4.1 Eyes, Ears, Nose, and Throat Diseases
Key Takeaways
- Sudden painless monocular vision loss with a curtain-like defect suggests retinal detachment or vascular occlusion — refer immediately, do not adjust
- Acute angle-closure glaucoma presents with severe eye pain, halos, nausea, and a mid-dilated fixed pupil — ophthalmic emergency
- True vertigo (spinning) with new neurologic deficits or inability to walk demands stroke workup before any cervical manipulation
- BPPV produces brief vertigo triggered by head position changes, with a positive Dix-Hallpike and no neurologic deficit
- Peritonsillar abscess and Ludwig angina cause drooling, trismus, and airway risk — emergency referral, not office management
4.1 Eyes, Ears, Nose, and Throat Diseases
Quick Answer: EENT complaints enter chiropractic offices constantly because head, neck, jaw, and upper-cervical symptoms overlap with musculoskeletal care. Part II rewards the ability to name the most likely clinical impression from a short vignette and recognize red flags that override manipulation — painless vision loss, acute glaucoma, central vertigo, facial droop with forehead sparing, and any throat infection with airway compromise.
Why EENT Matters in Chiropractic Screening
Doctors of chiropractic evaluate patients who describe "sinus pressure," "jaw pain," "dizziness," or "something in my eye" while seeking neck or headache care. The NBCE General Diagnosis domain (19% of Part II) tests whether you can integrate history and limited exam findings into a working diagnosis and decide whether chiropractic care is appropriate, requires co-management, or must stop until a medical referral clears the patient. EENT diseases are high-yield because they sit at the intersection of musculoskeletal mimicry and true medical emergency.
Eyes: Red Eye, Vision Change, and Pain Patterns
Conjunctivitis — bacterial, viral, or allergic — produces bilateral or unilateral injection, tearing, and discharge. Vision remains intact, pupils are equal and reactive, and there is no severe pain. Patients may report gritty discomfort rather than deep pain. Allergic conjunctivitis often accompanies seasonal rhinitis; viral conjunctivitis may follow URI symptoms; bacterial infection shows purulent discharge and eyelid crusting.
Uveitis (iritis) demands sharper discrimination. Patients report deep eye pain, photophobia, and blurred vision. The hallmark finding is ciliary flush (perilimbal injection) and consensual photophobia (pain in the affected eye when light shines in the unaffected eye). Uveitis is associated with HLA-B27 spondyloarthropathies — a link chiropractors should recognize when ankylosing spondylitis is in the differential for back pain. Uveitis requires ophthalmology referral; manipulation does not treat the underlying inflammation.
Acute angle-closure glaucoma is an ophthalmic emergency. Presentation includes sudden severe eye pain, headache, nausea, halos around lights, and a mid-dilated, sluggish or fixed pupil. Intraocular pressure rises rapidly. This is not conjunctivitis and not a tension headache — immediate emergency referral is required.
Vision loss patterns separate retinal from neurologic causes:
| Presentation | Likely Impression | Red Flag Action |
|---|---|---|
| Sudden painless monocular "curtain" or shadow across vision | Retinal detachment | Emergency ophthalmology — time-sensitive |
| Sudden painless monocular complete vision loss | Central retinal artery occlusion | Emergency — "eye stroke," minutes matter |
| Gradual central blur with metamorphopsia (wavy lines) | Macular degeneration | Ophthalmology referral |
| Binocular diplopia that resolves when one eye is covered | Cranial nerve III, IV, or VI palsy or orbital pathology | Neurology/neuro-ophthalmology workup |
Any new monocular vision change is a manipulation hold until ophthalmic clearance — even if neck pain is the chief complaint.
Ears: Otitis, Hearing Loss, and Vertigo
Otitis externa (swimmer's ear) causes external ear canal pain worsened by tragal pressure, often with drainage. Otitis media produces ear pain, fever, and possible conductive hearing loss; bulging tympanic membrane on inspection supports the impression. Both are medical management cases; cervical adjusting does not address middle-ear infection.
Sudden sensorineural hearing loss (unilateral over hours) requires urgent ENT evaluation — steroids within days may preserve hearing.
Vertigo is the highest-risk EENT-related chief complaint in chiropractic practice because cervical manipulation has been debated in vertebrobasilar insufficiency contexts, and because posterior circulation stroke can mimic peripheral vertigo.
Benign paroxysmal positional vertigo (BPPV) produces brief (under one minute) spinning triggered by head position changes — rolling in bed, looking up, bending forward. The Dix-Hallpike test reproduces symptoms with characteristic nystagmus (torsional, toward the lower ear in posterior canal BPPV). There is no new neurologic deficit, gait is generally steady between episodes, and hearing is unaffected. Canalith repositioning (Epley maneuver) is appropriate within chiropractic scope when peripheral BPPV is confidently diagnosed.
Vestibular neuritis causes prolonged continuous vertigo lasting days, often after a viral illness, with severe imbalance but no hearing loss (distinguishing it from labyrinthitis, which includes hearing loss). Patients appear acutely ill and may need vestibular suppressants early; they are poor candidates for cervical HVLA during the acute phase.
Central vertigo red flags — any of the following demand emergency evaluation before manipulation:
- Continuous vertigo not tied to position, or vertigo lasting days without improvement
- New neurologic signs: diplopia, dysarthria, ataxia, limb weakness, sensory loss
- Severe headache unlike prior migraines ("thunderclap" quality)
- Inability to walk or HINTS exam suggesting central cause (skew deviation, direction-changing nystagmus, normal head impulse in acute setting)
- Risk factors: hypertension, diabetes, anticoagulation, recent neck trauma
The Part II trap: a patient with "dizziness" and neck pain may have vertebrobasilar insufficiency or stroke, not cervicogenic dizziness. Age over 60, vascular risk factors, and spontaneous (non-positional) vertigo push the impression away from BPPV.
Nose and Sinuses
Acute bacterial rhinosinusitis is suggested when symptoms persist beyond 10 days without improvement, include double worsening (improve then worsen), or present with high fever plus purulent nasal discharge for 3–4 consecutive days. Maxillary tooth pain, unilateral facial pain worsened by bending forward, and purulent anterior or posterior drainage support the impression. Distinguish from allergic rhinitis (clear discharge, sneezing, pale boggy turbinates, seasonal pattern) and viral URI (self-limited, peaks then resolves within a week).
Epistaxis from Kiesselbach area (anterior) is common and usually benign. Posterior epistaxis in an elderly or hypertensive patient can be life-threatening — brisk bleeding, difficulty controlling, hemodynamic compromise warrants emergency care.
Nasal polyps with anosmia suggest chronic rhinosinusitis or aspirin-exacerbated respiratory disease; unilateral polyp raises concern for inverted papilloma or malignancy.
Chiropractors may treat associated headache and cervical tension once acute infection is ruled out or resolving, but active purulent sinusitis with fever is not an ideal time for aggressive upper-cervical work.
Throat and Adjacent Soft Tissue
Viral pharyngitis causes odynophagia, low fever, and cervical lymphadenopathy without tonsillar exudate. Streptococcal pharyngitis (GABHS) adds sudden onset, fever, tender anterior cervical nodes, and tonsillar exudate; absence of cough supports bacterial cause. Centor criteria help risk-stratify. Untreated GABHS can lead to rheumatic fever — Part II may test recognition, not antibiotic prescribing detail.
Peritonsillar abscess presents with severe unilateral throat pain, trismus (difficulty opening mouth), uvular deviation away from the abscess, and hot-potato voice. This is an ENT emergency — needle drainage or surgery, not outpatient analgesics alone.
Ludwig angina is bilateral submandibular space infection with board-like submandibular swelling, drooling, dysphagia, and imminent airway compromise. Emergency surgical airway management may be required. Any chiropractor who sees floor-of-mouth swelling and drooling must refer immediately — this is not TMJ dysfunction.
Infectious mononucleosis (EBV) causes severe pharyngitis, posterior cervical lymphadenopathy, fatigue, and atypical lymphocytosis. Ampicillin or amoxicillin cause a characteristic maculopapular rash — a classic Part II association. Splenomegaly carries rupture risk; contact sports and heavy manipulation of the thoracic spine and abdomen should be deferred.
TMJ and Chiropractic Overlap
Temporomandibular disorders produce localized joint pain, clicking, and limited opening without fever, trismus from infection, or systemic illness. Distinguish internal derangement and myofascial pain from odontogenic pain (worse with chewing, dental trigger) and from parotid pathology (swelling below the ear). TMJ care — soft tissue, exercise, occlusal referral — is within chiropractic scope when red flags are absent.
Part II Clinical Reasoning Framework
When an EENT vignette appears on Part II, work through four steps:
- Localize — eye, ear, nose, throat, or adjacent structure
- Time course — sudden vs gradual; positional vs continuous
- Associated signs — fever, neurologic deficit, vision change, airway symptoms
- Most likely impression — pick the diagnosis best supported by the cluster, not the single finding
If a red flag is present, the correct answer often involves referral or hold on manipulation, even when neck pain is also in the stem.
A 58-year-old patient reports sudden painless vision loss in the right eye described as a "curtain coming down" over the visual field. Visual acuity is markedly reduced in that eye. There is no eye pain. What is the most likely clinical impression?
A 45-year-old patient has brief spinning vertigo lasting 20 seconds when rolling onto the right side in bed. Dix-Hallpike to the right reproduces symptoms. There is no headache, diplopia, or limb weakness. Gait is normal between episodes. What is the most likely diagnosis?
A 22-year-old presents with severe sore throat, fever, trismus, and the uvula deviated to the left. The patient speaks as if holding a hot potato in the mouth. What is the most appropriate clinical impression and action?
A patient with deep eye pain, marked photophobia, and blurred vision has perilimbal injection (ciliary flush). Consensual photophobia is present. Which diagnosis is most likely?