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Otolaryngology Internal Medicine Board Review Mark A.Howell M.D.,F.A.C.S. Ear,Nose and Throat Associates Johnson City ,Tennessee Disclosure of Conflict: I Have Nothing To Declare Question one: Otology 55-year-old male complains of “ringing” in ears constantly. Sound is very highfrequency. Wife has stated to patient is not listening to her. She notices difficulty understanding words even though he may hear them.Patient denies ear pain or history of ear infections. He denies family history of hearing loss. He did have military service and worked as an jet airplane mechanic.Patient only current medication is 81 mg aspirin.This most likely represents: #1) congenital hearing loss #2) acoustic trauma (noise induced hearing loss) #3 drug induced hearing loss (ASA) #4 presbycusis (age-related hearing loss) Question one: Otology answer #2 acoustic trauma (noise induced hearing loss) Other considerations: #4 presbycusis (age associated hearing loss) no family history of hearing loss and age. #3 and #1 her unlikely based on patient’s history. 81 mg aspirin dose should not raised salicylate levels to the level to cause hearing loss and tinnitus. What his next logical step? #1 MRI of head; #2 audiogram; #3 thyroid functions; #4 electrolytes, cholesterol and triglycerides. Question TWO: Otology/oncology 35-year-old female presents with history of flulike symptoms 6 weeks ago. During the acute illness her ears were stuffy and hearing decreased bilaterally. Everything cleared with time but persists with left ear decreased hearing and fullness. Patient experiences roaring sensation in her left ear. She denies pain or discharge or dizziness. She had noted some change in her hearing in the left ear for some time but nothing as significant as this. Still has sensation of popping and cracking and her left ear. Examination reveals a dull retracted left tympanic membrane with amber appearance in the inferior portion of tympanic membrane. Nose reveals mild edema mucous membranes and turbinates. Head and neck exam is otherwise benign. Weber testing with 256 Hz tuning fork lateralizes to the left ear. Question TWO: Otology/oncology what is most probable diagnosis? #1) viral induced acute sudden sensory neural hearing loss #2) noise induced hearing loss #3) presbycusis #4) otitis media with effusion with associated conductive hearing loss I) What his next appropriate step? #1) audiogram #2) oral antibiotics and or antiviral agents #3) oral steroids #4) CT scan of temporal bone#5) topical nasal steroid spray #4) otitis media with effusion and conductive hearing loss #1) audiogram; #5) topical nasal steroid spray; #3) possibly oral steroids Question TWO: Additional history Patient symptoms did not recover for 2 months. What would be our next concern or consideration? What would cause persistent middle ear effusion an adult? Our next concern would be why there is persistent middle ear effusion in an adult and some reason for Eustachian tube dysfunction that is persistent. Our next most appropriate step would be direct visualization of the nasopharynx around the Eustachian tube opening particularly if no response to therapy. In addition we may want to do imaging of nasopharynx and oropharynx to rule out obstructive lesion particularly neoplasm and then adult with persistent unilateral middle ear effusion. This particular patient did have a nasopharyngeal carcinoma in the left nasopharynx identified by biopsy with minimal findings on CT scanning and direct visualization suggested abnormality in this area. Question THREE: Otology 45-year-old female usual state of good health awakened one week ago with decreased hearing in the left ear with associated roaring tinnitus. Patient denies dizziness or unsteadiness or vertigo. Patient’s vital signs are normal. Ear exam appears normal with normal tympanic membrane appearance and normal movement to pneumatic otoscopy. The remainder of head and neck exam was benign. Tuning fork testing with 256 Hz tuning fork performing a Weber test lateralized to the contralateral ear. Patient denies pain or drainage from ear. Question THREE: What is most likely diagnosis? #1 otitis media with effusion in the left ear #2 Ménière’s disease with acute flare #3 noise induced hearing loss #4 sudden sensorineural hearing loss syndrome I) what is next most appropriate step? #1 audiometric testing #2 ENT evaluation #3 oral steroid taper #4 antiviral therapy #5 antibiotic therapy #4) sudden sensorineural hearing loss syndrome Next most appropriate step to confirm this would be full audiometric study and if confirmatory would consider an oral steroid taper for 10-14 days and reevaluate audiometric result. If no response to systemic steroids a series of middle ear steroid infusions can be performed to respond to sensory neural hearing loss. Additional consideration is to rule out retrocochlear disease that can cause nerve hearing loss suddenly as an acoustic neuroma. This is usually a small percentage of cases but standard of care would dictate MRI scanning of the posterior fossa and internal auditory canals. Question FOUR: Otology/neurotology 40-year-old male history of mild hypertension and obesity presents for evaluation of recurrent episodes of “dizziness”. Dizziness is described as sudden onset while doing any activity at any time with the room spinning associated nausea and vomiting. This lasts several hours and then resolves spontaneously. Was seen in the emergency room on 2 different occasions with negative evaluation was normal EKG and CT scan of the head. After these episodes patient has unsteadiness for a few days which then resolves. He was treated with meclizine after emergency room visits. This is now his third episode that was very similar. He notes a pressure in his right ear and notices some decreased hearing associated after the spells. Physical examination revealed normal ear exam normal movement to pneumatic otoscopy. No nystagmus or dizziness initiated with positive pressure to the tympanic membrane. Today he states his hearing is satisfactory in both ears. Postural testing revealed no nystagmus or induced vertigo. Question FOUR: What is most likely diagnosis? #1 paroxysmal positional vertigo #2 vestibular neuronitis #3 sudden sensorineural hearing loss #4 otitis media with effusion #5 endolymphatic hydrops (Ménière’s disease) I) what is next most appropriate step? #1 audiometric testing #2 vestibular evaluation #3 consider diuretic therapy #4 MRI scan of the head #5 otolaryngology or otology evaluation Most appropriate answer here is #5) Ménière’s disease. Classically Ménière’s disease is characterized by episodic vertigo that resolves spontaneously but patients can be very ill with nausea and vomiting. This usually a spontaneous onset no inciting factors. In addition they will have fullness or pressure in the affected ear and roaring tinnitus and then hearing loss associated with the inner ear membrane disruption that occurs we believe with this condition. So episodic vertigo, fluctuating hearing and tinnitus is a classic triad for Ménière’s disease. The next appropriate step would be audiometric testing to see if there is lowfrequency hearing loss consistent with Ménière syndrome. This should be unilateral. If consistent with presumptive diagnosis of Ménière’s disease would lead to treatment with salt restriction and a diuretic therapy and usually MRI scanning of posterior fossa since retrocochlear disease as previously discussed can mimic Ménière’s disease . Question Five: Otology /neurotology 40-year-old female usual state of good health with recent URI with acute onset of “dizziness” described as the” room spinning around”. There was associated diaphoresis and nausea and vomiting which lasted for several hours before she went to the emergency room. There she was evaluated with essentially normal vital signs normal EKG and CT scan of the head. Patient treated with antiemetics. Vertigo persisted for about 24 hours would improve at times when she would remain motionless and was worse with any type of movement. After 24 hours she was better but still had some unsteadiness on movement which lasted several days. She now presents some 2 weeks past the episode with little or no residual symptoms. She no longer takes the meclizine. Her exam today reveals normal ear exam and neurologic exam. Pneumatic otoscopy was negative with good tympanic membrane movement and negative dizziness or nystagmus.Her gait and Romberg were normal.She denies hearing loss or tinnitus or visual changes.She has had no previous episodes of any illness like this. Question 5: Most likely diagnosis? #1)Ménière’s disease (endolymphatic hydrops) #2)Paroxysmal positional vertigo #3)Vestibular neuronitis #4)Vestibular dysfunction secondary to vertebral basilar artery insufficiency #5)Perilymph fistula Next most appropriate step? #1 audiometric testing #2 vestibular suppressants #3 otolaryngology referral #4 neurologic referral #3) vestibular neuronitis is most likely diagnosis. Negative fistula test rules out perilymph fistula at least initially. Lack of recurrence would suggest against Ménière’s disease particularly with no hearing loss.Basilar artery and vertebral artery disease is possibility though no other typical manifestations or exhibited. Vestibular neuronitis characteristically manifested by acute vertigo without hearing loss that resolves and a short period of time with a residual recovery time with disequilibrium but spontaneously completely recovers. Normal audiometric findings are noted there may be some unilateral weakness on vestibular testing which suggested the possibility of viral etiology. Next most appropriate testing would be audiometric testing and vestibular evaluation probably as a component of otolaryngology consultation. Questions 6: Otology 30-year-old female in her usual state of good health with no significant medical problems only currently on oral contraceptives. Patient awakened one morning with sudden onset of rotational vertigo causing some nausea but no vomiting and lasted 10-15 minutes and resolves spontaneously. Patient denies any visual problems or neurologic deficits or hearing changes or tinnitus. She noted when she would turn over in bed in particular to her right side she would develop again this sensation that would resolve after a few minutes. She also noted that when she would stand up and look up or sometimes turned to the side she would have similar sensation. She was concerned about driving having experienced a motor vehicle accident some 3 weeks ago it was significant enough for air bag deployment. Her physical examination is benign and ear exam and neurologic exam is essentially normal. Weber testing with 256 tuning fork is midline. DixHallpike maneuver was performed which produced rotary nystagmus with her right ear down and vertigo that was frightening to her but resolved within one to 2 minutes. Dix-Hallpike maneuver to the left ear did not produce vertigo. Question 6: What is most likely diagnosis? #1)Ménière’s disease (endolymphatic hydrops) #2)Vestibular neuronitis #3)Paroxysmal positional vertigo #4)Vertebrobasilar artery insufficiency I) next most appropriate step? #1 vestibular exercises #2 canalith repositioning procedure #3 vestibular suppressants #4 MRI scan of the head #5 oral steroid therapy#6 physical therapy referral for vestibular rehabilitation and positional therapy #3) paroxysmal positional vertigo-this presentation was classic with recent mild head injury that now patient precipitates positional related vertigo without hearing loss or other findings. It resolves spontaneously and rapidly and is specifically related to certain positional moves. Positive Dix-Hallpike maneuver is classic. Most appropriate step would be to initiate vestibular exercises to fatigue this and canalith repositioning procedure or for certain patient’s with other problems like gait disturbance and other medical problems of disequilibrium with superimposed paroxysmal positional vertigo a physical therapy evaluation with vestibular rehabilitation might be beneficial. Question 7: Otology/head and neck infection 60-year-old obese female diabetic poorly controlled on insulin. Patient smokes one pack per day of cigarettes. Patient presents today with complaint of severe ear pain and decreased hearing progressively worsening over the last 2 weeks. Complains of drainage and discharge from her ear now painful to touch. She relates a history of spending significant time at Boone lake. Patient’s examination reveals exquisitely tender right external ear to manipulation or touching. Ear canal is markedly swollen tympanic membrane cannot be visualized. Patient’s external ear is slightly prominent projecting more than her left ear. Patient’s blood sugar is 450. Temperature is 100 and patient is tachycardic. Question 7: What is most likely scenario? #1Acute otitis media with otorrhea #2Acute external otitis with peri-auricular cellulitis #3Right acute parotitis #4Acute mastoiditis #5 Meningitis I) what our next most appropriate steps? #1 CT scan of head and temporal bone #2 lumbar puncture #3 oral antibiotics #4 exam and debridement of external ear canal and topical steroid and antibiotic therapy #5 otolaryngology consultation #2) acute external otitis with periauricular cellulitis would initially seem to be the best option. It is important differentiate otitis media and mastoiditis in this setting because these can present in a similar fashion or be associated with an external otitis secondary to patient’s otorrhea from the middle ear. If possible it is important to debride the external ear canal to visualize the tympanic membrane and determine if there is middle ear disease. If not imaging of the temporal bone and mastoid would help us determine if there is fluid density there versus simply external canal evidence of infection and surrounding cellulitis. Next most appropriate step would be to evaluate the ear canal and debridment to visualize tympanic membrane which might require otolaryngology intervention. CT scanning of the temporal bone would be another way to determine middle ear and mastoid disease.Critical to this external ear canal disease is the use of topical therapy antibiotics and steroids as well as systemic therapy for the surrounding cellulitis.This may also represent malignant external otitis seen in diabetic patients. Question 8: Otology 55-year-old male with lifelong history of ear problems beginning in childhood. Several year history of progressive hearing changes without pain or drainage or discharge. Patient does not pursue regular medical evaluation. Now with 3 weeks onset of sudden ear discharge . Patient’s hearing has changed in the left ear has had pressure sensation and associated dizziness described as vertigo with certain head movements. He is also noted the last 2-3 days difficulty drinking and eating with liquid leaking from the left side of his mouth. Patient was seen in the emergency room with essentially normal vital signs. Ear exam revealed mucopurulent discharge and tympanic membrane cannot be seen well in the left ear. There is also noted to be some weakness of the branches of the facial nerve on the left. On examination the ear positive pressure to the tragus elicits dizziness and some eye movements.CT scan of the head reveals opacification of left mastoid cavity and middle ear. Radiologist recommends temporal bone high-resolution CT scan and possible MRI scan. Question 8: What is most likely scenario? #1 acute otitis media with otorrhea #2 mastoiditis, acute #3 Chronic otitis media with probable cholesteatoma #4 Lateral semicircular canal fistula #5 VII nerve weakness (Bell’s palsy) #6 All of the above #7 1,2,3, and 4 What is next most appropriate step? #1 otolaryngology consultation #2 steroids #3 temporal bone CT scan high-resolution #4 systemic and topical antibiotic therapy #5 all of the above #3 is most appropriate answer. This appears to be an acute exacerbation of acute otitis media superimposed on a chronic ear condition which most likely could represent cholesteatoma which had eroded the lateral semicircular canal and is causing facial nerve pressure with resultant paresis of facial nerve. This is not Bell’s palsy because Bell’s palsy by definition is idiopathic facial nerve paralysis or paresis when no other etiology can be determined. The facial nerve passes through the temporal bone in its horizontal and vertical components and is subject to involvement by temporal bone disease. The next most appropriate steps would be #5 all of the above including otolaryngology consultation; high-resolution CT scanning of the temporal bone; antibiotics and steroids and the probable need for surgical intervention to decompress the facial nerve . Question 9: Oncology 53-year-old white male employed as a pharmaceutical representative to the regional medical practices presents with persistent complaints of sore throat on the right side for 3 months without response to oral antibiotic therapy on 2 courses previously. Has some sensation of fullness to his right upper neck. Denies hoarseness or difficulty swallowing. Otherwise has no medical problems on no medications. Patient does not use tobacco in any form and never has noticed to use alcohol. Examination reveals normal ear exam and nasal exam. Oral cavity appears normal. Oropharynx reveals no evidence of exudate or ulcers there is no significant asymmetry but the right tonsil possibly is slightly more prominent . Exam of nasopharynx and hypopharynx is negative. Digital palpation of the tonsils reveals some slight increased firmness to the right side. Palpation of the neck reveals some slight tenderness right jugulodigastric area but no obvious discrete mass and perhaps some fullness in right jugulodigastric area. Patient has grown increasingly concerned. Question 9: How would you approach this patient? #1 Consider this chronic tonsillitis and try another course of antibiotic therapy #2 Pursuing infectious disease evaluation #3 Assume this is cervical adenitis and probably reactive #4 Consider mononucleosis #5 Consider tonsil neoplasm even though he does not smoke or use alcohol What would be next appropriate step? #1 ultrasound or CT scan of the neck #2 otolaryngology referral#3 a third course of antibiotic therapy and steroids #4 tonsillectomy #5 infectious disease consultation #6 recommendation to cruise in the Bahamas #5 evaluate for some abnormality of the right tonsil which good represent right tonsillar neoplasm. While squamous cell carcinoma of the head and neck has reduced by 50% at most sites; squamous cell carcinoma of the oropharynx has increased to 250% since 1988. These patients usually present with a low T. stage and a high N stage. There is now become a clear association with HPV. If current trends continue oropharyngeal squamous cell carcinoma will surpass the incidence of cervical carcinoma by 2020. Next appropriate step would be CT scanning soft tissues of the neck to rule out neoplasm of right tonsil or adenopathy. Fine-needle aspiration of cervical adenopathy may confirm diagnosis. Question 10: Laryngology 55-year-old male presents with a history of left ear pain for the last 3-4 months. Patient denies hearing loss or drainage or discharge. He denies pain on opening and closing the mouth for chewing or turning his head from side to side. He has noticed also for the last 2 months increasing hoarseness but denies significant difficulty swallowing. He was diagnosed with gastroesophageal reflux disease and is currently on omeprazole. He denies significant complaints of heartburn or indigestion. When asked if he using tobacco he denies this currently. When asked if he ever use tobacco he states he has he stopped smoking one and a half packs per day approximately 4 weeks ago. Occasional ethanol use. On examination ear canals and TMs appear normal. Weber testing with 256 tuning fork is midline. TMJ is nontender laterally and posteriorly. Nasal exam and oral cavity and oropharynx are benign on exam.Palpation of the neck is nontender there is no palpable adenopathy and posterior cervical area is nontender to palpation. Question 10: What is the primary concern? #1 Gastroesophageal reflux poorly controlled #2 Laryngeal polyposis #3 Laryngitis secondary to voice use and abuse #4 Laryngeal neoplasm Next most appropriate step? #1 visualization of endolarynx and true vocal cords. #2 otolaryngology referral for this purpose and definitive diagnosis #3 CT scanning of the larynx and neck#4 oral antibiotics #5 oral steroids #6 speech therapy referral #4 rule out laryngeal neoplasm is most likely next diagnosis with associated hoarseness and cigarette use and left otalgia which can be a sign of supraglottic laryngeal and glottic laryngeal neoplasm. Unilateral otalgia in an adult with normal ear exam and no obvious etiology on examination of common sites of referred ear pain like the temporomandibular joint or the cervical spine suggest the possibility of oral pharyngeal or laryngeal disease that needs to be evaluated.Particularly in the patient at high risk for upper respiratory tract neoplasm these areas should be visualized directly.Radiological imaging sometimes may be required to evaluate this problem also. Next most appropriate step are #1 and #2.direct visualization of the upper respiratory tract which is done on otolaryngology comprehensive evaluation. Question 11: Oncology 20-year-old female presents for complaints of nasal bleeding and nasal congestion. Patient in good health no other medical problems on no medications except oral contraceptives. Complains of seasonal related nasal congestion rhinorrhea and occasional bloody nasal discharge. Denies facial pain or pressure or any purulent nasal discharge. Exam reveals normal ear canals and tympanic membranes. Nasal exam reveals dry mucous membranes some anterior crusty secretions on the nasal septum. Oral cavity oropharynx appear normal. Examination of the neck is negative except for a nodule right paratracheal area above the sternoclavicular joint. It is nontender and moves on swallowing. Patient denies hoarseness or difficulty swallowing. There is no family history of medical problems of significance. Her grandmother had a history of enlarged thyroid. Question 11: How would you advise this patient? #1 Tell patient to use nasal saline spray and nasal saline gel to anterior nasal membranes #2 Have patient drink more liquids #3 Advised her to have ultrasound of thyroid #4 Tell her nodule and neck is not significant probably represents goiter #5 Evaluate thyroid function tests #6 CT scan of neck and sinuses #7 1,2 and 3 #8 5 and 6 #9 1, 2 and 4 #7 1,2 and 3. Patient presents with nasal complaints and asymptomatic nodule right neck that on a complete head and neck exam reveals probable thyroid nodule. Patient is advised symptomatic care of the nose with saline irrigation ,topical saline gel and increased oral fluid intake. Next step would be to proceed with thyroid ultrasound. Thyroid ultrasound revealed 2-1/2 cm thyroid nodule with some calcification. Fine-needle aspiration was done which revealed papillary carcinoma and this patient required total thyroidectomy and long-term monitoring. Question 12: Head and neck 56-year-old male presents with his wife who is insisted he be evaluated for problems with snoring . Husband states his wife complains of his snoring and sleeps in a separate room because of this. This has been going on for many years. Wife cannot really describe patient’s breathing because she does not sleep with him at night. Patient is a truck driver and is often on the road also. Patient is reluctant to provide much history regarding his sleep. His wife however states that he is restless in his sleep and seems extremely tired which has progressed over the years. She notes that he falls asleep easily during the day. Examination of the patient reveals him to be alert and cooperative no acute distress and does appear fatigued but is not obese. When questioned he does complain of nasal congestion difficulty breathing through his nose particularly on the left side. His oral cavity reveals elevation of the tongue; the oropharynx can be seen partially and looks rather crowded. Tonsils do not appear to be enlarged and uvula is somewhat elongated. After some discussion the patient does relate some morning fatigue and daytime somnolence. Patient has a history of hypertension currently on Lisinopril. Patient also has a history of heartburn indigestion on omeprazole. Question 12: With his next most appropriate evaluation and this situation? #1Thyroid function study #2 Otolaryngology consultation for evaluation of upper respiratory tract airway #3 Chest x-ray #4 Pulmonary function studies #5 Polysomnography(sleep study) #6 EKG #7 1, 2, and 5 #8 1,2,and3 #9 3,4,and 6 #7 is most appropriate answer. Patient has suspicious history for obstructive sleep apnea and may be reluctant to pursue this evaluation since he is a truck driver and this can have direct influence on his employment. Hypothyroidism can manifest itself as obstructive sleep apnea-type symptoms and correction of this particularly in men can occasionally resolve the issue. Evaluation of the upper respiratory tract for obstructive lesions or anatomic airway obstruction is indicated. Sleep study would be indicated to confirm the diagnosis and its significance and severity. This patient did indeed have a very positive sleep study with AHI of 35 and with no easily amenable surgical options patient initiated CPAP. Difficulty with chronic nasal obstruction required corrective nasal surgery and now he is able to use nasal CPAP to treat his obstructive sleep apnea. Treatment of this and ongoing monitoring is crucial to him maintaining his employment as a truck driver. Question 13:Rhinology 75-year-old male currently hospitalized for exacerbation of chronic obstructive pulmonary disease on oral nebulized steroids and bronchodilators and oral steroids. History of coronary artery disease and coronary artery stents in place with associated atrial fibrillation currently rate controlled. Patient maintained on Coumadin for anticoagulation . Patient with home oxygen 2 L per minute by nasal cannula. Patient also uses topical nasal steroid spray.Patient continues to smoke one pack per day of cigarettes. During hospitalization developed acute nasal bleeding from the left nasal airway and posterior pharyngeal bleeding uncontrolled by ice packs and pressure to the nose. Otolaryngology consultation is requested but unavailable for some time til finishes round of golf. What is the most likely problem and next best option for treatment. What is most appropriate diagnoses? #1 nasal tumor with necrotic bleeding #2 posterior sphenoethmoidal arterial bleeding secondary to atherosclerotic vascular disease. #3 anterior septal bleeding from Kiesselbach plexus secondary to dry mucous membranes and crusting #4 mucosal bleeding secondary to anticoagulation with Coumadin #5 nasal septal inflammation and irritation secondary to chronic use of nasal steroid spray topically #6 arterial venous malformation of the maxillofacial area #7 #1 and 2 #8 #3 and 4 and 5 Most correct answer is: #8-#3 and #4 and #5. This is a common scenario that we encounter repeatedly in the hospital with patient’s on anticoagulation and nasal oxygen with by nasal cannula. We are called multiple times a year for this scenario in which humidified or not he may divide oxygen tries anterior nasal septal mucous membranes and actually can cause ulceration in the same location continuously which then released erosion of anterior nasal septal vessels in active bleeding. Because of anticoagulation bleeding becomes more significant and usually requires intervention. Nasal steroid spray topically can also commonly cause nasal bleeding and may be aggravating factor in this scenario. Were next appropriate steps? Are first intervention would be topical vasoconstrictive agents as oxymetazoline spray with pledgets or cotton ball saturated with oxymetazoline spray and placed in the nose to offer immediate pressure to control anterior septal bleeding. If unsuccessful the next most appropriate step is to place a rapid rhino pack to compress and control bleeding. Further manipulation of nasal mucous membranes with instrumentation create multiple bleeding sites because patient is anticoagulated. Using atraumatic balloon pack is the first best step.complicating this treatment however is impairment of patient’s oxygenation potentially by creating nasal airway obstruction. Therefore oxygenation should be monitored closely. Epistaxis anterior and posterior? Nasal bleeding is usually a product of either anterior nasal circulation from anterior ethmoid artery complex 90% of the time for a posterior circulation bleeding site from the internal maxillary artery and sphenopalatine artery, and in elderly patients with vascular disease. Anterior nasal bleeding usually self-limited unless patient has coagulopathy and can be managed easily. Posterior epistaxis from posterior circulation is usually more severe and progressive requiring anterior posterior packing and sometimes embolization and sometimes surgical intervention to control. Bleeding in this area is usually more severe and can be life-threatening. Posterior epistaxis is basically defined as that which he cannot see or identify from anterior examination of the nose. In this setting or if there’s a question consultation with otolaryngology is definitely indicated. In addition the packing usually stays in place for 3 days unless anticoagulated in which case we leave it approximately 5-7 days and stop anticoagulation or reverse if possible. Question #14: Head and neck 67-year-old male with history of chronic cigarette use one pack per day for 40 years and frequent ethanol use presents with increasing painful swallowing and difficulty swallowing with associated weight loss. Patient has had more frequent bloody mucus discharge on clearing his throat and over recent days frequent bright red bleeding. Patient with history of atrial fibrillation currently on anticoagulation Rivaroxaban. Patient developed during the night excessive bright red bleeding; vomiting dark blood as well as spitting bright red bleeding from the oral cavity and oropharynx. Patient admitted to the hospital for support and diagnostic efforts for bleeding site. CT scan of the neck with contrast revealed large base of tongue enhancing mass. Examination of hypopharynx and larynx suggested neoplasm base of tongue with recurrent active bleeding. It is our next best plan? What is most likely diagnosis? #1 base of tongue malignant tumor probable squamous cell carcinoma with erosion of major vessel active bleeding secondary to anticoagulation #2 arteriovenous malformation now with active bleeding exacerbated by anticoagulation #3 pharyngotonsillitis secondary mucosal hemorrhage #4 foreign body with trauma to the hypopharynx and base of tongue Most likely diagnosis? #1 patient tongue squamous cell carcinoma with erosion of major vessel and significant bleeding exacerbated by anticoagulation. Appropriate step would be to consider local control bleeding site which is very difficult with significant neoplastic tumors of the hypopharynx or larynx or consider embolization of vasculature to the tumor in this area. Another important feature is to reverse anticoagulation in order to be able to do these procedures without exacerbating bleeding. One step would be to reverse patient’s anticoagulation. How would you proceed with that?