HEENT

The patient has viral conjunctivitis (adenovirus). What are the indications and the steps taken?

Indicators: Watery discharge, burning/gritty sensation, recent upper respiratory infection, preauricular lymph node swelling.
Special Tests: Fluorescein stain only if pain or photophobia to rule out corneal involvement.
Labs: None.
Imaging: None.
Treatment: Supportive care; artificial tears; cold compresses.
Referral: Only if vision changes or corneal involvement suspected.
Differentials:

• Dangerous: Herpes simplex keratitis.

• Common: Allergic conjunctivitis.

• Alternative: Dry eye syndrome.

The patient has bacterial conjunctivitis. What are the indications and the steps taken?

Indicators: Purulent discharge, eyelids stuck together in the morning, minimal itching.
Special Tests: Fluorescein stain if pain or photophobia.
Labs: Culture if severe, recurrent, or in contact lens wearers.
Imaging: None.
Treatment: Topical antibiotics such as erythromycin ointment or polymyxin‑trimethoprim drops; fluoroquinolone drops (e.g., ciprofloxacin) for contact lens wearers.
Referral: Urgent if contact lens wearer with pain (risk of corneal ulcer).
Differentials:

• Dangerous: Corneal ulcer (infectious keratitis).

• Common: Viral conjunctivitis.

• Alternative: Blepharitis.

The patient has allergic conjunctivitis. What are the indications and the steps taken?

Indicators: Intense itching, watery discharge, bilateral symptoms, eyelid swelling, “cobblestoning” of conjunctiva.
Special Tests: None.
Labs: None.
Imaging: None.
Treatment: Antihistamine drops (e.g., olopatadine); mast‑cell stabilizer drops; cool compresses.
Referral: Only if refractory or vision changes occur.
Differentials:

• Dangerous: Acute angle‑closure glaucoma (if severe pain + vision loss).

• Common: Viral conjunctivitis.

• Alternative: Atopic keratoconjunctivitis.

The patient has a corneal ulcer (keratitis). What are the indications and the steps taken?

Indicators: Severe pain, photophobia, decreased vision, corneal opacity or infiltrate, contact lens use.
Special Tests: Fluorescein stain showing round or irregular ulcer.
Labs: Corneal culture if severe or contact lens related.
Imaging: None.
Treatment: Topical fluoroquinolone drops such as moxifloxacin; discontinue contact lenses.
Referral: Emergent ophthalmology.
Differentials:

• Dangerous: Herpes simplex keratitis.

• Common: Corneal abrasion.

• Alternative: Severe dry eye disease.

The patient has acute angle-closure glaucoma. What are the indications and the steps taken?

Indicators: Sudden severe eye pain, halos around lights, nausea/vomiting, mid‑dilated fixed pupil, cloudy cornea.
Special Tests: Tonometry showing elevated intraocular pressure.
Labs: None.
Imaging: None.
Treatment: Acetazolamide; topical beta‑blocker such as timolol; pilocarpine; emergent ophthalmology.
Referral: Emergent ophthalmology.
Differentials:

• Dangerous: Iritis (anterior uveitis).

• Common: Corneal abrasion.

• Alternative: Migraine with visual aura.

The patient has open-angle glaucoma. What are the indications and the steps taken?

IIndicators: Gradual peripheral vision loss, elevated intraocular pressure, optic disc cupping.
Special Tests: Tonometry; visual field testing.
Labs: None.
Imaging: Optical coherence tomography (OCT).
Treatment: Prostaglandin analogs such as latanoprost; topical beta‑blockers such as timolol.
Referral: Routine ophthalmology for long‑term management.
Differentials:

• Dangerous: Retinal detachment.

• Common: Cataracts.

• Alternative: Diabetic retinopathy.

The patient has iritis/uveitis. What are the indications and the steps taken?

Indicators: Photophobia, consensual pain, ciliary flush, constricted pupil, blurred vision.
Special Tests: Slit lamp exam showing “cells and flare.”
Labs: HLA‑B27 testing, syphilis testing, ANA if recurrent.
Imaging: None.
Treatment: Topical steroids (ophthalmology‑directed); cycloplegic drops such as cyclopentolate.
Referral: Urgent ophthalmology.
Differentials:

• Dangerous: Acute angle‑closure glaucoma.

• Common: Corneal abrasion.

• Alternative: Viral conjunctivitis.

The patient has a subconjunctival hemorrhage. What are the indications and the steps taken?

Indicators: Painless bright red patch on sclera; no vision changes; often after coughing or straining.
Special Tests: None.
Labs: INR if on anticoagulants.
Imaging: None.
Treatment: Reassurance; resolves spontaneously.
Referral: Only if recurrent or associated with trauma + vision change.
Differentials:

• Dangerous: Globe rupture (if trauma).

• Common: Conjunctivitis.

• Alternative: Bleeding disorder.

The patient has a hordeolum (stye). What are the indications and the steps taken?

Indicators: Painful, tender eyelid nodule; acute onset; localized swelling.
Special Tests: None.
Labs: None.
Imaging: None.
Treatment: Warm compresses; topical antibiotics such as erythromycin if draining.
Referral: Ophthalmology if not improving or if cellulitis develops.
Differentials:

• Dangerous: Preseptal cellulitis.

• Common: Chalazion.

• Alternative: Blepharitis.

The patient has a chalazion. What are the indications and the steps taken?

Indicators: Painless eyelid nodule; chronic; non‑tender; often follows a hordeolum.
Special Tests: None.
Labs: None.
Imaging: None.
Treatment: Warm compresses; steroid injection or excision if persistent.
Referral: Ophthalmology if persistent beyond 1 month.
Differentials:

• Dangerous: Sebaceous gland carcinoma (rare).

• Common: Hordeolum.

• Alternative: Blepharitis.

The patient has blepharitis. What are the indications and the steps taken?

Indicators: Crusting, burning, morning irritation, lid margin inflammation.
Special Tests: None.
Labs: None.
Imaging: None.
Treatment: Lid hygiene; warm compresses; topical antibiotics such as erythromycin if severe.
Referral: Only if refractory or associated with vision changes.
Differentials:

• Dangerous: Orbital cellulitis.

• Common: Allergic conjunctivitis.

• Alternative: Rosacea‑associated ocular inflammation.

The patient has retinal detachment. What are the indications and the steps taken?

Indicators: Flashes of light, floaters, “curtain” over vision; painless.
Special Tests: Dilated fundus exam; ocular ultrasound if unable to visualize.
Labs: None.
Imaging: Ocular ultrasound.
Treatment: Surgical repair (pneumatic retinopexy, vitrectomy).
Referral: Emergent ophthalmology.
Differentials:

• Dangerous: Central retinal artery occlusion.

• Common: Posterior vitreous detachment.

• Alternative: Migraine aura.

The patient has central retinal artery occlusion (CRAO). What are the indications and the steps taken?

Indicators: Sudden painless monocular vision loss; “cherry‑red spot” on exam.
Special Tests: Fundoscopy.
Labs: ESR and CRP if giant cell arteritis suspected.
Imaging: Carotid ultrasound; echocardiogram.
Treatment: Ocular massage; reduce intraocular pressure; treat giant cell arteritis if present.
Referral: Emergent ophthalmology + emergency department.
Differentials:

• Dangerous: Giant cell arteritis.

• Common: Retinal detachment.

• Alternative: Central retinal vein occlusion.

The patient has central retinal vein occlusion (CRVO). What are the indications and the steps taken?

Indicators: Painless monocular vision loss; “blood and thunder” appearance on retina.
Special Tests: Fundoscopy.
Labs: Consider hypercoagulability testing.
Imaging: Optical coherence tomography (OCT).
Treatment: Ophthalmology‑directed therapy such as anti‑vascular endothelial growth factor injections.
Referral: Urgent ophthalmology.
Differentials:

• Dangerous: Central retinal artery occlusion.

• Common: Diabetic retinopathy.

• Alternative: Hypertensive retinopathy.

The patient has a corneal abrasion. What are the indications and the steps taken?

Indicators: Severe eye pain, photophobia, tearing, foreign body sensation, history of trauma or rubbing.
Special Tests: Fluorescein stain showing linear or geographic uptake.
Labs: None.
Imaging: Computed tomography (CT) of the orbit if penetrating trauma suspected.
Treatment: Topical antibiotics such as erythromycin ointment or polymyxin‑trimethoprim drops; avoid contact lenses.
Referral: Urgent ophthalmology referral if large, central, or contact‑lens related.
Differentials:

• Dangerous: Corneal ulcer (infectious keratitis).

• Common: Conjunctivitis.

• Alternative: Foreign body under eyelid.

The patient has acute viral rhinosinusitis (common cold). What are the indications and the steps taken?

Indicators: Nasal congestion, rhinorrhea, facial pressure, symptoms <10 days, no fever or mild fever.
Special Tests: None.
Labs: None.
Imaging: None.
Treatment: Supportive care; intranasal corticosteroids such as fluticasone; saline irrigation.
Referral: Only if symptoms persist >4 weeks or complications suspected.
Differentials:

• Dangerous: Orbital cellulitis.

• Common: Allergic rhinitis.

• Alternative: Deviated septum.

The patient has acute bacterial rhinosinusitis. What are the indications and the steps taken?

Indicators: Symptoms >10 days, severe facial pain, purulent nasal discharge, fever, “double worsening.”
Special Tests: None.
Labs: None.
Imaging: Computed tomography (CT) of sinuses only if complications suspected.
Treatment: Amoxicillin‑clavulanate; doxycycline if penicillin‑allergic.
Referral: ENT if recurrent, chronic, or if complications (orbital swelling, neurologic signs).
Differentials:

• Dangerous: Cavernous sinus thrombosis.

• Common: Viral rhinosinusitis.

• Alternative: Dental abscess.

The patient has allergic rhinitis. What are the indications and the steps taken?

Indicators: Sneezing, itching, clear rhinorrhea, nasal crease, allergic shiners, seasonal pattern.
Special Tests: None in OSCE; allergy testing outpatient.
Labs: None.
Imaging: None.
Treatment: Intranasal corticosteroids such as fluticasone; oral antihistamines such as cetirizine.
Referral: Allergy specialist if refractory or unclear triggers.
Differentials:

• Dangerous: Acute bacterial sinusitis with fever and facial pain.

• Common: Viral rhinosinusitis.

• Alternative: Non‑allergic rhinitis (vasomotor).

The patient has anterior epistaxis (Kisselbach plexus). What are the indications and the steps taken?

Indicators: Unilateral bleeding, visible anterior source, history of nose picking or dry air.
Special Tests: Nasal speculum exam.
Labs: Only if recurrent or heavy bleeding → CBC, INR.
Imaging: None.
Treatment: Direct pressure; topical vasoconstrictor such as oxymetazoline; silver nitrate cautery if needed.
Referral: ENT if recurrent or unable to control bleeding.
Differentials:

• Dangerous: Posterior epistaxis.

• Common: Allergic rhinitis with mucosal irritation.

• Alternative: Nasal trauma.

The patient has epistaxis (posterior). What are the indications and the steps taken?

Indicators: Profuse bleeding, blood in throat, older adults, hypertension, anticoagulant use.
Special Tests: Posterior source on exam; difficulty visualizing anteriorly.
Labs: CBC, INR if on anticoagulants.
Imaging: None unless trauma → CT.
Treatment: Posterior nasal packing; topical vasoconstrictors; manage blood pressure.
Referral: Urgent ENT; ED for airway monitoring.
Differentials:

• Dangerous: Nasopharyngeal tumor.

• Common: Anterior epistaxis.

• Alternative: Septal perforation.

The patient has nasal polyps. What are the indications and the steps taken?

Indicators: Nasal obstruction, decreased smell, chronic congestion, asthma history, aspirin sensitivity (Samter triad).
Special Tests: Nasal endoscopy (ENT).
Labs: None.
Imaging: CT sinuses if surgical planning.
Treatment: Intranasal corticosteroids such as fluticasone; short course of oral steroids if severe.
Referral: ENT for persistent symptoms or large polyps.
Differentials:

• Dangerous: Sinonasal tumor.

• Common: Chronic sinusitis.

• Alternative: Deviated septum.

The patient has deviated septum. What are the indications and the steps taken?

Indicators: Chronic unilateral nasal obstruction, snoring, mouth breathing, history of trauma.
Special Tests: Anterior rhinoscopy.
Labs: None.
Imaging: None unless surgical planning → CT.
Treatment: Intranasal corticosteroids for inflammation; septoplasty if severe.
Referral: ENT if persistent obstruction.
Differentials:

• Dangerous: Nasal mass obstructing airway.

• Common: Allergic rhinitis.

• Alternative: Nasal polyps.

The patient has a nasal foreign body (mostly in pediatrics). What are the indications and the steps taken?

Indicators: Unilateral foul‑smelling discharge, unilateral obstruction, visible object.
Special Tests: Nasal speculum exam.
Labs: None.
Imaging: Only if button battery suspected → immediate X‑ray.
Treatment: Positive pressure (“parent’s kiss”); forceps removal; emergent removal if button battery.
Referral: ENT if unable to remove or if battery/magnet.
Differentials:

• Dangerous: Button battery causing tissue necrosis.

• Common: Acute sinusitis.

• Alternative: Allergic rhinitis with unilateral swelling.

This patient has viral pharyngitis. What are the indications and the steps taken?

Indicators: Sore throat, cough, rhinorrhea, hoarse voice, low‑grade fever, gradual onset.
Special Tests: None unless ruling out strep.
Labs: Rapid strep test only if Centor score suggests.
Imaging: None.
Treatment: Supportive care; NSAIDs; hydration.
Referral: Only if symptoms persist >10 days or red flags develop.
Differentials:

• Dangerous: Peritonsillar abscess.

• Common: Streptococcal pharyngitis.

• Alternative: Infectious mononucleosis.

This patient has streptococcal pharyngitis (group A strep). What are the indications and the steps taken?

Indicators: Sudden sore throat, fever, tonsillar exudates, tender anterior cervical lymph nodes, absence of cough.
Special Tests: Rapid strep test; throat culture if negative but high suspicion.
Labs: None beyond strep testing.
Imaging: None.
Treatment: Penicillin V or amoxicillin; azithromycin if penicillin‑allergic.
Referral: ENT if recurrent infections or complications.
Differentials:

• Dangerous: Peritonsillar abscess.

• Common: Viral pharyngitis.

• Alternative: Infectious mononucleosis.

This patient has infectious mononucleosis (EBV). What are the indications and the steps taken?

Indicators: Sore throat, fatigue, posterior cervical lymphadenopathy, tonsillar exudates, splenomegaly.
Special Tests: Monospot test; heterophile antibody test.
Labs: Complete blood count showing lymphocytosis.
Imaging: None.
Treatment: Supportive care; avoid contact sports for 3–4 weeks.
Referral: If airway obstruction or severe tonsillar hypertrophy.
Differentials:

• Dangerous: Airway obstruction from tonsillar swelling.

• Common: Streptococcal pharyngitis.

• Alternative: Cytomegalovirus infection.

This patient has peritonsillar abscess. What are the indications and the steps taken?

Indicators: Severe unilateral throat pain, muffled “hot potato” voice, uvular deviation, trismus, drooling.
Special Tests: Needle aspiration (diagnostic and therapeutic).
Labs: None required but CBC may show leukocytosis.
Imaging: CT neck with contrast if diagnosis unclear.
Treatment: Drainage + antibiotics such as ampicillin‑sulbactam or clindamycin.
Referral: Urgent ENT; ED if airway compromise.
Differentials:

• Dangerous: Epiglottitis.

• Common: Severe streptococcal pharyngitis.

• Alternative: Retropharyngeal abscess.

This patient has a retropharyngeal abscess. What are the indications and the steps taken?

Indicators: Fever, neck stiffness, dysphagia, drooling, muffled voice, pain with neck extension.
Special Tests: None bedside.
Labs: CBC may show leukocytosis.
Imaging: CT neck with contrast (diagnostic).
Treatment: IV antibiotics such as ampicillin‑sulbactam; surgical drainage if large.
Referral: Emergent ENT; ED for airway monitoring.
Differentials:

• Dangerous: Epiglottitis.

• Common: Peritonsillar abscess.

• Alternative: Cervical lymphadenitis.

This patient has epiglottis. What are the indications and the steps taken?

Indicators: Sudden sore throat, drooling, tripod positioning, muffled voice, fever, severe pain with minimal oropharyngeal findings.
Special Tests: Do NOT use tongue depressor; airway exam in controlled setting.
Labs: Blood cultures if hospitalized.
Imaging: Lateral neck X‑ray showing “thumbprint sign” (only if stable).
Treatment: Airway management; IV antibiotics such as ceftriaxone.
Referral: Emergent ENT + ED airway team.
Differentials:

• Dangerous: Retropharyngeal abscess.

• Common: Severe viral pharyngitis.

• Alternative: Peritonsillar abscess.

This patient has laryngitis. What are the indications and the steps taken?

Indicators: Hoarseness, recent URI, mild sore throat, voice fatigue, no severe pain.
Special Tests: None.
Labs: None.
Imaging: None.
Treatment: Voice rest; hydration; avoid whispering; treat reflux if suspected.
Referral: ENT if hoarseness persists >3 weeks.
Differentials:

• Dangerous: Laryngeal cancer (persistent hoarseness).

• Common: Viral pharyngitis.

• Alternative: Gastroesophageal reflux disease.

This patient has oral candidiasis (thrush). What are the indications and the steps taken?

Indicators: White plaques on tongue or buccal mucosa that scrape off; mild soreness; immunosuppression or inhaled steroid use.
Special Tests: None needed; potassium hydroxide (KOH) prep if uncertain.
Labs: None.
Imaging: None.
Treatment: Nystatin oral suspension; clotrimazole troches.
Referral: If recurrent or immunocompromised.
Differentials:

• Dangerous: Esophageal candidiasis (if dysphagia).

• Common: Viral pharyngitis.

• Alternative: Leukoplakia (does not scrape off).

This patient has hand, foot, and mouth disease (coxsackievirus). What are the indications and the steps taken?

Indicators: Painful oral ulcers, fever, vesicular rash on hands/feet, common in children.
Special Tests: None.
Labs: None.
Imaging: None.
Treatment: Supportive care; hydration; analgesics.
Referral: Only if dehydration or inability to tolerate oral intake.
Differentials:

• Dangerous: Herpetic gingivostomatitis.

• Common: Viral pharyngitis.

• Alternative: Aphthous ulcers.

This patient has acute otitis media. What are the indications and the steps taken?

Indicators: Ear pain, fever, decreased hearing, bulging erythematous tympanic membrane, decreased mobility on pneumatic otoscopy.
Special Tests: Pneumatic otoscopy (reduced mobility).
Labs: None.
Imaging: None.
Treatment: Amoxicillin; amoxicillin‑clavulanate if recurrent or severe.
Referral: ENT if recurrent (>3 episodes in 6 months).
Differentials:

• Dangerous: Mastoiditis.

• Common: Otitis media with effusion.

• Alternative: Viral upper respiratory infection with referred pain.

This patient has otitis media w/ effusion (serous otitis). What are the indications and the steps taken?

Indicators: Fullness, hearing loss, no fever, retracted tympanic membrane, air‑fluid level.
Special Tests: Pneumatic otoscopy (reduced mobility).
Labs: None.
Imaging: None.
Treatment: Watchful waiting; intranasal corticosteroids such as fluticasone if allergic component.
Referral: ENT if persistent >3 months or hearing loss affects speech in children.
Differentials:

• Dangerous: Nasopharyngeal carcinoma (adult unilateral effusion).

• Common: Acute otitis media.

• Alternative: Eustachian tube dysfunction.

This patient has acute otitis externa (“swimmer’s ear”). What are the indications and the steps taken?

Indicators: Ear pain worsened by tragus or pinna movement, itching, discharge, normal tympanic membrane.
Special Tests: Pain with tragus traction.
Labs: None.
Imaging: None.
Treatment: Topical antibiotic‑steroid drops such as ciprofloxacin‑dexamethasone.
Referral: ENT if severe swelling or suspected malignant otitis externa.
Differentials:

• Dangerous: Malignant otitis externa (diabetics).

• Common: Acute otitis media.

• Alternative: Contact dermatitis of the ear canal.

This patient has malignant otitis externa. What are the indications and the steps taken?

Indicators: Severe persistent ear pain, granulation tissue in canal, diabetes or immunocompromised, cranial nerve deficits.
Special Tests: None bedside.
Labs: ESR/CRP may be elevated.
Imaging: CT or MRI of temporal bone.
Treatment: IV antibiotics such as ciprofloxacin.
Referral: Emergent ENT.
Differentials:

• Dangerous: Skull base osteomyelitis.

• Common: Severe otitis externa.

• Alternative: Chronic otitis media.

This patient has TM perforation. What are the indications and the steps taken?

Indicators: Sudden pain relief after rupture, otorrhea, hearing loss, history of trauma or infection.
Special Tests: Otoscopy showing perforation.
Labs: None.
Imaging: None unless trauma → CT temporal bone.
Treatment: Keep ear dry; topical fluoroquinolone drops such as ofloxacin if infected.
Referral: ENT if large, posterior, or not healing after 6 weeks.
Differentials:

• Dangerous: Ossicular chain disruption (trauma).

• Common: Acute otitis media.

• Alternative: Otitis externa with discharge.

This patient has mastoiditis. What are the indications and the steps taken?

Indicators: Post‑auricular tenderness, swelling, fever, protruding ear, history of recent otitis media.
Special Tests: None bedside.
Labs: CBC may show leukocytosis.
Imaging: CT temporal bone (diagnostic).
Treatment: IV antibiotics such as ceftriaxone; possible mastoidectomy.
Referral: Emergent ENT.
Differentials:

• Dangerous: Intracranial abscess.

• Common: Acute otitis media.

• Alternative: Cellulitis behind the ear.

This patient has cerumen impaction. What are the indications and the steps taken?

Indicators: Hearing loss, fullness, tinnitus, inability to visualize tympanic membrane.
Special Tests: Otoscopy.
Labs: None.
Imaging: None.
Treatment: Cerumenolytics such as carbamide peroxide; irrigation if tympanic membrane intact.
Referral: ENT if recurrent or if tympanic membrane cannot be visualized safely.
Differentials:

• Dangerous: Sudden sensorineural hearing loss.

• Common: Otitis media with effusion.

• Alternative: Foreign body.

This patient has a foreign body in the ear canal. What are the indications and the steps taken?

Indicators: Pain, hearing loss, visible object, common in children.
Special Tests: Otoscopy.
Labs: None.
Imaging: None unless battery → X‑ray.
Treatment: Removal with forceps or irrigation (not for organic material or batteries).
Referral: ENT if battery, sharp object, or failed removal.
Differentials:

• Dangerous: Button battery causing necrosis.

• Common: Cerumen impaction.

• Alternative: Otitis externa.

This patient has sudden sensorineural hearing loss. What are the indications and the steps taken?

Indicators: Rapid unilateral hearing loss, normal ear exam, tinnitus, vertigo.
Special Tests: Weber test lateralizes to normal ear; Rinne test shows air > bone.
Labs: None.
Imaging: MRI brain/internal auditory canal.
Treatment: Urgent oral or intratympanic steroids (e.g., prednisone).
Referral: Emergent ENT.
Differentials:

• Dangerous: Acoustic neuroma.

• Common: Cerumen impaction (conductive).

• Alternative: Viral labyrinthitis.

This patient has benign paroxysmal positional vertigo (BPPV). What are the indications and the steps taken?

Indicators: Brief episodes of vertigo triggered by head movement, no hearing loss, no tinnitus.
Special Tests: Dix–Hallpike maneuver → positional nystagmus.
Labs: None.
Imaging: None unless atypical.
Treatment: Epley maneuver; vestibular rehabilitation.
Referral: ENT if atypical symptoms or persistent.
Differentials:

• Dangerous: Vertebrobasilar stroke.

• Common: Vestibular neuritis.

• Alternative: Ménière disease.