15.1 HEENT Diagnosis and Management

The current FNP-BC Test Content Outline scores HEENT as one of the 13 body systems and lists eye, ear, and skin agents among the official drug-agent classes. Domain II asks you to select diagnostics, interpret them, and name the syndrome. Domain IV asks you to implement nonpharmacologic care and prescribe those topical, otic, and ophthalmic agents safely. This section is the HEENT diagnosis-and-management chapter: decide which ear is infected, which throat needs a swab, and which red eye leaves the clinic in an ambulance.

Acute otitis media, otitis media with effusion, and otitis externa

These three diagnoses are not interchangeable, and mixing them is a high-yield FNP trap. Acute otitis media (AOM) is a middle-ear infection: middle-ear effusion plus acute inflammation. The tympanic membrane is bulging, there is acute otorrhea not caused by otitis externa, or there is intense erythema with distinct otalgia. A pink drum without a bulge and without a mobile-fluid exam is not AOM. Otitis media with effusion (OME) is fluid behind an intact drum without acute inflammatory signs — often after a resolved AOM or with eustachian-tube dysfunction during a cold or after air travel. OME is not treated with antibiotics. Otitis externa (OE) is a canal infection: tragal tenderness, canal edema, and debris. If you can see the drum, it is usually normal.

A 3-year-old who tugs an ear after a week of congestion and has a retracted drum with air-fluid levels has OME. The same child with a bulging, immobile, yellow drum and night waking has AOM. The teenager who swam all weekend and winces when you touch the tragus has OE.

AAP treat-versus-observe (the exam-relevant framework) uses age, laterality, and severity. Severe means moderate-to-severe otalgia, otalgia lasting at least 48 hours, or temperature ≥39°C (102.2°F).

Observation is not neglect. It is a time-limited shared decision with a family who can return. If pain or fever worsens, start antibiotics. When you treat, first-line is high-dose amoxicillin (80–90 mg/kg/day divided, using adult-equivalent maximums) if the child has not had amoxicillin in the past 30 days, does not have concurrent purulent conjunctivitis, and is not penicillin-allergic. Recent amoxicillin or otitis-conjunctivitis (think H. influenzae) moves you to amoxicillin-clavulanate. Duration is typically 10 days under age 2 or when severe, about 7 days at ages 2–5, and 5–7 days at 6 years and older. Analgesia with ibuprofen or acetaminophen is mandatory whether you treat or observe.

For OE, the FNP skill is delivery, not a macrolide. Place a wick if the canal is swollen shut. Use otic antibiotic–steroid drops (ciprofloxacin-dexamethasone or an equivalent labeled product). Do not put aminoglycoside drops through a known perforation or tube unless the product is labeled for middle-ear use. Oral antibiotics do not treat uncomplicated OE.

Streptococcal pharyngitis, abscess, and the airway

Most sore throats are viral. The exam still tests group A streptococcus (GAS) because treatment prevents acute rheumatic fever and reduces spread. Score Centor/McIsaac features — fever, absence of cough, tender anterior cervical nodes, tonsillar exudate — and adjust for age (plus 1 if 3–14 years, minus 1 if 45 or older). Do not swab a child who has clear viral features (cough, rhinorrhea, hoarseness, oral ulcers). If you test, a positive rapid antigen detection test (RADT) is enough to treat. A negative RADT in a child or adolescent needs a backup throat culture; adults generally do not. First-line treatment is penicillin V or amoxicillin for 10 days, or intramuscular benzathine penicillin G when adherence is doubtful. Macrolides are for true penicillin allergy, not for convenience. Treatment does not prevent post-streptococcal glomerulonephritis; it does prevent rheumatic fever. That distinction is a classic trap.

Peritonsillar abscess is not “a bad strep throat.” Look for a muffled hot-potato voice, uvular deviation, trismus, and unilateral swelling. Send to the emergency department or ENT for drainage; office amoxicillin is not the plan. Epiglottitis — now seen in under-immunized children and in adults — is an airway emergency: drooling, tripoding, stridor, and a toxic appearance. Do not examine the throat with a tongue blade in the clinic. Activate emergency services and protect the airway.

Sinusitis and allergic rhinitis

Acute rhinosinusitis is viral for the first 10 days in almost every primary-care visit. Acute bacterial rhinosinusitis is a clinical diagnosis when symptoms are persistent (at least 10 days without improvement), severe (fever ≥39°C plus purulent discharge or facial pain for at least three consecutive days), or double-sickening (worsening after an initial viral improvement). Color of mucus alone is not bacteria. Uncomplicated bacterial sinusitis may still be observed a few more days in a well adult; if you treat, amoxicillin with or without clavulanate is the usual first line. Imaging is not for routine acute sinusitis. Orbital swelling, vision change, severe headache, altered mental status, or a toxic immunocompromised patient leaves the office.

Allergic rhinitis is stepped. For intermittent mild disease, a second-generation oral antihistamine may suffice. For persistent or moderate-to-severe disease, an intranasal corticosteroid is first-line: aim the spray outward, use it daily, and give it two weeks before you declare failure. Intranasal antihistamines help itch and sneezing; combination sprays help mixed pictures. Avoid first-generation antihistamines in older adults (Beers Criteria). Limit topical decongestants to about three days to prevent rhinitis medicamentosa. Refer for immunotherapy when avoidance and stepped medicines fail or when allergen-driven asthma travels with the rhinitis.

Red eye, lid lesions, teeth, wax, and hearing

Never place a steroid drop into an undiagnosed red eye that might be dendritic keratitis or iritis. That is the eye/ear/skin-class safety rule the TCO is pointing at.

Hordeolum is an acute, painful infection of a lid gland (a stye). Warm compresses are first-line; add a topical ophthalmic antibiotic if it is draining or if surrounding cellulitis is starting. Chalazion is a chronic, usually painless meibomian granuloma. Warm compresses; refer if it persists or threatens the visual axis. Do not incise lids in the hallway and do not freeze either lesion.

A dental abscess is referred to dentistry for source control. Start systemic antibiotics only if there is spreading facial cellulitis, fever, or immunocompromise — never as a substitute for drainage. Floor-of-mouth swelling or airway compromise is an emergency (Ludwig angina territory).

Cerumen that blocks hearing or hides the drum can be softened and irrigated if the tympanic membrane is intact and there is no tube, perforation, or prior otologic surgery. Foreign bodies in the ear or nose: do not irrigate vegetable matter or a button battery. Batteries and penetrating objects are ENT emergencies the same day.

Hearing in older adults belongs on the Medicare annual wellness visit as a function question even though USPSTF gives an “I” (insufficient evidence) statement for routinely screening asymptomatic adults. Ask about difficulty, social withdrawal, and safety. Sudden sensorineural hearing loss over hours to 72 hours is an ENT emergency — not wax and not a three-week follow-up. Gradual bilateral loss is usually presbycusis; refer for audiometry and discuss amplification. A whispered-voice screen or handheld audiometry can support the referral; it does not replace it.