ENT OSCE Study Guide — Physical Diagnosis 2

How this guide is set up

How to read a card

Each condition has the same rows: what you'll hear (history), exam, the top differentials with what separates each, testing, treatment, and an OSCE move (what to say or do in the room).
Each region ends with its Don't Miss diagnoses and a Tell Them Apart table.
Gray tags like EME 29 point to the lecture deck and slide number. Tags like AAO-HNS 2019 point to a practice guideline. Lines with no tag are standard clinical teaching that isn't in your slides.

EarExam toolkit · Cerumen impaction · AOM · Otitis externa · OME · ETD/barotrauma · SNHL · Don't miss: mastoiditis, malignant OE, SSNHL NoseViral rhinitis · Allergic rhinitis · Bacterial sinusitis · Epistaxis · Nasal foreign body · Don't miss: unilateral adult symptoms, orbital complications ThroatViral pharyngitis · Strep pharyngitis · Oral candidiasis · GERD/LPR · Aphthous ulcers · Don't miss: PTA, epiglottitis, mono, head and neck cancer Heads-UpHeads-up: where the slides and other references disagree · Sources

Deck key

A gray tag such as EME 29 points to a lecture deck and its slide number. A gold tag such as AAO-HNS 2019 points to a published practice guideline. A line with no tag is standard clinical teaching that is not in the slides.

Tag	Lecture deck
EME	Disorders of the External and Middle Ear (Griffenkranz)
IE	Inner Ear, Balance and Hearing Loss (Jaquith)
NS	Nose & Paranasal Sinuses (Griffenkranz)
OC	Disorders of the Oral Cavity, Salivary Glands, and Neck (Shah)
NM	Neoplasms and Neck Masses (Shah)

Ear

Ear Exam Toolkit

Use a 512 Hz tuning fork. Weber: fork on the top of the head. Rinne: fork on the mastoid until the sound fades, then next to the canal IE 39–40.

Pattern	Weber	Rinne (affected ear)	Think of
Normal	Midline, equal both ears	AC > BC	n/a
Conductive loss	Lateralizes to the bad ear	BC = AC or BC > AC	Cerumen, OME, AOM, perforation, otosclerosis IE 11
Sensorineural loss	Lateralizes to the good ear	AC > BC	SSNHL, presbycusis, noise, Ménière's, acoustic neuroma IE 14

Tuning fork patterns IE 39–42

Tympanogram	What it means	Think of
Type A	Normal pressure and mobility	Normal ear, or SNHL with a normal middle ear IE 25
Type B	Flat, little or no peak	Middle ear fluid (AOM, OME) IE 26
Type C	Peak at negative pressure (significant past −200 mm H₂O)	Eustachian tube dysfunction IE 22, 27
Type As	Normal pressure, shallow peak (stiff)	Otosclerosis, ossicular fixation IE 28
Type Ad	Normal pressure, very tall peak (floppy)	Ossicular discontinuity, flaccid TM IE 29

1. Cerumen Impaction

The highest-volume ear complaint. Wax gets pushed deep, usually by the patient.

What you'll hear	Muffled hearing (conductive), ear fullness, itching EME 27; sometimes tinnitus, dizziness, or ear pain Reflex cough when the canal is touched: Arnold's nerve (auricular branch of CN X) Risk factors: cotton swabs and other attempts to clean the canal EME 27, hearing aids and earbuds, older adults, narrow or hairy canals
Exam	Otoscopy: wax partly or fully blocking the canal. Can be wet and sticky, dry and flaky, or dark EME 28 If you can't see the TM, you can't rule out a perforation. Ask about tubes, prior ear surgery, or a known perforation before irrigating Tuning forks: Weber lateralizes to the blocked ear, Rinne BC ≥ AC on that side IE 39–42
Top differentials	Otitis externa — Pain on tragal traction; the canal is edematous rather than merely full of wax Otitis media with effusion — A conductive loss with a clear canal and fluid behind the drum
Testing	Clinical diagnosis. It only counts as an impaction if it causes symptoms or blocks an exam you need AAO-HNS 2017 After removal, look at the canal and TM again and recheck hearing. Still decreased → audiometry
Treatment	Softening drops first: carbamide peroxide 6.5% (Debrox), mineral oil, or plain water/saline EME 29 Irrigation with body-temperature water (too hot or cold → caloric vertigo). Only if the TM is known to be intact EME 29 Curette/loop or suction under direct view. Best for soft wax and a cooperative patient; can hurt if done wrong EME 29 Tubes or perforation present → ENT does the removal EME 29 Be careful irrigating diabetics or immunocompromised patients (risk of malignant otitis externa) Teach: nothing goes in the canal. Clean only the opening with a washcloth over a finger EME 28. No ear candling
OSCE move	“Before I irrigate I'd confirm there's no history of perforation or tubes, use body-temperature water, and afterward I'd re-look at the TM and recheck hearing.”

2. Acute Otitis Media (AOM)

Middle ear infection. Mostly peds, peak around age 2, usually a few days into a URI EME 12–14.

What you'll hear	Ear pain, fever, decreased hearing EME 15. Infants: ear tugging, fussiness, poor sleep or feeding Started after a cold Risk factors: daycare, smoke exposure, bottle propping, pacifier use, not breastfed, adenoid hypertrophy, allergies EME 14
Exam	Bulging TM (most specific sign), erythema, landmarks and light reflex gone, purulent fluid may be visible EME 16 Pneumatic otoscopy: decreased or absent mobility EME 16 May have cervical nodes EME 16 Perforated: pus in the canal (suppurative OM), and the pain often gets better once the TM ruptures EME 13 Always check behind the ear for mastoid tenderness or swelling
Top differentials	Otitis media with effusion — Fluid WITHOUT pain, fever or bulging — the distinction that decides antibiotics Otitis externa — Pain on tragal traction with a swollen canal; the drum is normal if seen
Testing	Clinical diagnosis. Tympanometry is optional (type B) EME 17 IE 26 AAP criteria: moderate–severe bulging, OR new otorrhea not from otitis externa, OR mild bulging plus ear pain < 48 h or intense erythema. A middle ear effusion has to be there AAP 2013 Bugs: S. pneumoniae, nontypeable H. influenzae, M. catarrhalis EME 14
Treatment	Pain control for everyone: acetaminophen or ibuprofen EME 18 Many resolve on their own EME 18. Antibiotics vs watchful waiting AAP 2013: Under 6 months: antibiotics 6–23 months: antibiotics if bilateral or severe. Unilateral and non-severe → antibiotics or observe 2 years and up: antibiotics if severe. Non-severe → antibiotics or observe 48–72 h with a safety-net plan “Severe” = moderate–severe pain, pain ≥ 48 h, or temp ≥ 39 °C (102.2 °F) First line: high-dose amoxicillin 80–90 mg/kg/day divided BID EME 18 Amox-clav (90 mg/kg/day of the amoxicillin part) if amoxicillin in the last 30 days, purulent conjunctivitis at the same time (think H. flu), or known amoxicillin failure Non-severe PCN allergy: cefdinir, cefuroxime, cefpodoxime, or ceftriaxone Not better in 48–72 h → re-examine and step up (amoxicillin → amox-clav → ceftriaxone 50 mg/kg IM daily × 3 days) Duration: under 2 yr or severe = 10 days; 2–5 yr = 7 days; 6 yr and up = 5–7 days Recurrent AOM (≥ 3 in 6 months or ≥ 4 in 12 months) or complications → ENT for tympanostomy tubes EME 13, 18 Complications: TM perforation, mastoiditis, labyrinthitis, meningitis EME 19
OSCE move	Say “pneumatic otoscopy” out loud and describe bulging plus no mobility. Then decide antibiotics vs observation based on age, one or both ears, and severity.

3. Otitis Externa (OE)

Infection of the ear canal (“swimmer's ear”). Most common in kids and teens, in the summer EME 54.

What you'll hear	Ear pain that's worse when the ear is touched or moved, itching, drainage, fullness, muffled hearing EME 57 Risk factors: swimming/water, humidity, Q-tips or scratching, anything that plugs the canal (earbuds, hearing aids), dermatitis or psoriasis, radiation EME 56
Exam	Pain with tragal pressure or pulling the auricle (the hallmark) EME 57–58 Red, swollen canal with discharge or debris; periauricular and anterior cervical nodes EME 58 TM is normal if you can see it (often you can't because of the swelling) Otomycosis: itches more than it hurts EME 62. Aspergillus = black/gray spores (“wet newspaper”); Candida = white fluffy, curd-like material EME 63
Top differentials	Acute otitis media — No tragal tenderness; the drum bulges and the canal is normal Otomycosis — Itch predominates, with visible hyphae or a wet-newspaper appearance
Testing	Clinical diagnosis. Culture only if severe, chronic or recurrent, immunosuppressed, post-op, or failing treatment EME 55 Bugs: Pseudomonas aeruginosa (#1), S. epidermidis, S. aureus, fungi EME 54 Differential: otomycosis, suppurative OM, contact dermatitis, psoriasis, canal carcinoma EME 55
Treatment	Clean out the debris so the drops can reach the canal EME 59 Topical drops are first line, not oral antibiotics EME 59 AAO-HNS 2014 Ciprofloxacin-dexamethasone (Ciprodex) 4 gtt BID × 7 days, or ofloxacin 0.3% 10 gtt daily × 7 days Neomycin/polymyxin B/hydrocortisone (Cortisporin) 4 gtt TID–QID × 7 days, only if the TM is intact (ototoxic). Neomycin can cause contact dermatitis Mild cases: acidifying drops like acetic acid EME 59 TM not intact, tubes, or can't tell → fluoroquinolone drops only Drops with a steroid help with pain and swelling EME 59 Canal too swollen for drops to get in → place an ear wick EME 59 Oral antibiotics only if it spreads past the canal, the patient is diabetic or immunocompromised, or drops can't be delivered AAO-HNS 2014 Otomycosis: clean it out and use a topical antifungal (like clotrimazole 1% solution) EME 63 Keep the ear dry, give pain control, recheck if not better in 48–72 h. Prevention: dry ears after swimming, acidifying drops
OSCE move	Do tragal pressure and pinna pull before the otoscope goes in. Teach drop technique: lie with the ear up, fill the canal, pump the tragus, stay down 3–5 minutes.

4. Otitis Media with Effusion (OME)

Fluid behind the TM with no acute infection. Often left over after AOM EME 13–14.

What you'll hear	No pain and no fever. Muffled hearing and fullness, or no symptoms at all (found on otoscopy) EME 15 Kids: speech or language delay, not paying attention, trouble in school EME 19 Adult with one-sided fluid that won't go away = red flag
Exam	Dull TM (amber/yellow or gray), air-fluid level or bubbles, often retracted EME 16 Decreased mobility on pneumatic otoscopy; no bulging and no real redness EME 16 Weber to the affected ear, Rinne BC ≥ AC IE 39–42
Top differentials	Eustachian tube dysfunction — Retraction without fluid; the earlier point on the same spectrum Acute otitis media — Pain, fever and bulging, which this lacks
Testing	Clinical diagnosis; tympanometry type B EME 17 IE 26 Hearing test if the fluid lasts ≥ 3 months or the child is at risk for speech or learning problems AAO-HNS 2016 Adult with unilateral, persistent OME → nasopharyngoscopy to rule out a nasopharyngeal carcinoma blocking the eustachian tube NS 69–70. Higher risk in people of Southern Chinese or Southeast Asian descent; linked to EBV
Treatment	Watchful waiting. Most clear up on their own; recheck about every 3 months EME 18 Don't use antibiotics, steroids, antihistamines, or decongestants. They don't clear the fluid AAO-HNS 2016 Lasts ≥ 3 months with hearing loss or speech concerns → ENT for tympanostomy tubes. Adenoidectomy if big adenoids are blocking the eustachian tube EME 18 Complications: temporary conductive hearing loss, speech delay, acquired cholesteatoma EME 19
OSCE move	Say “no pain, no fever, no bulging.” For an adult, say “I'd refer for nasopharyngoscopy to rule out a nasopharyngeal mass.”

5. Eustachian Tube Dysfunction (ETD) / Barotrauma

The eustachian tube is swollen shut, so the middle ear can't equalize. Usually after a cold or allergies; lasts days to weeks EME 8.

What you'll hear	Fullness, mild–moderate muffled hearing, crackling or popping with swallowing or yawning EME 8 Worse with altitude changes (flying, mountains) or diving, and worse with a cold Barotrauma: ear pain (usually on descent) and conductive hearing loss after flying or diving; can cause middle ear bleeding or a TM rupture EME 22
Exam	Retracted TM (short process of the malleus stands out, handle looks shortened), decreased mobility EME 9 Barotrauma: hemotympanum, perforation, or effusion EME 23 IE 58 Inner ear involvement (vertigo, tinnitus, SNHL, nausea/vomiting) → round or oval window rupture, a perilymph fistula EME 23 IE 63–64
Top differentials	Otitis media with effusion — Amber fluid or a visible level behind the drum, not just retraction Cerumen impaction — Wax occludes the canal; the drum cannot be seen at all
Testing	Clinical diagnosis. Tympanometry type C (negative pressure) IE 22, 27; type B if fluid has built up Tuning forks or audiometry if hearing is down. An SNHL pattern after a dive or flight → urgent ENT
Treatment	Treat the cause: intranasal steroids; short-term oral or nasal decongestants (oxymetazoline no more than 3 days) EME 10 Autoinflation: exhale against a closed nose, swallow, yawn, chew gum EME 10, 25. Caution with active nasal discharge, since it can push infected mucus into the middle ear and cause AOM EME 10 Avoid flying or diving until it clears EME 10. If they have to fly: decongestant beforehand, swallow and yawn on descent EME 24; infants feed during descent Severe pain and hearing loss with an intact TM → ENT for myringotomy. Frequent flyers with repeated episodes → tubes EME 25 Perforation: keep it dry. Most heal on their own over several weeks EME 46 Any inner ear symptoms → urgent ENT IE 64
OSCE move	Ask about recent flights, diving, and a recent cold or allergy flare. Describe the TM as retracted, not bulging.

6. Sensorineural Hearing Loss (SNHL)

Problem in the cochlea (hair cells) or CN VIII and beyond. Usually not fixable, but it can often be stabilized, some causes are preventable, and sudden loss may respond to steroids in the first weeks IE 12–13.

What you'll hear	“People mumble,” trouble hearing in groups or crowded rooms, on the phone, or the TV; the partner complains IE 37–38 Hearing is worse in background noise and the patient may talk loudly (conductive loss is the opposite) IE 42 Tinnitus, often the first symptom IE 44. Red flag: one-sided or pulsatile IE 45 Onset matters: gradual and both ears (presbycusis, noise, ototoxic drugs) vs sudden and one ear (see Sudden SNHL in Don't Miss) Ask about: noise exposure (job, firearms, concerts) IE 54; ototoxic meds (aminoglycosides, furosemide, aspirin, platinum chemo) IE 52; head trauma IE 56; episodes of spinning vertigo IE 69; a recent URI with vertigo IE 95; a “pop” with flying, diving, or straining IE 64; family history IE 71; autoimmune disease IE 65; STI/HIV risk IE 67–68; DM or vascular disease IE 14; facial numbness or weakness, imbalance IE 74, 97
Exam	Otoscopy is normal (if you see wax or fluid, it's conductive) IE 42 Whisper test / finger rub for a quick screen Weber lateralizes to the good ear; Rinne AC > BC IE 39–42 Cranial nerves (V and VII can be involved with acoustic neuroma) IE 97, gait and Romberg, nystagmus, cerebellar signs. Dix-Hallpike only if the vertigo is positional IE 93
Top differentials	Conductive loss — Weber toward, Rinne negative, and usually a visible cause Acoustic neuroma — Asymmetric, with speech discrimination worse than the pure tone loss predicts
Testing	Pure tone audiometry confirms the type and severity IE 17 Severity: normal 0–20 dB · mild 20–40 · moderate 40–60 · severe 60–80 · profound > 80 IE 9 Presbycusis = both ears, symmetric, high frequencies first IE 15, 60. Ménière's = fluctuating low-frequency loss IE 69. Noise-induced classically shows a notch around 4,000 Hz Tympanometry type A (middle ear is fine) IE 25 Speech discrimination worse than the tone loss predicts → think acoustic neuroma IE 74 One-sided or asymmetric SNHL → MRI with gadolinium, the gold standard for retrocochlear causes IE 75 Labs aren't routinely needed IE 35–36. Exception: syphilis (FTA-ABS or MHA-TP; VDRL is not helpful) IE 35. HIV if risk factors IE 67 Vestibular testing (ENG) if there's vertigo or one-sided loss with balance symptoms IE 31–32
Treatment	Treat or remove the cause when you can; otherwise stabilize and amplify IE 13 Hearing aids; cochlear implant evaluation for severe–profound loss (audiology/ENT) Prevention: hearing protection and avoiding loud noise IE 46, 54; monitor aminoglycoside levels IE 52; stop or change ototoxic drugs with the prescriber Sudden loss → oral steroids and urgent ENT (see Don't Miss) IE 13, 79 Acoustic neuroma → observation with yearly MRI, surgery, or radiation IE 75 Labyrinthitis → symptom care, oral steroids, meclizine or diazepam for acute vertigo IE 95 Syphilis → antibiotics plus systemic steroids IE 68 Tinnitus: masking noise, biofeedback; no drug has beaten placebo IE 45–46 Communication tips for family: face the patient, speak slowly and clearly, cut background noise
OSCE move	Look in the ear first so you can say “canal and TM are normal.” Do Weber and Rinne and name the pattern out loud (“Weber goes to the good ear, Rinne is AC > BC, so this is sensorineural”). Order an audiogram, and for one-sided loss, an MRI with gadolinium.

SNHL causes to keep straight

Cause	Clues	Workup / management
Presbycusis	Older adult, gradual, both ears, symmetric, high pitches first; hears talking but can't make out words; misses the doorbell or phone IE 15, 60–61	Audiogram; hearing aids
Noise-induced	Job, guns, concerts. Temporary shift (full ears, “crickets”) recovers in 24–48 h; repeated exposure → permanent IE 54–55	Audiogram; hearing protection
Ototoxicity	Aminoglycosides (most common), loop diuretics, aspirin, platinum chemo; both ears; often nephrotoxic too IE 52–53	Stop or adjust the drug; monitor aminoglycoside levels
Ménière's disease	Spinning vertigo lasting hours, fluctuating low-frequency loss, low “blowing” tinnitus, one-sided fullness, N/V IE 69–70, 97	Audiogram; ENT
Acoustic neuroma	One-sided, progressive (can be sudden), tinnitus, poor speech understanding, imbalance; may involve CN V and VII IE 72–74, 97	MRI with gadolinium; observe, surgery, or radiation IE 75
Labyrinthitis	Fairly sudden SNHL plus acute vertigo, usually viral IE 95	Symptom care, oral steroids, meclizine/diazepam; antibiotics if bacterial
Perilymph fistula	SNHL + vertigo after head injury, barotrauma, or heavy straining; sometimes a “pop” IE 63–64	Symptom care, ENT
Syphilis / HIV	Fluctuating SNHL, tinnitus, fullness, episodic vertigo; can look just like Ménière's IE 67–68	FTA-ABS or MHA-TP, HIV test; antibiotics + steroids IE 68
Autoimmune	Both ears, progressive with ups and downs, ± balance problems IE 65–66	ENT/rheum; no routine autoimmune screening IE 36
Sudden SNHL	One ear, over ≤ 72 h, normal ear exam IE 79	See Don't Miss: steroids now, urgent ENT

Don’t Miss: Ear

Mastoiditis

Picture	Complication of AOM: the infection spreads into the mastoid air cells EME 19. Mostly kids. Recent or current AOM plus pain behind the ear and fever.
Exam	Redness, swelling, tenderness, or fluctuance behind the ear; the auricle is pushed forward and out; the crease behind the ear is gone. The TM usually looks like AOM.
Top differentials	Acute otitis media — Ear pain without postauricular swelling or auricular protrusion Postauricular lymphadenitis — A discrete mobile node; the auricle is not displaced
Testing	CT temporal bone with contrast (abscess, bone erosion, intracranial spread). CBC, CRP, blood cultures, and a culture of the middle ear fluid. MRI if an intracranial complication is suspected.
Treatment	Admit. IV antibiotics (e.g., ceftriaxone ± vancomycin) and ENT for myringotomy ± tube; mastoidectomy for an abscess or no improvement. Watch for meningitis EME 19, sigmoid sinus thrombosis, brain abscess, and facial nerve palsy.

Malignant (Necrotizing) Otitis Externa in a Diabetic

Picture	Elderly diabetic or immunocompromised patient with “otitis externa” that won't get better. Pseudomonas in > 95% EME 61. Pain out of proportion to the exam, often worse at night, with heavy drainage EME 61.
Exam	Granulation tissue on the floor of the canal, visible necrosis of the canal, and facial nerve (CN VII) weakness EME 61. Later: CN IX, X, XI.
Top differentials	Ordinary otitis externa — Responds to drops within days and has no granulation or night pain Otomycosis — Itch dominates, visible hyphae or curd, no bone involvement
Testing	CT or MRI shows infection in the bone and skull base EME 61. ESR/CRP (high, used to follow treatment), culture of the drainage, glucose/A1c. Biopsy to rule out canal carcinoma, which looks similar and also fails OE treatment EME 71.
Treatment	ENT and usually admission. Long course of antipseudomonal antibiotics, e.g., ciprofloxacin EME 61 (IV cefepime or piperacillin-tazobactam if severe), typically 6–8 weeks. Tight glucose control; debridement as needed.

Sudden Sensorineural Hearing Loss (SSNHL)

Picture	Hearing loss in one ear that comes on over ≤ 72 hours; patients often notice it on waking or on the phone. Fullness, tinnitus, ± vertigo. Easy to mistake for wax or fluid, so actually look in the ear. It's a syndrome, not a disease (viral or vascular), and it needs a prompt ENT referral IE 79.
Exam	Otoscopy is normal IE 42. Weber lateralizes to the GOOD ear; Rinne AC > BC IE 39–42. Check cranial nerves, cerebellar signs, and gait. Vertigo plus neuro deficits means think stroke IE 77–78.
Top differentials	Cerumen impaction — Wax visible; Weber would lateralize TOWARD the blocked ear Otitis media with effusion — Amber drum with reduced mobility; conductive pattern
Testing	Audiometry as soon as possible to confirm SNHL IE 17. MRI with gadolinium to rule out acoustic neuroma, the gold standard for retrocochlear causes IE 75. Routine labs aren't needed IE 35–36, except syphilis testing (FTA-ABS or MHA-TP, not VDRL) IE 35, 68. Consider HIV if risk factors IE 67. No routine head CT AAO-HNS 2019.
Treatment	Oral steroids right away: prednisone about 1 mg/kg/day (max ~60 mg) for 7–14 days, then taper AAO-HNS 2019. Steroids help most in the first couple of weeks IE 13; after that the window closes. Urgent ENT referral IE 79. Salvage options: intratympanic steroid injections, hyperbaric oxygen. Repeat audiometry; hearing aid or cochlear implant evaluation if recovery is incomplete.
OSCE move	“This came on suddenly in one ear with a normal ear exam, so I'm treating it as sudden SNHL: audiogram today, start prednisone now, urgent ENT referral, and an MRI with gadolinium.”

Tell Them Apart: Ear

	AOM	OME	Otitis Externa	ETD
Pain	Yes	No	Yes, worse moving the ear	Pressure or mild pain
Fever	Often	No	Usually no	No
Tragal / pinna pain	No	No	Yes	No
TM	Red, bulging, landmarks gone	Dull/amber, air-fluid level	Normal if seen; canal swollen	Retracted
Mobility	Decreased or absent	Decreased	Normal	Decreased
Tympanogram	Type B	Type B	Type A if tolerated	Type C
Antibiotics?	Oral (or observe)	No	Topical drops	No

Nose

1. Viral Rhinitis (Common Cold)

Viral URI. 90–98% of acute rhinosinusitis is viral, not bacterial NS 10.

What you'll hear	Scratchy throat first, then congestion, sneezing, and clear runny nose that can turn thick and yellow/green Color alone doesn't mean bacterial; only pure clear discharge is somewhat helpful (points to viral or allergic) NS 19 Peaks day 3–5, improving by day 7–10; cough can hang on longer Low-grade fever possible (more in kids), sick contacts Rhinovirus is most common; also parainfluenza, influenza NS 11, coronavirus, RSV
Exam	Red, swollen nasal mucosa (vs pale and boggy in allergies), clear to mucoid discharge Mild pharyngeal redness. Facial pain is not reproducible on palpation the way it is in bacterial sinusitis NS 18
Top differentials	Allergic rhinitis — Lots of itching and sneezing, pale bluish boggy mucosa, no fever, and it is seasonal or trigger-linked Acute bacterial rhinosinusitis — Purulence with tender, often one-sided facial pain, and 10 days, double worsening or severe onset
Testing	None needed. No test reliably separates viral from bacterial NS 21 Flu or COVID testing only if it would change treatment
Treatment	Supportive: fluids, rest, saline spray or irrigation, acetaminophen or NSAIDs NS 22, 24 Decongestants short term; caution with high blood pressure NS 26. Oxymetazoline no more than 3 days (rebound congestion = rhinitis medicamentosa) Intranasal ipratropium for a runny nose NS 26 Honey for cough (not under age 1). Avoid OTC cough and cold meds in young kids Influenza: oseltamivir 75 mg BID × 5 days NS 24 No antibiotics. Come back if it lasts past 10 days, gets better then worse, high fever, or eye swelling
OSCE move	Give the timeline in plain words: “This should peak in 3–5 days and be better by 7–10. If you're not improving after 10 days or you get better and then worse, come back.”

2. Allergic Rhinitis

IgE reaction to an allergen. Very common and increasing. The diagnosis is mostly the history NS 66.

What you'll hear	Sneezing fits, itchy nose/eyes/palate, clear watery runny nose, congestion, itchy watery eyes, no fever Seasonal (pollen) or year-round (dust mites, pets, mold). Timing and triggers are the key history Personal or family history of asthma or eczema
Exam	Pale/bluish, boggy (swollen) turbinates with clear discharge from both sides NS 67; ± nasal polyps NS 67 Allergic shiners, Dennie-Morgan lines, transverse nasal crease (“allergic salute”), red eyes, cobblestoning of the back of the throat
Top differentials	Viral rhinitis — Days rather than a season, with sore throat and no itch Vasomotor rhinitis — Triggered by temperature, odors and food; no itch or sneezing fits
Testing	Clinical diagnosis NS 66 Allergy testing (skin prick or serum specific IgE) if the diagnosis is unclear, treatment isn't working, or to guide avoidance or immunotherapy NS 29 AAO-HNS 2015 No imaging for routine allergic rhinitis If polyps are present: CBC with diff, IgE NS 64. Kids with polyps → sweat chloride test for cystic fibrosis NS 61, 64
Treatment	Most patients (80%) end up on 2 or more allergy meds NS 26 Avoid triggers: allergen-proof bedding covers, HEPA filter, pets out of the bedroom, windows closed during pollen season Intranasal steroid = most effective single drug: fluticasone (Flonase), mometasone, budesonide NS 68. Aim away from the septum; full effect takes days to weeks. Caution with chronic use NS 68 Non-drowsy oral antihistamine for sneezing and itch: loratadine, cetirizine, fexofenadine, levocetirizine NS 68. Drowsy ones can be tried at night NS 68 Intranasal antihistamine (azelastine) works fast and can be combined with the nasal steroid for moderate–severe symptoms Intranasal ipratropium for runny nose NS 68 Leukotriene inhibitor at night (montelukast, zafirlukast) NS 68. Not first line; montelukast has a boxed warning for mood/behavior effects. Most useful if asthma is also present Decongestants short term only; caution with chronic use and HTN NS 68 Immunotherapy (shots or under-the-tongue tablets) if not controlled NS 68 Eye drops (olopatadine, ketotifen) for eye symptoms; saline rinses; local honey NS 24
OSCE move	Ask about seasons, pets, itchy eyes, asthma, and eczema. Say “pale, boggy turbinates.” Start a nasal steroid and teach the technique.

3. Acute Bacterial Rhinosinusitis

Rhinosinusitis lasting < 4 weeks NS 9. Maxillary > ethmoid > frontal > sphenoid NS 3. Only 0.5–2% of viral cases turn bacterial NS 10.

What you'll hear	Purulent nasal drainage plus congestion and/or facial pain/pressure that's worse bending over or lying down NS 9, 18 Upper tooth pain, bad breath, decreased smell, headache, retro-orbital pain, ear pain, cough NS 17–18 Call it bacterial when you see one of three patterns NS 16 IDSA 2012: Persistent: 10 days or more without improvement Severe onset: fever ≥ 39 °C (102 °F) with purulent discharge or facial pain for 3–4 days in a row at the start Double worsening: gets better, then worse again after day 5–6 Risk factors: allergies, smoking, immunocompromise, anatomic problems like a deviated septum NS 14
Exam	Purulent discharge, swollen mucosa, sinus tenderness (often one-sided maxillary) NS 16 Confirm the fever and make sure they didn't take an antipyretic NS 19 Check the eyes (swelling, eye movements, vision) and mental status every time NS 17 Bugs: S. pneumoniae, nontypeable H. influenzae, M. catarrhalis in kids NS 11
Top differentials	Viral rhinosinusitis — Peaks at days 3 to 6 and improves — no double worsening Allergic rhinitis — Itch, sneezing, clear discharge, and it is seasonal or exposure-linked
Testing	Clinical diagnosis. No routine imaging; X-rays and CT can't tell viral from bacterial NS 21 CT sinus if it keeps coming back, treatment fails, a complication is suspected (eye or brain), or it's chronic NS 21
Treatment	Symptom care for everyone: saline irrigation (Neti pot with distilled or boiled water), intranasal steroids, NSAIDs, short-term decongestants NS 22, 24 Antibiotics if it's bacterial NS 23. Adults with reliable follow-up can also do watchful waiting AAO-HNS 2015 First line: amox-clav 875/125 mg BID or 500/125 mg TID NS 23 Antibiotics in the last 30 days or high resistance: amox-clav ER 2000/125 mg BID NS 23 PCN allergy: doxycycline 100 mg BID, or moxifloxacin 400 mg daily NS 23 Duration: adults 5–7 days, kids 10–14 days IDSA 2012. Avoid macrolides and TMP-SMX because of resistance Recent treatment failure: amox-clav ER 2000 mg BID or moxifloxacin NS 23 Medical treatment fails → ENT referral NS 24 Chronic sinusitis (> 12 weeks) → CT sinus, ENT, allergy testing NS 28–29
OSCE move	Pin down the timeline out loud: “How many days has it been? Did you get better and then worse?” Then say “no imaging unless I suspect a complication.”

4. Epistaxis

Peaks in kids under 10 and adults 45–65, more in winter NS 45. 90% anterior, from Kiesselbach's plexus NS 46.

What you'll hear	Which side, how long, how much, how often. Blood down the back of the throat or from both sides → think posterior NS 45–46 Most common cause is the patient's finger; chronic dry nose is a risk factor NS 45 Other causes: trauma, recent surgery, intranasal steroids, cocaine NS 48 Meds: warfarin, aspirin, clopidogrel, DOACs, NSAIDs NS 48 Bleeding disorders (personal or family history), cirrhosis, HIV, tumors NS 48 Symptoms from blood loss (lightheaded, chest pain, short of breath), especially with CAD or COPD NS 48 Recurrent bleeds plus small red spots on the lips/tongue/fingers and family history → HHT
Exam	ABCs and vitals first. Normal appearance, vitals, and breathing = good sign NS 48 Have the patient blow out clots NS 49, then look with a nasal speculum and light to find the source Anterior: Kiesselbach's plexus on the front of the septum NS 46 Posterior: usually sphenopalatine artery branches. Heavier bleeding, higher risk for aspiration NS 45–46. Look at the back of the throat for ongoing bleeding
Top differentials	Posterior epistaxis — No visible anterior point; blood running down the pharynx Bleeding disorder or anticoagulation — Recurrent, bilateral, with bruising elsewhere
Testing	Most patients need no labs PT/INR only if anticoagulated NS 49 Massive or prolonged bleed: hematocrit, type and crossmatch, two large-bore IVs NS 49 Coag workup if a bleeding disorder is suspected; CT or endoscopy if a mass or recurrent posterior bleeding
Treatment	Step 1: Sit up and lean forward at the waist; spit out blood instead of swallowing it NS 50 Step 2: Blow out clots, then spray oxymetazoline (Afrin) NS 49 Step 3: Pinch the soft part of the nose against the septum continuously for 10 minutes, no peeking NS 49. Cold compress on the bridge NS 50 Step 4: Visible anterior spot → silver nitrate cautery after topical anesthetic. Only cauterize one side of the septum (both sides → septal perforation) Step 5: Still bleeding → packing: nasal tampon, gauze, balloon catheter, or clotting foam/gel NS 51 Step 6: Posterior bleed → posterior packing or balloon, admit, ENT NS 51 Don't automatically stop anticoagulants for a bleed you've controlled; talk with the prescriber Home care: no nose blowing after packing NS 51; humidifier, saline spray, petroleum jelly inside the nose, trim nails, no picking. Teach the pinch technique for next time NS 50
OSCE move	Start with ABCs and vitals, then narrate the pinch correctly: lean forward, pinch the soft part (not the bony bridge), 10 minutes without letting go.

5. Nasal Foreign Body

Mostly young kids. Unilateral, purulent, foul-smelling discharge in a young child = foreign body until proven otherwise NS 54.

What you'll hear	Often nobody saw it happen. Beads, food, toy parts, paper, button batteries, magnets One-sided foul, purulent, maybe bloody discharge; one-sided stuffiness
Exam	Look with an otoscope or headlight. Seeing it makes the diagnosis NS 54 Usual spots: nasal floor just under the inferior turbinate, or up high in front of the middle turbinate NS 54 Check the other nostril and both ears too (kids who put one thing in often put in more)
Top differentials	Unilateral sinusitis — Discharge without an object; far less common at this age Choanal atresia — Congenital, present from birth, with clear rather than foul discharge
Testing	Usually none; imaging is rarely needed NS 54 X-ray if a metal object is possible or unknown (button battery, magnet). A button battery shows a “double ring” on the front view
Treatment	Button battery = emergency. It burns through tissue within hours and can perforate the septum. Emergent removal by ENT. Don't put saline drops in first Magnets on both sides of the septum are just as urgent (pressure necrosis) Prep: oxymetazoline ± topical lidocaine; hold the child still (papoose) or sedate if needed Try positive pressure first: the “parent's kiss” (block the clear nostril, parent gives a quick puff into the child's mouth). Older kids can blow with the clear side blocked Instruments: alligator forceps for soft or graspable things; a right-angle hook or curette behind round or hard things; a balloon catheter passed behind the object and pulled forward; suction Don't push it backward (aspiration risk). Don't irrigate organic items like beans; they swell After removal, recheck both sides for injury or a second object Refer to ENT if posterior, stuck, failed attempt, battery or magnets, or significant tissue damage (“ENT is your friend”) NS 54
OSCE move	Say the one-liner (“unilateral foul discharge in a toddler is a foreign body until proven otherwise”), check the other nostril and ears, and specifically ask about batteries and magnets.

Don’t Miss: Nose

Unilateral Obstruction or Bleeding in an Adult

Picture	Tumor until proven otherwise. One-sided stuffiness, repeated one-sided nosebleeds, one-sided ear fluid, facial numbness, double vision, headache, or a neck mass NS 70. Nasopharyngeal carcinoma is common in Southern China, Southeast Asia, North Africa, the Middle East, and the Arctic; men 2–3×; linked to EBV, HPV, smoking, and salty diets NS 69. Teen boy with one-sided obstruction and heavy nosebleeds → juvenile nasopharyngeal angiofibroma (very vascular; don't biopsy in clinic).
Exam	Look for a one-sided mass or polyp (a one-sided “simple polyp” isn't always simple NS 63). Check cranial nerves (V, VI), eyes, both ears for effusion, and neck nodes.
Top differentials	Unilateral nasal polyp or inverted papilloma — A one-sided "simple polyp" is not always simple, and a papilloma can harbor carcinoma Retained nasal foreign body — Foul one-sided discharge with an object on inspection, the childhood cause of the same one-sided picture
Testing	ENT nasal endoscopy with guided biopsy NS 70. CT and/or MRI with contrast.
Treatment	Prompt ENT referral NS 70. Treatment depends on the tumor (surgery, radiation, chemoradiation).

Periorbital Swelling, Vision Change, or Proptosis

Picture	Sinusitis spreading to the orbit (ethmoid sinuses are the classic source in kids). Your deck's “needs urgent attention” list: vision changes (especially double vision), periorbital swelling or redness, and altered mental status NS 17. In an immunocompromised or DKA patient, think invasive fungal sinusitis (Mucor, Rhizopus) NS 12; look for a black eschar on the turbinate or palate.
Exam	Preseptal: red, swollen eyelid, but vision, eye movements, and pupils are normal, no pain moving the eye, no proptosis. Orbital (post-septal): proptosis, pain with eye movement, limited movement or double vision, decreased vision, chemosis, afferent pupillary defect. Both eyes involved plus cranial nerve palsies and toxic → cavernous sinus thrombosis. Headache, stiff neck, confusion → intracranial spread.
Top differentials	Uncomplicated bacterial sinusitis — Facial pain and purulence WITHOUT eye or neurological signs Pre-septal cellulitis — Lid swelling but the eye is white, movements full and painless
Testing	CT orbits and sinuses with contrast for any sign of spread outside the sinus NS 21. CBC, blood cultures. MRI if you're worried about the brain.
Treatment	Orbital cellulitis or abscess: admit, IV antibiotics (e.g., ampicillin-sulbactam, or ceftriaxone + vancomycin ± metronidazole), urgent ophthalmology and ENT; surgical drainage for an abscess or vision loss. Mild preseptal cellulitis in a reliable patient can be treated orally (amox-clav) with a recheck the next day. Invasive fungal: emergency surgical debridement plus IV amphotericin B.

Tell Them Apart: Nose

	Viral Rhinitis	Allergic Rhinitis	Bacterial Sinusitis
Discharge	Clear, can turn colored	Clear, watery	Purulent
Itch / sneezing	Some sneezing	Lots of itching and sneezing	No
Fever	Low-grade, early	None	Can be high (severe onset)
Mucosa	Red, swollen	Pale/bluish, boggy	Red, purulent drainage
Facial pain	Minimal, not reproducible	Pressure only	Yes, often one-sided and tender
Timeline	Peaks day 3–5, better by 7–10	Seasonal or trigger-linked, recurring	≥ 10 days, severe onset, or double worsening
Treatment	Supportive	Nasal steroid ± antihistamine	Amox-clav (or watchful waiting)

Throat

1. Viral Pharyngitis

About 70% of pharyngitis is viral OC 70.

What you'll hear	Sore throat plus cough, runny nose, hoarseness, conjunctivitis, ear pain or headache OC 72 Cough is the most useful sign against strep Clues to the virus: adenovirus (pink eye + sore throat), coxsackie (herpangina = vesicles/ulcers on the tonsils and soft palate OC 72), HSV (gingivostomatitis) OC 25, EBV (mono), acute HIV (sexual risk, rash, ulcers) OC 70
Exam	Red pharynx ± a little exudate, red eyes, runny nose, maybe nodes OC 72
Top differentials	Streptococcal pharyngitis — Exudate, tender anterior nodes, fever, and NO cough Infectious mononucleosis — Posterior nodes, marked fatigue, splenomegaly, palatal petechiae
Testing	Clinical. No strep test when the viral features are obvious OC 72 Flu or COVID test if it changes treatment; Monospot if mono is possible; HIV test if risk factors
Treatment	Supportive: fluids, rest, acetaminophen or NSAIDs OC 72, salt-water gargles, lozenges Avoid benzocaine sprays in children under 2 (methemoglobinemia) No antibiotics Come back for drooling, can't open the mouth, muffled voice, can't swallow, trouble breathing, or one-sided swelling
OSCE move	Ask about cough, runny nose, and pink eye, and say “the cough points away from strep.”

2. Group A Strep Pharyngitis

GABHS (S. pyogenes). Kids and teens (not usually under 3), winter and spring, droplet spread, incubation 2–5 days OC 73.

What you'll hear	Sudden sore throat, fever > 100.4 °F, painful swallowing, no cough, abdominal pain OC 73; headache, nausea in kids Scarlet fever: sandpaper rash, strawberry tongue
Exam	Red tonsils and pharynx with purulent exudate, tender anterior cervical nodes OC 73 Palatal petechiae, swollen uvula
Top differentials	Viral pharyngitis — Cough, coryza and hoarseness present; low Centor score Infectious mononucleosis — POSTERIOR nodes and splenomegaly; giving amoxicillin causes a rash
Testing	Use the Centor score (table below) OC 74, 76 Rapid antigen test and throat culture (culture is the gold standard) OC 74 Negative rapid test → confirm with a throat culture OC 74. (IDSA says this for kids and teens; adults usually don't need the backup culture.) Don't test kids under 3 or patients with obvious viral features IDSA 2012 ASO titers show a past strep infection (used for rheumatic fever); see the heads-up box at the end OC 74
Treatment	Supportive: fluids, soft diet, rest, pain relief, avoid irritants OC 77 Penicillin VK × 10 days OC 77: kids 250 mg BID–TID; adults 250 mg QID or 500 mg BID Amoxicillin can be substituted OC 77: 50 mg/kg once daily (max 1,000 mg) × 10 days IM benzathine penicillin G once if you're worried about adherence or they can't take pills OC 77: 600,000 U if < 27 kg, 1.2 million U if ≥ 27 kg Mild PCN allergy: cephalexin or cefadroxil OC 77 Severe PCN allergy: clindamycin or a macrolide (azithromycin × 5 days) OC 77 Why we treat: prevent rheumatic fever OC 78 (works if started within 9 days), prevent abscess, feel better sooner, stop spread. Back to school after 12–24 h of antibiotics Rheumatic fever shows up about 2–3 weeks after the infection (range 1–5), peak ages 5–15 OC 78
OSCE move	Say each Centor item as you check it. Don't reach for amoxicillin if mono is still on the table OC 87.

Centor score (with McIsaac age points) OC 76

Criterion	Points	Score → What to do
Fever > 100.4 °F	+1	0–1: no test, no antibiotics
Tonsillar exudate or swelling	+1	2–3: rapid strep; treat if positive
Tender anterior cervical nodes	+1	4–5: test and treat if positive (IDSA: don't treat on score alone)
No cough	+1
Age 3–14 / 15–44 / ≥ 45	+1 / 0 / −1

3. Oral Candidiasis (Thrush)

Candida albicans. Common in infants and immunosuppressed patients OC 88.

What you'll hear	Painful mouth, taste changes, painful swallowing OC 89 Always ask why: dentures, poor oral hygiene, diabetes, anemia, chemo or radiation, oral or inhaled steroids, broad-spectrum antibiotics, older age, HIV or immunosuppression OC 88 Trouble or pain swallowing with thrush → think esophageal candidiasis (AIDS-defining in HIV)
Exam	Creamy white, curd-like patches on a red base, usually on the buccal mucosa and tongue OC 89 Scrapes off with a tongue depressor (leukoplakia and lichen planus don't) OC 89, 133 Hairy leukoplakia = painless, corrugated, on the side of the tongue, doesn't scrape off; strongly linked to HIV OC 136 Can have fever and lymphadenopathy OC 89; look for redness under dentures and cracks at the mouth corners
Top differentials	Leukoplakia — Does NOT scrape off — and it is premalignant Lichen planus — Lacy striae that do not wipe away
Testing	Clinical diagnosis. KOH prep shows spores and pseudohyphae OC 90 Work up the cause: glucose/A1c, HIV test if no clear reason, CBC, med list Culture if it's not responding (resistant species)
Treatment	Saline and peroxide rinses OC 90 Mild: nystatin oral suspension 100,000 U/mL, 4–6 mL swish QID × 7–14 days, or clotrimazole troche 10 mg 5×/day × 7–14 days OC 90 Moderate–severe: fluconazole 100–200 mg PO daily × 7–14 days OC 90 (check drug interactions) Esophageal: systemic fluconazole 200–400 mg daily × 14–21 days HIV patients may need a longer fluconazole course; refractory → itraconazole or voriconazole OC 90 Infants: nystatin 1 mL to each side of the mouth QID; treat mom's nipples if breastfeeding; boil pacifiers and bottle nipples Fix the cause: rinse and spit after an inhaled steroid and use a spacer; take dentures out at night and soak them; control blood sugar
OSCE move	Actually scrape it and say what's left (red base). Then say your “why” workup out loud: dentures, inhaler, antibiotics, A1c, HIV.

4. GERD / Laryngopharyngeal Reflux (LPR)

Acid reaching the larynx and pharynx. Your decks only mention reflux as a cause of laryngitis OC 57 and chronic throat symptoms OC 80, so most of this box is from outside references.

What you'll hear	Morning hoarseness, constant throat clearing, globus (“lump in my throat”), chronic cough, feeling of postnasal drip Often no heartburn at all (“silent reflux”) Triggers: late or large meals, caffeine, alcohol, chocolate, fatty or spicy food, citrus, tomato, smoking, obesity
Exam	Office exam is often normal; the back of the throat may look thickened or granular OC 80 On laryngoscopy: redness and swelling of the back of the larynx (arytenoids), vocal fold swelling, thick mucus Always feel the neck for nodes
Top differentials	Laryngeal carcinoma — The diagnosis the scope exists to exclude: hoarseness past two weeks, more so in a smoker Vocal cord nodules or polyps — A discrete lesion on the cord rather than diffuse posterior redness and swelling
Testing	Hoarseness lasting more than 2 weeks is not a diagnosis by itself; refer to ENT for laryngoscopy to rule out cancer and polyps OC 58 Guideline: scope if not better by 4 weeks, or right away if something serious is suspected (smoker, neck mass, stridor, coughing blood). Don't start a PPI for hoarseness alone without looking at the larynx AAO-HNS 2018 Typical GERD symptoms: an empiric PPI trial is reasonable EGD for alarm features: trouble or pain swallowing, weight loss, GI bleeding or anemia, persistent vomiting
Treatment	Lifestyle: lose weight, raise the head of the bed, no food 2–3 h before bed, avoid triggers, stop smoking, cut back alcohol OC 80 PPI 30–60 minutes before breakfast (e.g., omeprazole 20–40 mg) × 8 weeks. LPR often needs BID for 2–3 months, then taper to the lowest dose that works H2 blocker (famotidine) at bedtime or antacids for breakthrough Voice care: hydrate, humidify, sip water instead of clearing, voice rest OC 57 Not improving → GI or ENT. Long-term PPI risks (C. diff, fractures, low Mg/B12) → use the lowest effective dose
OSCE move	Ask about morning hoarseness, throat clearing, globus, late meals, smoking, and alcohol. Then say you'd scope anyone with hoarseness that isn't getting better, especially a smoker.

5. Aphthous Ulcers (Canker Sores)

Most common cause of recurrent mouth ulcers in teens and young adults OC 15. Recurrent aphthous stomatitis = Sutton's disease OC 17.

What you'll hear	Painful ulcers, often with burning or tingling before they show up OC 16 Triggers: cheek biting or dental work, stress OC 15; low iron or zinc OC 13; low B12 or folate; certain toothpastes (SLS) Systemic clues: genital ulcers or eye inflammation (Behçet) OC 14, 19, diarrhea or weight loss (Crohn's, celiac), HIV
Exam	Round, shallow, painful ulcer with a yellow-gray center and a red halo OC 17 Non-keratinized (movable) mucosa only: buccal and labial mucosa, non-attached gingiva, underside of tongue, soft palate OC 15 Minor (< 1 cm, most common, heals in 7–10 days) · Major (> 1 cm, lasts > 1 month, can scar) · Herpetiform (many 1–3 mm ulcers, lasts > 1 month) OC 16 HSV is different: vesicles first, then clustered ulcers, with a prodrome; primary infection brings fever and nodes OC 25–26
Top differentials	Herpes simplex — Vesicles first, on KERATINIZED mucosa, clustered rather than solitary Behcet syndrome — Oral ulcers PLUS genital ulcers and uveitis — the reason to ask
Testing	Clinical diagnosis OC 17 Frequent, severe, or unusual: CBC, iron studies, B12, folate, zinc, celiac serology, HIV; GI workup if GI symptoms HSV suspected → PCR of the lesion (most sensitive and specific) OC 27 An ulcer that won't heal (especially in a smoker or drinker) → biopsy to rule out cancer OC 146
Treatment	Self-limited; watching it is fine OC 17 Topical steroids: triamcinolone in dental paste, fluocinonide gel OC 17; dexamethasone swish-and-spit Pain: silver nitrate cautery OC 17, topical lidocaine (don't swallow; careful in young kids) Other options in your deck: antibiotic or antiseptic rinses, dilute water rinses, Lactobacillus capsules, Kanka OC 17 Avoid triggers and correct any deficiency Severe or frequent: oral steroids OC 17, colchicine; refer (and rheum if Behçet)
OSCE move	Name the location (non-keratinized) and the look (yellow-gray base, red halo). Ask about genital ulcers, eye symptoms, and GI symptoms.

Don’t Miss: Throat

Peritonsillar Abscess (PTA)

Picture	Pus between the tonsil capsule and the pharyngeal muscles; a complication of untreated strep or tonsillitis. Most common deep neck infection; teens and young adults, more in males OC 96. Severe sore throat (usually one side), fever, painful swallowing, drooling, “hot potato” voice, can't open the jaw OC 98, ear pain on the same side.
Exam	Classic triad: trismus (most reliable), uvula deviated away from the abscess, muffled voice OC 99. Bulging of the soft palate on one side, tonsil pushed toward the midline OC 98. Tender nodes. Check the airway: stridor, handling secretions.
Top differentials	Severe tonsillitis — Bilateral and symmetric with no palatal deviation or trismus Retropharyngeal abscess — Neck stiffness and a widened prevertebral space; younger child
Testing	Clinical; confirmed when pus comes out on drainage OC 100. Ultrasound tells abscess from cellulitis and can guide the needle OC 100. CT with contrast if unclear, you can't see because of trismus, or you're worried it spread deeper OC 100. CBC, culture of the pus, Monospot. Bugs: GABHS, S. aureus, H. influenzae, plus anaerobes like Fusobacterium OC 96.
Treatment	Secure the airway first OC 101. Needle aspiration or I&D OC 101 (keep the needle shallow; the carotid is behind and lateral). Antibiotics: IV amox-clav or clindamycin, add MRSA coverage if severe; milder cases or once they can swallow → PO amox-clav or clindamycin OC 101. Pain control and fluids. Tonsillectomy for recurrent tonsillitis or recurrent PTA, usually after the infection settles OC 101. Complications: airway obstruction, spread to the retropharyngeal space → mediastinitis OC 103, 107.
OSCE move	Check the airway before anything else, then measure how far they can open the mouth. Say the triad out loud: “trismus, uvula pushed away from the swollen side, muffled voice.” Then give the plan: ultrasound or CT if unsure, needle aspiration or I&D, antibiotics.

Epiglottitis (Supraglottitis)

Picture	ENT emergency OC 60. Classically kids 2–6 from Hib (down over 90% since the vaccine); can hit adults; also S. pneumoniae, S. aureus, strep OC 60. Kids: sudden and fast, over hours; the 4 D's: drooling, dysphagia, dysphonia (“hot potato”), distress OC 61–62. Adults: severe sore throat and painful swallowing, fever, shortness of breath, slower course OC 61–62.
Exam	Irritable, sitting in the tripod/sniffing position, drooling, muffled voice; inspiratory stridor is a late sign OC 62. Don't do a tongue-blade exam, draw blood, or anything else that upsets the patient; it can trigger complete obstruction OC 63.
Top differentials	Peritonsillar abscess — Trismus with uvular deviation; the mouth CAN be examined Retropharyngeal abscess — Neck stiffness with a widened prevertebral space on X-ray
Testing	Diagnosis starts from the history and how the patient looks OC 63. Lateral neck X-ray “thumbprint sign” is not necessary OC 63–64; only if stable. Fiberoptic laryngoscopy is the gold standard OC 63, done where the airway can be secured. Blood cultures and a supraglottic swab once the airway is safe OC 66.
Treatment	Airway first. Kids: to the OR for airway (intubation, trach backup) OC 66. Adults: close observation, humidified oxygen, steroids, nebulized epinephrine; intubate if it's closing OC 66. IV ceftriaxone (or cefotaxime) + vancomycin × 7–10 days; PCN/ceph allergy → vancomycin + a quinolone or carbapenem OC 67. Prevention: Hib vaccine OC 65; rifampin prophylaxis for household contacts when there's an under-vaccinated young child in the home.

Mono with Splenomegaly

Picture	EBV (90%) or CMV; ages 15–24; spread through saliva OC 81. Prodrome of malaise, headache, low-grade fever, then the triad: fever, tonsillar pharyngitis ± exudate, cervical lymphadenopathy OC 82, often posterior nodes. Heavy fatigue. Rash after amoxicillin or penicillin OC 87.
Exam	Big tonsils ± exudate, palatal petechiae, cervical nodes, splenomegaly, hepatomegaly OC 82. Left upper quadrant or left shoulder pain with low blood pressure = splenic rupture.
Top differentials	Streptococcal pharyngitis — Anterior nodes, no splenomegaly, shorter course Cytomegalovirus infection — A very similar illness with a NEGATIVE monospot
Testing	CBC with differential (lymphocytosis with atypical lymphocytes) + heterophile/Monospot OC 85. Monospot is often negative in the first week and in kids under 4 → EBV serology (IgM = current infection) OC 84. LFTs. Test for strep too if indicated. Ultrasound to follow the spleen OC 86.
Treatment	Supportive: fluids, acetaminophen or NSAIDs, rest; no antiviral works OC 86. Steroids only if the airway is in trouble OC 86. No contact sports or heavy lifting for about 1 month and until the spleen is back to normal OC 86. Avoid amoxicillin and ampicillin OC 87.

Unilateral Throat Pain + Neck Mass in a Smoker Over 40

Picture	Head and neck squamous cell carcinoma until proven otherwise NM 39. Malignancy red flags: no infectious source, mass > 2 weeks, > 1.5 cm, firm, non-tender, not mobile, age > 40, tobacco and alcohol NM 13. Other symptoms: ear pain with a normal ear exam, hoarseness, trouble or pain swallowing, a non-healing ulcer, bleeding, ill-fitting dentures, trismus OC 146 NM 37, weight loss. HPV-related oropharynx cancer hits younger non-smokers and can look like a cystic neck mass OC 144 NM 22.
Exam	Complete head and neck exam: look at every mucosal surface, palpate the mouth and pharynx, describe the mass (location, size, mobility, tenderness, consistency), check the thyroid, other node areas, liver, and spleen NM 15. Look for leukoplakia and erythroplakia (erythroplakia: 90% dysplasia or cancer) OC 133–135.
Top differentials	Traumatic ulcer — Resolves once the denture or sharp tooth is corrected Aphthous ulcer — Heals in 7 to 10 days; on non-keratinized mucosa
Testing	CT neck with contrast and FNA biopsy (not an excisional biopsy first) NM 18, 39. Fiberoptic laryngoscopy to find the primary NM 37. HPV testing, CBC, CMP OC 147; MRI or PET for staging, chest X-ray for mets OC 147.
Treatment	Refer to ENT early NM 19. A trial of antibiotics is common, but if the mass is still there, keep working it up NM 18. Cancer treatment is surgery ± radiation or chemo depending on site and stage OC 148. Tobacco and alcohol cessation.

Tell Them Apart: Sore Throat

	Viral	Group A Strep	Mono
Typical age	Any	Kids 5–15	15–24
Cough / runny nose	Yes	No	Usually no
Onset	Gradual	Sudden, with fever	Prodrome, then fever
Exudate	Sometimes, mild	Yes, purulent	Often, with big tonsils
Nodes	Mild	Tender anterior cervical	Posterior + anterior
Extra clues	Pink eye, hoarseness, vesicles	Palatal petechiae, belly pain, scarlet fever rash	Heavy fatigue, big spleen, rash with amoxicillin
Test	None	Rapid strep ± culture	CBC + Monospot
Treatment	Supportive	Penicillin or amoxicillin × 10 days	Supportive, no contact sports

Tell Them Apart: White Patches and Ulcers

Lesion	Scrapes off?	What it looks like	Next step
Thrush	Yes, red base	Creamy, curd-like plaques OC 89	KOH, antifungal, find the cause
Leukoplakia	No	White patch; premalignant, 5–20% become SCC OC 133	Biopsy OC 134
Erythroplakia	No	Red patch; 90% dysplasia or cancer OC 135	Biopsy
Hairy leukoplakia	No	Painless, corrugated, side of tongue OC 136	HIV test
Lichen planus	No	Lacy white lines (Wickham striae) OC 21	Symptom control, biopsy if unsure
Aphthous ulcer	n/a	Shallow ulcer, yellow-gray base, red halo, non-keratinized mucosa OC 15, 17	Clinical; topical steroid
HSV	n/a	Vesicles → clustered ulcers, prodrome OC 26	PCR; acyclovir OC 27

Heads-Up and Sources

Where the slides and other references disagree

Where your slides and standard references disagree, learn the accurate version given here; the site's quizzes key it. Each item says what the slide says instead.

Monospot timing OC 84: the slide says the test can be falsely positive early. Most references say it's falsely negative in the first week (and in kids under 4), which is why you repeat it or order EBV serology.
ASO as the “definitive test” for strep OC 74: ASO shows a strep infection in the past few weeks. It's used for rheumatic fever and post-strep GN, not to diagnose an acute sore throat. Rapid test, culture, or PCR diagnoses strep throat.
Backup culture after a negative rapid strep OC 74: the slide says always. IDSA says kids and teens; adults usually don't need it.
“Centor” table with age points OC 76: adding the age points makes it the McIsaac modification. Same idea.
Montelukast NS 26, 68: listed as a nighttime add-on. It carries an FDA boxed warning for neuropsychiatric effects, and the allergic rhinitis guideline doesn't use it as first-line therapy.
Sinusitis first-line drug NS 23: the slide (IDSA) says amox-clav. The AAO-HNS adult guideline allows amoxicillin with or without clavulanate and also allows watchful waiting.

Topics your decks barely cover

Viral rhinitis, GERD/LPR, mastoiditis, and orbital complications of sinusitis only show up briefly in the slides, so most of those boxes come from the guidelines below and general references. Doses are standard adult and pediatric guideline doses; double-check them against your program's preferred drug reference.

Sources

Your lecture decks: EME, IE, NS, OC, NM (see deck key on page 1)
AAP. Diagnosis and management of acute otitis media, 2013
AAO-HNS clinical practice guidelines: Cerumen Impaction (2017), Acute Otitis Externa (2014), Otitis Media with Effusion (2016), Sudden Hearing Loss (2019), Adult Sinusitis (2015), Allergic Rhinitis (2015), Nosebleed (2020), Hoarseness/Dysphonia (2018), Adult Neck Mass (2017)
IDSA guidelines: Group A Streptococcal Pharyngitis (2012), Acute Bacterial Rhinosinusitis (2012), Candidiasis (2016)

Abbreviations

The cards use clinical shorthand so a row stays scannable in the room. Every abbreviation they use is spelled out here.

AAO-HNS	American Academy of Otolaryngology–Head and Neck Surgery
AAP	American Academy of Pediatrics
AC	air conduction
AOM	acute otitis media
ASO	antistreptolysin O
BC	bone conduction
BID	twice daily
CBC	complete blood count
CN	cranial nerve
CRP	C-reactive protein
CT	computed tomography
DM	diabetes mellitus
EBV	Epstein–Barr virus
ED	emergency department
EGD	esophagogastroduodenoscopy
ENG	electronystagmography
ENT	ear, nose and throat
EOM	extraocular movement
ESR	erythrocyte sedimentation rate
ETD	eustachian tube dysfunction
FTA-ABS	fluorescent treponemal antibody absorption
GABHS	group A beta-hemolytic Streptococcus
GERD	gastroesophageal reflux disease
GI	gastrointestinal
HEPA	high-efficiency particulate air
HIV	human immunodeficiency virus
HPV	human papillomavirus
HSV	herpes simplex virus
HTN	hypertension
I&D	incision and drainage
IDSA	Infectious Diseases Society of America
IgE	immunoglobulin E
IM	intramuscular
IV	intravenous
KOH	potassium hydroxide
LPR	laryngopharyngeal reflux
MHA-TP	microhemagglutination assay for Treponema pallidum
MRI	magnetic resonance imaging
MRSA	methicillin-resistant Staphylococcus aureus
N/V	nausea and vomiting
NSAID	non-steroidal anti-inflammatory drug
OE	otitis externa
OM	otitis media
OME	otitis media with effusion
OSCE	objective structured clinical examination
PCN	penicillin
PCR	polymerase chain reaction
PMH	past medical history
PO	by mouth
PPI	proton pump inhibitor
PTA	peritonsillar abscess
QID	four times daily
SNHL	sensorineural hearing loss
SSNHL	sudden sensorineural hearing loss
STI	sexually transmitted infection
TID	three times daily
TM	tympanic membrane
URI	upper respiratory infection
VDRL	Venereal Disease Research Laboratory