Eyes, Ears, Nose, and Throat
What you must know
Ear: acute otitis media requires bulging tympanic membrane or otorrhea, not just redness; observe mild cases in older children, treat with amoxicillin when severe or in young infants. Otitis externa is painful with canal manipulation and is treated with topical antibiotic plus steroid drops; malignant otitis externa occurs in diabetes. Distinguish conductive from sensorineural hearing loss with tuning forks: Weber lateralizes to the conductive ear and away from the sensorineural ear; Rinne is normal in sensorineural loss and abnormal in conductive loss. Sudden sensorineural hearing loss is an emergency requiring urgent steroids and ENT referral. Vertigo: BPPV is brief, positional, positive on Dix-Hallpike, and treated with Epley repositioning.
Nose and throat: most rhinosinusitis is viral. Bacterial features include symptoms over 10 days, double worsening, or severe onset with fever over 39 C for several days; treat with amoxicillin-clavulanate when antibiotics are indicated. Pharyngitis: use Centor criteria, confirm with rapid strep testing, treat with penicillin or amoxicillin. Drooling, tripod positioning, muffled voice, and stridor indicate epiglottitis - do not examine the throat; secure the airway.
Eyes: differentiate conjunctivitis (discharge, normal vision) from keratitis, uveitis, and acute angle-closure glaucoma (pain, halos, mid-dilated pupil, decreased vision, nausea). Chemical splash requires immediate copious irrigation before any examination. Screen for diabetic retinopathy and treat retinopathy in pregnancy and hypertension appropriately.
Traps
- Prescribing antibiotics for a viral upper respiratory infection.
- Treating a red painful eye with topical steroids before ruling out herpes or corneal abrasion.
- Missing acute angle-closure glaucoma or sudden sensorineural hearing loss.
- Depressing the tongue in suspected epiglottitis.
Rule of thumb
Painful red eye with decreased vision or photophobia is not conjunctivitis - same-day ophthalmology.