Study guide
High-Yield EENT for the PANCE
EENT (eye, ear, nose, throat/mouth) is ~7% of the NCCPA PANCE blueprint and is dominated by can't-miss vision- and airway-threatening emergencies plus high-frequency infections. This guide targets the most-tested red-eye, hearing/vertigo, sinus, and pharyngeal presentations with current first-line therapy.
Vision-Threatening Eye Emergencies
- ◆Acute angle-closure glaucoma: severe eye pain, headache, halos around lights, mid-dilated fixed pupil, hard/red eye, IOP often >40; treat with topical timolol + apraclonidine + pilocarpine and oral/IV acetazolamide (+ mannitol), definitive Rx = laser peripheral iridotomy.
- ◆Central retinal artery occlusion: sudden painless monocular vision loss, pale retina with cherry-red spot, afferent pupillary defect; a 'stroke of the eye' — get emergent ophthalmology, check ESR/CRP/platelets for GCA, and evaluate for emboli; classic bedside ocular massage/lowering IOP has limited benefit, and hyperacute non-arteritic cases within ~4.5 hrs may be considered for thrombolysis at stroke centers.
- ◆Retinal detachment: painless flashes, showers of floaters, and a 'curtain/shadow' over vision; requires urgent surgical repair — do not delay referral.
- ◆Orbital (postseptal) cellulitis: pain with extraocular movement, proptosis, diplopia, decreased vision — CT orbits + IV antibiotics + admission; contrast with preseptal cellulitis (eyelid swelling, NO pain on EOM, no proptosis/vision change).
- ◆Acute anterior uveitis (iritis): deep aching pain, photophobia, ciliary (perilimbal) flush, cells/flare; screen for HLA-B27 associations (ankylosing spondylitis, IBD) and refer for topical steroids + cycloplegia.
Common Red Eye & Eyelid Disorders
- ◆Bacterial conjunctivitis: purulent discharge, lids matted shut — topical trimethoprim-polymyxin or erythromycin; contact-lens wearers need Pseudomonas coverage with a topical fluoroquinolone (ciprofloxacin/ofloxacin).
- ◆Viral conjunctivitis (adenovirus): watery discharge, preauricular node, highly contagious — supportive care/hygiene; allergic conjunctivitis is bilateral, itchy, stringy discharge → topical antihistamine.
- ◆Hyperacute conjunctivitis with copious purulent discharge = gonococcal — ceftriaxone 1 g IM single dose (emergency, risk of corneal perforation) plus empiric chlamydia coverage; indolent case with follicles = chlamydial (inclusion) → doxycycline 100 mg PO BID x7d first-line, azithromycin 1 g PO single dose as alternative.
- ◆Corneal abrasion: fluorescein uptake with slit lamp; topical antibiotic, do NOT patch, never prescribe home topical anesthetics; contact-lens abrasions get antipseudomonal coverage.
- ◆Hordeolum (stye): acute, painful, focal Staph aureus abscess of eyelid → warm compresses. Chalazion: chronic, painless meibomian-gland granuloma. Dacryocystitis: tender, red swelling at medial canthus (lacrimal sac) → systemic antibiotics.
- ◆Hyphema (blood in anterior chamber after trauma): upright positioning, eye shield, check IOP, screen for sickle cell; watch for rebleeding.
Ear: Otitis, Hearing Loss & Cerumen
- ◆Acute otitis media: bulging, immobile, erythematous TM with effusion; first-line high-dose amoxicillin 80–90 mg/kg/day, use amoxicillin-clavulanate if abx in last 30 days, treatment failure, or concurrent conjunctivitis.
- ◆Otitis externa ('swimmer's ear'): pain with tragal traction, canal edema/discharge → topical antibiotic drops (fluoroquinolone ± steroid); keep ear dry. Malignant/necrotizing OE in elderly diabetics = Pseudomonas invasion → IV antipseudomonal therapy.
- ◆Cholesteatoma: painless otorrhea with a retraction-pocket/keratin mass and conductive hearing loss; can erode ossicles → surgical (needs CT/ENT).
- ◆Weber/Rinne: conductive loss → Weber lateralizes TO the affected ear and Rinne shows bone > air; sensorineural loss → Weber lateralizes to the GOOD ear and air > bone (normal Rinne).
- ◆Mastoiditis: postauricular pain/erythema with a protruding auricle following AOM → CT, IV antibiotics, ENT.
Vertigo & Vestibular Disorders
- ◆BPPV: brief (<1 min) positional vertigo triggered by head movement; diagnose with Dix-Hallpike (fatigable rotary nystagmus), treat with Epley (canalith repositioning) — no hearing loss.
- ◆Meniere disease: episodic vertigo (minutes–hours) + fluctuating low-frequency sensorineural hearing loss + tinnitus + aural fullness; low-salt diet, diuretics.
- ◆Vestibular neuritis: acute, continuous, severe vertigo lasting days WITHOUT hearing loss (post-viral); labyrinthitis is the same but WITH hearing loss.
- ◆Central causes (posterior stroke): vertical/direction-changing nystagmus, other neuro deficits, abnormal HINTS exam — image emergently, don't anchor on 'benign' peripheral vertigo.
Nose & Sinus
- ◆Acute rhinosinusitis is usually viral; suspect bacterial if symptoms persist >10 days, are severe (fever ≥39°C + purulence ≥3–4 days), or 'double-worsen' — first-line amoxicillin-clavulanate (amoxicillin ± clavulanate per AAO-HNS), with high-dose reserved for resistance-risk patients.
- ◆Allergic rhinitis: sneezing, clear rhinorrhea, itchy eyes, pale/boggy turbinates, allergic shiners → intranasal corticosteroids are most effective first-line, add oral/intranasal antihistamines.
- ◆Epistaxis: >90% anterior from Kiesselbach plexus → direct pressure, oxymetazoline, cautery/packing; posterior bleeds (bleeding both sides/into pharynx) are higher-risk and may need balloon packing/ENT.
- ◆Nasal polyps: obstruction/anosmia; in a child think cystic fibrosis, and polyps + asthma + aspirin sensitivity = Samter triad.
Oropharynx & Deep Neck Infections
- ◆Group A strep pharyngitis: use Centor/McIsaac (fever, tonsillar exudates, tender anterior cervical nodes, absence of cough, age); confirm with rapid antigen/culture — first-line penicillin or amoxicillin (treat to prevent rheumatic fever).
- ◆Infectious mononucleosis (EBV): posterior cervical adenopathy, splenomegaly, atypical lymphocytes, positive heterophile/Monospot (may be falsely negative first week); AVOID amoxicillin (rash) and no contact sports ~3–4 weeks (splenic rupture risk).
- ◆Peritonsillar abscess: unilateral swelling with uvula deviation, trismus, 'hot potato' voice → needle aspiration/I&D + antibiotics.
- ◆Epiglottitis: rapid-onset high fever, drooling, tripod posture, stridor, 'thumbprint sign' on lateral neck film → secure airway first, do not agitate; retropharyngeal abscess shows widened prevertebral space and neck stiffness.
- ◆Oral candidiasis (thrush): removable white plaques → nystatin or oral fluconazole; consider underlying immunosuppression/inhaled-steroid use in adults.