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

Explanation: Advances in imaging techniques have led to an increased detection of incidental thyroid nodules (ITNs). While extrathyroidal ultrasound remains the most common method of identifying ITNs, they can also be detected using CT, MRI, or FDG-PET. Consequently, the American College of Radiology has issued recommendations on when further investigation is necessary. According to these guidelines, ITNs measuring ≥1 cm in patients below 35 years of age or ≥1.5 cm in patients aged 35 or older, those exhibiting local tissue invasion, or suspicious lymph nodes should undergo further evaluation. In cases where multiple ITNs are present, the criteria apply to the largest nodule. Given that our patient meets these criteria, further workup is warranted.Following a thorough patient history collection and physical examination, the next step in evaluating a thyroid nodule involves conducting an ultrasound and assessing thyroid-stimulating hormone (TSH) levels. Ultrasound is the preferred imaging modality for assessing thyroid nodules as it can identify suspicious features and provide accurate information regarding their size and number. If the ultrasound and TSH findings raise concerns regarding malignancy, the subsequent step in the evaluation process is fine needle aspiration.

References:

Hoang JK, Langer JE, Middleton WD, et al. Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. J Am Coll Radiol. 2015;12(2):143-150. [Article Link]Tamhane S, Gharib H. Thyroid nodule update on diagnosis and management. Clin Diabetes Endocrinol. 2016;2:17. Published 2016 Oct 3. [Article Link]