas should increase a suspicion for neurofibromatosis D. You can have decreased taste or taste disturbances with these 64. Your patient is a 72 year-old female that presents with recurrent nose bleeds of right nostril and has right sided cervical lymphadenopathy. She is not on any anticoagulants. Her labs including INR, CBC and PTT are normal. Which of the following is the most likely diagnosis? A. Blood dyscrasia B Thrombocytopenia C. AV malformation D. Malignancy 65. Which of the following is the most appropriate management for an auricular hematoma? A. Observation B. Incision and drainage C. Ice for 20 minutes 4 times per day D. Start cephalexin 66. Which of the following bacteria is not a possible cause of bacterial tonsillitis? A. Group A Streptococcus B. Neisseria Gonorrhea C. Mycoplasma D. Proteus 67. Your patient is 54 year old immunocompetent male that presents with right sided parotitis, trismus, and a fever of 101.6. Which of the following antibiotic regimens are most appropriate? A. Naficillin and Metronidazole B. Naficillin C. Metronidazole D. Azithromycin 68. Your patient is a 54 year old male that presents with erythema and redness to the right submandibular area. There is no pain to palpation over the floor of the mouth. Physical exam of the mouth reveals pus covering from the salivary duct. There is no dental pain or trismus. Which of the following is not true regarding the patient's condition? A. Usually resolves in 7-10 days with antibiotics B. Typically responds to Keflex or dicloxacillin C. If the diagnosis is in question an ultrasound of the neck is the best imaging modality D. Can be caused by salivary duct stone 69. Your patient is a 65 year old male that presents with Fordyce spots noted in his oral cavity. What is the likely etiology of these? A. Mucocele B. Melanoma C. Amalgam tattoo D. Benign Sebaceous Cyst Tumor 70. A 30-year-old man comes to your office for assessment of dizziness. The dizziness occurs when he rolls over from the lying position to either the left side or the right side. It also occurs when he is looking up. He describes a sensation of “the world spinning around” him. The episodes usually last 10 to 15 seconds. They have been occurring for the past 6 months and occur on average one or two times per day. A. vestibular neuronitis B. acute labyrinthitis C. positional paroxysmal vertigo D. meniere disease 71. A 39-year-old woman comes to your office with a 2-day history of “unrelenting dizziness.” The room feels like it is spinning, and there is associated nausea and vomiting. There has been no hearing loss, tinnitus, or sensation of aural fullness. The patient has just recovered from an upper respiratory tract infection. The patient is afebrile. On examination, nystagmus is present. The slow phase of the nystagmus is toward the left, and the rapid phase of the nystagmus is toward the right. There is a significant ataxia present. A. vestibular neuronitis B. acute labyrinthitis C. positional vertigo D. othostatic hypotension Answers: 1. C. Biopsy 2. D. Kiesselbach's Plexus 3. B. Presbycusis 4. A. a right-sided conductive hearing loss 5. B. Benign Paroxysmal Positional Vertigo (BPPV ) 6. C. Epiglottitis 7. A. HIV 8. B. Incision and drainage 9. C. Cerumen Impaction 10. A. Group A Streptococcus 11. C. Sinusitis 12. A. a right-sided conductive hearing loss 13. C. Firm pressure to the area superior to the nasal alar cartilage 14. D. M. catarrhalis 15. B. Increased ear pain with tragus palpation 16. A. The presence of an immunocompromised condition 17. B. Tympanic membrane immobility 18. C. Fever 19. A. Streptococcus pyogenes pharyngitis 20. B. Trimethoprim-sulfamethoxazole 21. C. Muffled "hot potato" voice 22. C. A few days to a week 23. A. URIs persisting beyond 10 days 24. B. S. pneumoniae 25. A. Nasal congestion responsive to decongestant use 26. A. Amoxicillin 27. D. High-dose amoxicillin with clavulanate 28. B. Slowly progressive, usually symmetric and predominantly high frequencies 29. B. Pale, swollen nasal mucosa with clear, watery discharge 30. C. Allergic rhinitis 31. C. localized nasal mucosa trauma 32. B. clarithromycin 33. B. Bulging of the TM 34. A. Start antibiotics immediately 35. D. Acute otitis media 36. E. Obstructive sleep apnea 37. Anterior epistaxis 38. B.Acute bacterial rhinosinusitis 39. B. Cholesteatoma 40. B. Meniere disease 41. Bacterial pharyngitis 42. C. topical nystatin 43. A. Labyrinthitis 44. C. Allergic Rhinitis 45. D. Cerumen impaction 46. C. S. Pneumoniae 47. D. Meniere's Disease 48. C. Peritonsillar abscess 49. B. Augmentin 50. A. Give a Racemic Epinephrine aerosol treatment and discharge the patient home on steroids 51. B. MRI of the soft tissue neck is the imaging study of choice for 52. D. Streptococcus Virdans 53. D. orthostatic hypotension 54. C. An ulcerated lesion with indurated margins 55. D. Oral cancer 56. C. After a rain shower 57. B. Benign paroxysmal positional vertigo 58. B. A wet mount potassium hydroxide preparation 59. D. Oral leukoplakia 60. B. Pseudomonas 61. E. Meniere disease 62. D. Bactrim 63. A. Chemotherapy is the cornerstone of therapy 64. D. Malignancy 65. B. Incision and drainage 66. D. Proteus 67. A. Naficillin And Metronidazole 68. C. If the diagnosis is in question an ultrasound of the neck is the best imaging modality 69. D. Benign Sebaceous Cyst Tumor 70. C. positional paroxysmal vertigo 71. A. vestibular neuronitis A 38-year-old woman comes to your office with a 1-year history of episodic dizziness, ringing in both ears, a feeling of aural fullness, and hearing loss. The symptoms come on every 1 or 2 weeks and usually last for 12 hours. Nausea and vomiting are present. When asked to describe the dizziness, the patient says, “The world is spinning around me.” On physical examination, the patient has horizontal nystagmus. The slow phase of the nystagmus is to the left, and the rapid phase is to the right. Audiograms reveal bilateral sensorineural hearing loss in the low frequencies. 1.What is the treatment A. vestibular neuronitis B. acute labyrinthitis C. positional paroxysmal vertigo D. orthostatic hypotension E. Meniere disease 2. The treatment of this disorder includes each of the following except: A. decreased caffeine intake B. decreased alcohol intake C. use of a thiazide diuretic D. salt restriction E. Epley maneuvers 3. All except which of the following are true regarding this disease? A. it is also known as primary endolymphatic hydrops B. surgery is a treatment option C. there is a low-frequency sensorineural hearing loss D. steroids are a treatment option E. vertigo can be treated with benzodiazepines A 23-year-old woman comes to your office with a 6-month history of dizziness. She "feels dizzy" when she stands up (as if she is going to faint). The sensation disappears within a minute. She has a history of major depression. She started taking doxepin 6 months ago, and her depression has improved much since that time. The patient's blood pressure is 140/ 90 mm Hg sitting and decreases to 90/ 70 mm Hg when she stands. There is no ataxia, nystagmus, or other symptoms. 4. What is the most likely diagnosis in this patient? A. vestibular neuronitis B. acute labyrinthitis C. benign positional paroxysmal vertigo D. orthostatic hypotension 5. What is the best treatment for this patient? A. an antiemetric b. increase antidepressant dose c. education and reassurance d. epley maneuvers e. prednisone A 30-year-old man comes to your office for assessment of dizziness. The dizziness occurs when he rolls over from the lying position to either the left side or the right side. It also occurs when he is looking up. He describes a sensation of “the world spinning around” him. The episodes usually last 10 to 15 seconds. They have been occurring for the past 6 months and occur on average one or two times per day. 6. What is the most likely diagnosis in this patient? a. vestibular neuronitis b. acute labyrinthitis c. positional paroxysmal vertigo d. orthostatic hypotension e. Ménière disease 7. What is the treatment of choice for this patient? a. avoidance of alcohol and caffeine b. dimenhydrinate c. a thiazide diuretic d. reassurance and simple exercises e. endolymphatic surgery A 39-year-old woman comes to your office with a 2-day history of “unrelenting dizziness.” The room feels like it is spinning, and there is associated nausea and vomiting. There has been no hearing loss, tinnitus, or sensation of aural fullness. The patient has just recovered from an upper respiratory tract infection. The patient is afebrile. On examination, nystagmus is present. The slow phase of the nystagmus is toward the left, and the rapid phase of the nystagmus is toward the right. There is a significant ataxia present. 8. What is the most likely diagnosis in this patient? a. vestibular neuronitis b. acute labyrinthitis c. positional vertigo d. orthostatic hypotension e. Ménière disease 9. What is the treatment of choice for this patient? a. avoidance of alcohol and caffeine b. a thiazide diuretic c. endolymphatic surgery d. reassurance and antiemetics e. antibiotics The patient returns to your office the next day saying her ear hurts and she cannot taste anything in her mouth. The vertigo has not improved. On examination, you notice crops of vesicles on the pinna of the left ear and a subtle left facial droop. 10. What is the most likely diagnosis? a. Lyme disease b. impetigo c. otitis externa d. Ramsay Hunt syndrome e. lacunar stroke 11. What is the treatment for the diagnosis? a. oral antibiotics b. prednisone c. acyclovir d. prednisone and acyclovir e. hospitalization and intravenous antibiotics A 26-year-old woman comes to your office with a 6-day history of severe dizziness associated with ataxia and right-sided hearing loss. She had an upper respiratory tract infection 1 week ago. At that time, her right ear felt plugged. On examination, there is fluid behind the right eardrum. There is horizontal nystagmus present, with the slow component to the right and the quick component to the left. Ataxia is present. 12. What is the most likely diagnosis in this patient? a. vestibular neuronitis b. acute labyrinthitis c. positional vertigo d. orthostatic hypotension e. Ménière disease 13. What is the treatment of choice for this patient? a. avoidance of caffeine and alcohol b. a thiazide diuretic c. endolymphatic surgery d. rest and antiemetics e. none of the above The patient returns to your office 2 days later stating that she had fever throughout the night. She continues to have all the symptoms she had before but overall feels worse and woke this morning in a sweat. On examination, her temperature is 39.5° C, pulse is 122 beats per minute, and blood pressure is 96/60 mm Hg. She appears ill. 14. What is the likely reason for the change in symptoms? a. misdiagnosed sinusitis b. conversion to bacterial labyrinthitis c. acute otitis media d. worsening of her viral illness e. viral meningitis 15. What is the current treatment of choice? a. education and reassurance b. hospitalization and intravenous antibiotics c. lumbar puncture d. prednisone e. anticholinergics Hearing Loss in Adults 16. What is the most common cause of sensorineural hearing loss in the adult population? a. Ménière disease b. chronic otitis media c. presbycusis d. otosclerosis e. mastoiditis 17. What is the most common cause of conductive hearing loss in adults who have normalappearing tympanic membranes? a. Ménière disease b. chronic otitis media c. presbycusis d. otosclerosis e. mastoiditis A 37-year-old woman comes to your office for assessment of hearing loss. She has had problems intermittently for the past 12 months. On examination, the Weber tuning fork test lateralizes to the right ear, and the Rinne tuning fork test is negative in the right ear (bone conduction is greater than air conduction [BC > AC]). 18. This suggests which of the following? a. a right-sided conductive hearing loss b. a left-sided conductive hearing loss c. a right-sided sensorineural hearing loss d. a left-sided sensorineural hearing loss e. a or d A 43-year-old man comes to your office for assessment of hearing loss. He has had hearing difficulties for the past 4 years. On examination, the Weber tuning fork test lateralizes to the left ear. The Rinne tuning fork test is normal bilaterally (AC > BC). 19. This suggests which of the following? a. a right-sided conductive hearing loss b. a left-sided conductive hearing loss c. a right-sided sensorineural hearing loss d. a left-sided sensorineural hearing loss e. b or c 20. Which of the following statements is (are) true regarding the condition of acute mastoiditis? a. it is a complication of acute otitis media b. it is most likely caused by Streptococcus pneumoniae c. otalgia, aural discharge, and fever are characteristically seen 2 or 3 weeks after an episode of acute suppurative otitis media d. none of the above e. a, b, and c A 42-year-old woman comes to your office complaining of severe facial pain in the region of her right maxilla, fever, and a purulent discharge from the right side of her nose, all of which started after a recent upper respiratory infection. She is taking no medications and has no known drug allergies. Her temperature is elevated to 38.3° C. There is tenderness over the right maxillary sinus and a greenish discharge in her right naris. The rest of her examination is normal. 21. Which of the following statements concerning rhinosinusitis is (are) true? a. the most common types of sinusitis are allergic sinusitis and viral sinusitis b. rhinovirus is the most common cause of viral sinusitis c. viral sinusitis is often accompanied by fever, malaise, and systemic symptoms d. a and b e. a, b, and c 22. Acute bacterial rhinosinusitis is caused most commonly by which of the following organisms? a. S. pneumoniae b. Haemophilus influenzae c. Moraxella catarrhalis d. Streptococcus pyogenes e. Staphylococcus aureus 23. Which of the following is the most predictive factor distinguishing viral rhinosinusitis and bacterial rhinosinusitis? a. thick and greenish nasal discharge b. facial pain c. degree of fever d. duration of symptoms e. systemic symptoms 24. What is the antibacterial drug of first choice for moderate to severe acute bacterial rhinosinusitis? a. amoxicillin-clavulanate (10- to 15-day course) b. trimethoprim-sulfamethoxazole (10- to 15-day course) c. cefuroxime (10-day course) d. ciprofloxacin (10- to 14-day course) e. erythromycin (10-day course) 25. Which of the following is not considered to be a criterion suggestive of chronic sinusitis? a. duration longer than 12 weeks b. nasal obstruction c. nasal polyps d. lack of response to antibiotic therapy e. facial pain A 12-year-old boy is brought to your office by his mother. He is complaining of right ear pain for the past 24 hours. The mother states that he spent the past 4 days swimming in the pool and began to complain of pain in the right ear yesterday afternoon. She states that she noticed some fluid on his pillow after he woke up this morning. The patient states that he has been using cotton swabs in his ear to remove excess water. On examination, the patient is afebrile. Otoscopic examination is significant for purulent material in the ear canal with significant erythema. The tympanic membrane is erythematous, but there is no adjacent fluid. He has pain when you pull on the pinna. 26. What is the most likely diagnosis? a. otitis media b. otitis externa c. otitis media and otitis externa d. auricular cellulitis e. mastoiditis 27. What is the most common organism in this problem? a. adenovirus b. Pseudomonas aeruginosa c. S. aureus d. rhinovirus e. Streptococcus spp. You prescribe the patient a topical solution of polymyxin, neomycin, and hydrocortisone. The patient returns 4 days later. His mother states that they lost the prescription and now he is getting worse. Otoscopic examination at this time reveals increased debris and purulent material and a 2- mm perforation in the tympanic membrane. 28. What is the most appropriate treatment at this time? a. referral to an ear, nose, and throat specialist b. represcribe the polymyxin, neomycin, hydrocortisone otic solution c. prescribe an otic aminoglycoside d. prescribe an otic fluoroquinolone e. irrigate the ear to remove excessive debris A 25-year-old man with a history of schizophrenia stable on his current antipsychotic regimen presents with a seizure. His mother noted that her son complained of a headache and feeling warm for the past ten days. The headache was exacerbated whenever he bent over. This morning, the mother brought him to the hospital after he fell from the top of the stairs and appeared to convulse his arms and legs. He takes quetiapine and a multivitamin. In the trauma bay, the patient appears to be breathing comfortably and follows the nurse's commands. His temperature is 100.9°F (38.3°C), blood pressure is 140/70 mmHg, pulse is 80/min, respirations are 15/min, and his oxygen saturation is 95% on room air. He complains of a headache over the top of his eyebrows. He has a few scrapes and bruises throughout his body. His left arm and leg are weaker than his right limbs. His cranial nerves are grossly intact bilaterally. Computed tomography of his head is shown in Figure A. Which of the following is the most likely cause of this patient's presentation? A. Budding yeast organisms with hyphae B. Streptococcus species C. Staphylococcus species D. Bacteroides fragilis E. Toxoplasma gondii cysts A 15-year-old boy presents with clear fluid discharge from his nose for 2 days duration. His also reports having episodes of sneezing, feelings of congestion, and a cough. His symptoms only occuring during the spring months and finds it difficult to walk outside without exacerbating his symptoms. On nasal exam, the mucosa and turbinates appear edematous. Ans: Allergic Rhinitis A 23-year-old man presents to his primary care physician for a runny nose, sneezing, and coughing that has persisted for a few months. He denies feeling weak or tired, but states that his symptoms have disrupted his every day life. The patient has no significant past medical history. He drinks alcohol occasionally on the weekends. His temperature is 98.6°F (37.0°C), blood pressure is 124/88 mmHg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam reveals a healthy young man who is repetitively blowing his nose. Percussion of his sinuses elicits no symptoms. Inspection of the patient's oropharynx is unremarkable. Which of the following is the best next step in management? A. Amoxicillin B. Diphenhydramine C. Intranasal saline D. Intranasal steroid E. Loratadine A 20-year-old female presents to your clinic for evaluation. She complain of months of daily rhinorrhea, which she describes as watery and clear, as well as nasal congestion bilaterally. In addition, she reports frequent watery and itchy eyes, as well as daily sneezing. Her temperature is 100.1 deg F (37.8 deg C), blood pressure is 120/70 mmHg, pulse is 70/min, and respirations are 15/min. On exam, you note edematous, boggy turbinates with watery rhinorrhea. Which of the following is a treatment for the patient’s condition? A. Intravenous penicillin B. Oral amoxicillin C. Oral acetaminophen D. Intranasal fluticasone E. Intravenous vancomycin A 30-year-old previously healthy male presents to your office with complaints of facial pressure and rhinorrhea for the past 3 weeks. The patient reports that several weeks prior, he had a “common cold” which resolved. However, he has since developed worsening facial pressure, especially over his cheeks and forehead. He reports over 1 week of green tinged rhinorrhea. His temperature is 100.1 deg F (37.8 deg C), blood pressure is 120/70 mmHg, pulse is 85/min, and respirations are 15/min. Nasal exam reveals edematous turbinates and purulent discharge. What is the most likely diagnosis? A. Acute viral rhinosinusitis B. Acute bacterial rhinosinusitis C. Subacute bacterial rhinosinusitis D. Allergic rhinitis E. Chronic rhinosinusitis An 8-year-old female presents to her pediatrician with nasal congestion. Her mother reports that the patient has had nasal congestion and nighttime cough for almost two weeks. The patient’s 3- year-old brother had similar symptoms that began around the same time and have since resolved. The patient initially seemed to be improving, but four days ago she began developing worsening nasal discharge and fever to 102.6°F (39.2°C) at home. Her mother denies any change in appetite. The patient denies sore throat, ear pain, and headache. She is otherwise healthy. In the office, her temperature is 102.2°F (39.0°C), blood pressure is 96/71 mmHg, pulse is 128/min, and respirations are 18/min. On physical exam, the nasal turbinates are edematous and erythematous. She has a dry cough. Purulent mucous can be visualized dripping from the posterior nasopharynx. Her maxillary sinuses are tender to palpation. Which of the following organisms is most likely to be causing this patient’s current condition? A. Adenovirus B. Moraxella catarrhalis C. Pseudomonas aeruginosa D. Staphylococcus aureus E. Streptococcus pyogenes A 5-year-old male presents to the pediatrician with a 10-day history of cough that is worse at night. The patient has a history of mild intermittent asthma and has been using his albuterol inhaler without relief. He has also been complaining of headache and sore throat, and his mother has noticed worsening rhinorrhea. The patient’s past medical history is otherwise unremarkable, and he has no known drug allergies. In the office, his temperature is 101.8°F (38.8°C), blood pressure is 88/65 mmHg, pulse is 132/min, and respirations are 16/min. The patient has purulent mucus draining from the nares, and his face is tender to palpation over the maxillary sinuses. His pharynx is erythematous with symmetric swelling of the tonsils. On lung exam, he has moderate bilateral expiratory wheezing. Which of the following is the best next step in management? A. Amoxicillin B. Amoxicillin-clavulanic acid C. Ampicillin-sulbactam C. Clindamycin D. Levofloxacin A 54-year-old male presents to the emergency department with nasal congestion and sore throat. He also endorses ten days of fatigue, rhinorrhea and cough, which he reports are getting worse. For the last four days, he has also had facial pain and thicker nasal drainage. The patient’s past medical history includes obesity, type II diabetes mellitus, and mild intermittent asthma. His home medications include metformin and an albuterol inhaler as needed. The patient has a 40 pack-year smoking history and drinks 6-12 beers per week. His temperature is 102.8°F (39.3°C), blood pressure is 145/96 mmHg, pulse is 105/min, and respirations are 16/min. On physical exam, he has poor dentition. Purulent mucus is draining from his nares, and his oropharynx is erythematous. His maxillary sinuses are tender to palpation. Which one of the following is the most common risk factor for this condition? A. Asthma B. Diabetes mellitus C. Poor dentition D. Tobacco use E. Viral infection