Download -click here for handouts (full page)

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?