Correct Answer: C

Explanation: The Centor criteria may be used to identify cases of tonsillitis more likely to be bacterial: 3-14 years old (+1), tonsillar exudate (+1), history of fever > 100.4ºF (+1), and absent cough (+1). Scores ≥ 2 warrant rapid strep test and/or throat culture. In select patients with scores ≥ 4, empiric antibiotic therapy may be considered; however, 2012 IDSA guidelines do not recommend empiric antibiotic therapy without confirmatory testing. Hospital admission is unnecessary unless the patient experiences worsening symptoms, such as stridor or inability to tolerate fluids as well as solids. If antibiotics are indicated, phenoxymethylpenicillin for 10 days is the treatment of choice, unless the patient has a penicillin allergy.

References:

Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2012; 55(10): p.e86–e102. doi: 10.1093/cid/cis629.

Correct Answer: B

Explanation: The thick white patches on this patient’s oral mucosa are suggestive of oral thrush (oropharyngeal candidiasis), a localized infection with Candida fungi. It is associated with immunosuppression and frequently occurs in patients with HIV infection, diabetes mellitus, and history of cancer. In immunocompetent patients, localized oropharyngeal candidiasis is managed with topical antifungals, such as nystatin “swish and swallow” or oral fluconazole.  Acyclovir (A) is an antiviral agent effective against herpes simplex virus and varicella zoster virus. Penicillin (C) is an beta-lactam antibiotic used to treat bacterial—not fungal—infections. Griseofulvin (D) and Terbinafine (E) are used for dermatophytoses, not candidiasis.

Image Credit: Photograph from David H. Spach, MD https://www.hiv.uw.edu/go/basic-primary-care/oral-manifestations/core-concept/all

References: 

Patton LL, Bonito AJ, Shugars DA. A systematic review of the effectiveness of antifungal drugs for the prevention and treatment of oropharyngeal candidiasis in HIV-positive patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92(2):170-179. doi:10.1067/moe.2001.116600

Correct Answer: D

Explanation: This patient’s otoscopic exam shows gray-colored fluid and air-fluid level (arrow) behind the tympanic membrane, suggestive of otitis media with effusion (OME). Also called serous otitis media, OME is a spontaneously resolving condition, and watchful observation is the preferred strategy except for children with hearing impairment, developmental delay, or specific conditions in whom OME is often persistent and needs to be addressed. Tympanostomy tubes may be indicated for children with OME for >3 months (chronic OME) and symptoms that are likely attributable to OME. Antihistamines, antibiotics, and decongestants are ineffective for OME and are not recommended for treatment.

References:

Rosenfeld RM, Culpepper L, Doyle KJ, Grundfast KM, Hoberman A, Kenna MA, Lieberthal AS, Mahoney M, Wahl RA, Woods CR Jr, Yawn B; American Academy of Pediatrics Subcommittee on Otitis Media with Effusion; American Academy of Family Physicians; American Academy of Otolaryngology--Head and Neck Surgery. Clinical practice guideline: Otitis media with effusion. Otolaryngol Head Neck Surg. 2004 May;130(5 Suppl):S95-118. doi: 10.1016/j.otohns.2004.02.002. PMID: 15138413. [Article Link]

Correct Answer: B (Diuretic)

Explanation: Ménière's disease is a chronic condition that currently has no cure, and its treatment aims to reduce the severity and frequency of vertigo attacks and improve the patient's quality of life. The approach to treatment involves a step-by-step escalation of therapies until the patient achieves sufficient symptom management. The initial therapy involves dietary and lifestyle modifications such as sodium restriction, caffeine and alcohol reduction, and stress reduction. Oral pharmacological therapy should include diuretics, typically thiazides, with or without potassium-sparing diuretics. These medications work by altering the electrolyte balance in the endolymph and reducing its volume, thereby decreasing the severity and frequency of vertigo attacks. Betahistine is another pharmacological option, commonly used as maintenance therapy in Europe. However, its use is limited in the United States due to limited evidence supporting its effectiveness. If lifestyle and oral pharmacological therapies are insufficient, intratympanic medications such as corticosteroids and/or gentamicin can be offered. It is important to note that gentamicin carries the risk of hearing loss when injected. If the above treatment options are not effective, surgical interventions such as endolymphatic sac decompression or shunt surgery, vestibular neurectomy, or surgical labyrinthectomy may be considered. This patient does not meet the criteria for a cochlear implant and instead could be offered a hearing aid to improve their hearing.

References:

Basura, G. J., Adams, M. E., Monfared, A., Schwartz, S. R., Antonelli, P. J., Burkard, R., ... & Buchanan, E. M. (2020). Clinical practice guideline: Ménière’s disease. Otolaryngology–Head and Neck Surgery, 162, S1-S55.

Hoskin, J. L. (2022). Ménière's disease: new guidelines, subtypes, imaging, and more. Current Opinion in Neurology, 35(1), 90-97.

Correct Answer: B (nasal decongestant spray)

Explanation:
History of nasal congestion following prolonged use of medication combined with erythematous nasal mucosa is suggestive of rhinitis medicamentosa, a condition of rebound nasal congestion following extended use of nasal decongestant sprays (oxymetazoline, phenylephrine, e.g.). These over-the-counter decongestant sprays lead to rapid relief of nasal congestion by causing vasoconstriction. Many days of regular use leads to rebound nasal congestion as the medication wears off, prompting patients to administer the medicine more frequently to obtain relief. This can lead to a vicious cycle, both caused and relieved by the medication, with escalating use. While antihistamines (A) cause drying of the mucosa, they do not cause rebound congestion. Nasal steroids (C) and bronchodilators (D) also do not cause rebound congestion. There is evidence steroids make rebound congestion less likely to occur when coadministered with the nasal decongestant. Allergic rhinitis (E) is more likely associated with sneezing and itching symptoms, and physical exam would show edematous, pale nasal mucosa, rather than the ‘beefy red’ mucosa classically associated with rhinitis medicamentosa.

References:
Vaidyanathan S, Williamson P, Clearie K, Khan F, Lipworth B. Fluticasone reverses oxymetazoline-induced tachyphylaxis of response and rebound congestion. Am J Respir Crit Care Med. 2010 Jul 1;182(1):19-24. doi: 10.1164/rccm.200911-1701OC. Epub 2010 Mar 4. PMID: 20203244.

https://pubmed.ncbi.nlm.nih.gov/20203244/

E (CN V3, Trigeminal Nerve)

C (House Brackmann Facial Nerve Grading System)

A (Superior parathyroid gland)

C (Peritonsillar abscess)