5.3 Eyes, Ears, Nose & Throat
Key Takeaways
- Eyes, Ears, Nose, and Throat (EENT) content is approximately 8% of the PANRE, about 19 items on a 240-question exam.
- A painful red eye with photophobia, decreased vision, ciliary flush, or contact-lens use is sight-threatening and requires urgent ophthalmologic evaluation, unlike simple viral conjunctivitis.
- Acute angle-closure glaucoma presents with a painful red eye, a fixed mid-dilated pupil, headache, nausea, and halos around lights, and is an ophthalmologic emergency.
- Most acute otitis media and acute bacterial rhinosinusitis are managed with watchful waiting or symptomatic care in appropriate patients, with antibiotics reserved for defined criteria such as severe, persistent, or worsening disease.
- Acute streptococcal pharyngitis is risk-stratified with the Centor/McIsaac criteria and confirmed by rapid antigen or culture before antibiotics; sudden vision loss and orbital cellulitis are EENT emergencies.
Why This Section Matters
The NCCPA PANRE blueprint allocates roughly 8% to Eyes, Ears, Nose, and Throat (EENT), about 19 items on a 240-question exam. EENT items frequently test the distinction between a benign, self-limited complaint and a sight-, hearing-, or airway-threatening emergency.
The Red Eye and Acute Visual Loss
The single most important EENT triage skill is separating a benign red eye from a dangerous one. Reassuring features point to conjunctivitis; alarming features point to deeper pathology.
| Diagnosis | Pain | Vision | Discriminating Clue |
|---|---|---|---|
| Viral conjunctivitis | None/mild | Normal | Watery discharge, often bilateral, contagious |
| Bacterial conjunctivitis | Mild | Normal | Purulent discharge, lids matted |
| Allergic conjunctivitis | None | Normal | Itching, watery, bilateral, atopic history |
| Corneal abrasion / keratitis | Significant | May decrease | Foreign-body sensation; fluorescein uptake; danger if contact-lens wearer |
| Acute angle-closure glaucoma | Severe | Decreased | Fixed mid-dilated pupil, halos, headache, nausea |
| Anterior uveitis (iritis) | Moderate | May decrease | Photophobia, ciliary (limbal) flush, small pupil |
Red flags that mandate urgent ophthalmology referral include severe pain, true vision loss, photophobia, ciliary flush, a fixed or irregular pupil, and any red eye in a contact-lens wearer.
Acute Visual Loss
Painless, sudden, monocular vision loss has a short differential the exam expects you to know:
- Central retinal artery occlusion: sudden, profound, painless loss; a "cherry-red spot" may be seen; treat as an ocular emergency analogous to a stroke.
- Central retinal vein occlusion: sudden, often less complete loss; diffuse retinal hemorrhages ("blood and thunder" fundus).
- Retinal detachment: floaters, photopsias (flashes), and a "curtain" over the visual field; requires urgent referral.
- Acute angle-closure glaucoma: painful red eye with halos, headache, nausea, and a fixed mid-dilated pupil — an emergency requiring immediate intraocular pressure lowering and ophthalmology.
- Giant cell (temporal) arteritis: vision loss with headache, jaw claudication, and scalp tenderness in older adults; start corticosteroids promptly to protect the other eye.
Any acute change in vision is treated as urgent until a sight-threatening cause is excluded.
Ear: Otitis and Hearing Loss
Acute otitis media (AOM) features a bulging, erythematous, immobile tympanic membrane with effusion and acute symptoms. In appropriately selected patients, observation with analgesia is reasonable; antibiotics (commonly high-dose amoxicillin first-line in those without penicillin allergy) are indicated for severe, persistent, bilateral young-infant, or worsening disease.
Otitis externa ("swimmer's ear") causes pain with tragal manipulation and a swollen, tender canal; treatment is topical otic preparations with aural toileting. Malignant (necrotizing) otitis externa in diabetic or immunocompromised patients is invasive and an emergency.
Hearing Loss Patterns
| Test | Conductive Loss | Sensorineural Loss |
|---|---|---|
| Weber (tuning fork on forehead) | Lateralizes to the affected ear | Lateralizes to the unaffected ear |
| Rinne (mastoid vs. ear canal) | Bone > air on the affected side (abnormal) | Air > bone bilaterally (normal pattern) |
Sudden sensorineural hearing loss is an emergency that warrants prompt evaluation and treatment, as early intervention improves the chance of recovery.
Nose: Rhinosinusitis and Epistaxis
Acute rhinosinusitis is most often viral and self-limited. Features suggesting acute bacterial rhinosinusitis include symptoms persisting beyond about 10 days without improvement, severe symptoms with high fever and purulent discharge, or "double sickening" (initial improvement followed by worsening). Many patients are managed with symptomatic care; antibiotics are reserved for those who meet bacterial criteria. Orbital or intracranial extension (proptosis, vision change, altered mental status, severe headache) is an emergency.
Epistaxis is most commonly anterior, from Kiesselbach plexus. Initial management is firm continuous pressure to the lower nasal cartilage with the patient leaning forward, with a topical vasoconstrictor and cautery or anterior packing if bleeding persists. Brisk posterior bleeding, hemodynamic instability, or anticoagulation raises acuity and may require posterior packing and specialist involvement.
Throat, Oral, and Dental
Pharyngitis
Most acute pharyngitis is viral. The Centor criteria (modified by McIsaac for age) estimate the probability of group A streptococcal infection: fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough (age also adjusts the score). Confirm with a rapid antigen detection test (with throat culture backup in children when negative) before prescribing antibiotics; penicillin or amoxicillin is first-line when streptococcal pharyngitis is confirmed, primarily to prevent rheumatic fever and suppurative complications.
The exam expects recognition of airway-threatening throat emergencies:
- Peritonsillar abscess: severe unilateral sore throat, "hot potato" voice, uvular deviation, trismus; needs drainage.
- Epiglottitis: rapid onset of fever, drooling, muffled voice, and tripod positioning; do not agitate the patient — secure the airway.
- Retropharyngeal abscess: neck pain, dysphagia, and stiffness, particularly in children.
Oral and Dental
Common oral problems include aphthous ulcers (recurrent, painful, shallow ulcers; supportive care), oral candidiasis (removable white plaques; consider immunosuppression or inhaled-steroid use), and leukoplakia (a white patch that cannot be wiped off and is potentially premalignant — biopsy if persistent). A dental abscess can spread to deep neck spaces; Ludwig angina (rapidly spreading submandibular cellulitis with tongue elevation and airway compromise) is an emergency.
Common EENT Emergencies Summary
- Acute angle-closure glaucoma, central retinal artery occlusion, retinal detachment, and giant cell arteritis-related vision loss.
- Orbital (post-septal) cellulitis with proptosis, pain on eye movement, or vision change.
- Sudden sensorineural hearing loss; necrotizing otitis externa.
- Epiglottitis, peritonsillar/retropharyngeal abscess, and Ludwig angina threatening the airway.
A 63-year-old presents with a severely painful red eye, blurred vision, halos around lights, headache, and nausea. The pupil is mid-dilated and minimally reactive. Which is the most likely diagnosis and appropriate disposition?
An adult with sore throat has tonsillar exudates, tender anterior cervical nodes, fever, and no cough. According to a Centor/McIsaac-based approach, what is the most appropriate next step?
On Weber and Rinne testing, the Weber test lateralizes to the right ear and the Rinne test shows bone conduction greater than air conduction in the right ear. This pattern is most consistent with which finding?