20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections

ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

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2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

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11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections

Key Takeaways Explain This Topic AI

Acute and chronic sinusitis, otitis media and externa, mastoiditis, common cold, pharyngitis, epiglottitis and deep head and neck infections are enumerated under upper respiratory tract infections.

Acute bacterial rhinosinusitis is suggested by symptoms persisting beyond ten days, severe symptoms, or double worsening after initial improvement.

Necrotizing otitis externa occurs in older adults with diabetes and requires imaging and prolonged antipseudomonal therapy.

Sudden sensorineural hearing loss is an emergency in which prompt corticosteroids improve recovery.

Asymmetric sensorineural hearing loss requires magnetic resonance imaging to exclude vestibular schwannoma.

Last updated: August 2026

1. Upper Respiratory Infections, Pharyngitis & Sinusitis
Acute Pharyngitis & Modified Centor (McIsaac) Criteria

Most adult pharyngitis is viral (rhinovirus, adenovirus, EBV, coronavirus). The primary clinical objective is identifying Group A Beta-Hemolytic Streptococcus ( Streptococcus pyogenes / GAS) to initiate prompt treatment, shorten symptoms, prevent suppurative complications, and prevent Acute Rheumatic Fever .

Modified Centor (McIsaac) Scoring System:

Fever history (>38.0°C / 100.4°F): +1 point
Absence of cough: +1 point
Tender anterior cervical lymphadenopathy: +1 point
Tonsillar exudates or swelling: +1 point
Age: 3–14 years (+1 point) | 15–44 years (0 points) | ≥45 years (-1 point)

Management Stratification Based on Centor Score:

Score 0–1 (<10% risk of GAS): No diagnostic testing; supportive symptomatic care (NSAIDs, lozenges). No antibiotics.

Score 2–3 (15–30% risk of GAS): Perform Rapid Antigen Detection Test (RADT) . Treat with antibiotics ONLY if RADT is positive . In adults, negative RADT does not require confirmatory throat culture due to very low incidence of rheumatic fever.

Score 4–5 (30–50% risk of GAS): Perform RADT (or empiric therapy in high-prevalence settings).

Antimicrobial Treatment of Confirmed GAS Pharyngitis:

First-Line Standard: Oral Penicillin V (500 mg PO BID-TID for 10 days) OR Oral Amoxicillin (500 mg PO BID or 1000 mg PO once daily for 10 days) . Zero documented GAS resistance worldwide.

Non-Severe Penicillin Allergy (non-IgE): Cephalexin (500 mg PO BID for 10 days) or Cefdinir.

Severe Penicillin Anaphylaxis (IgE-mediated): Oral Azithromycin (500 mg day 1, then 250 mg daily for 4 days) OR Oral Clindamycin (300 mg PO TID for 10 days) .

Complication — Peritonsillar Abscess (Quinsy):

Collection of pus between tonsillar capsule and pharyngeal constrictor muscle.

Clinical Triad: Severe unilateral sore throat, "hot potato" muffled voice , and trismus (inability to open mouth due to irritation of internal pterygoid muscle).

Physical Exam: Unilateral tonsillar bulge, erythematous soft palate, and deviation of the uvula to the contralateral unaffected side .

Management: Emergency needle aspiration or surgical incision and drainage (I&D) + IV Ampicillin-Sulbactam (3 g IV q6h) or IV Clindamycin (600–900 mg IV q8h) + single-dose IV Dexamethasone.

Acute Rhinosinusitis: Viral vs. Acute Bacterial Rhinosinusitis (ABRS)

Over 90–98% of acute rhinosinusitis cases are viral. Antibiotic stewardship requires strict adherence to the IDSA Clinical Diagnostic Criteria for ABRS (requires ≥1 of 3 presentations) :

Persistent Symptoms: Signs and symptoms of rhinosinusitis (purulent nasal discharge, nasal obstruction, facial pain/pressure) lasting ≥10 days without any evidence of clinical improvement.

Severe Onset: High fever ( ≥39.0°C / 102.2°F ) accompanied by concurrent purulent nasal discharge and severe facial pain lasting for ≥3 to 4 consecutive days at the onset of illness.

"Double-Sickening": Acute worsening of symptoms (new-onset fever, headache, increasing nasal congestion/discharge) following a typical 5–6 day viral upper respiratory infection that was initially improving.

Evidence-Based Treatment of ABRS:

First-Line Empiric Therapy: Oral Amoxicillin-Clavulanate (Augmentin 875/125 mg PO BID for 5–7 days) . (Covers beta-lactamase producing Haemophilus influenzae and Moraxella catarrhalis alongside Streptococcus pneumoniae ).

High-Dose Augmentin (2000/125 mg PO BID for 7–10 days): Indicated for patients aged ≥65 years, systemic comorbidities, recent antibiotic use within past 30 days, or moderate-to-severe infection.

Penicillin Allergy: Oral Doxycycline (100 mg PO BID for 5–7 days) OR a respiratory fluoroquinolone ( Levofloxacin 500 mg PO daily or Moxifloxacin 400 mg PO daily ). Note: Macrolides (Azithromycin) and TMP-SMX are NOT recommended due to high pneumococcal resistance (>30–40%).

Imaging Guidelines: Routine Sinus CT is NOT recommended for uncomplicated ABRS. Contrast-enhanced CT of paranasal sinuses/orbits is indicated only if orbital or intracranial complications are suspected (proptosis, ophthalmoplegia, visual changes, severe retro-orbital pain, altered mental status, meningismus).

2. Ear, Hearing & Skull Base Disorders
Sensorineural vs. Conductive Hearing Loss

Bedside evaluation using a 512-Hz tuning fork differentiates conductive hearing loss (CHL: external auditory canal or middle ear pathology) from sensorineural hearing loss (SNHL: cochlea or cranial nerve VIII pathology).

Tuning Fork Examination Normal Finding Conductive Hearing Loss (CHL) Sensorineural Hearing Loss (SNHL)

Weber Test (512-Hz fork on midline forehead/vertex) Sound heard equally in both ears (midline) Sound lateralizes to the AFFECTED ear (ambient room noise is blocked in affected ear, allowing bone conduction to sound louder) Sound lateralizes to the NORMAL / UNAFFECTED ear (sensorineural apparatus in unaffected ear senses sound better)

Rinne Test (512-Hz fork on mastoid [BC] then 1-2 cm from ear canal [AC]) Positive (AC > BC) in both ears (air conduction exceeds bone conduction) Negative (BC ≥ AC) in affected ear (bone conduction equals or exceeds air conduction due to middle ear defect) Positive (AC > BC) in affected ear (both AC and BC are reduced, but AC remains greater than BC)

Common Etiologies — Cerumen impaction, otitis media with effusion, otosclerosis, cholesteatoma, tympanic membrane perforation Presbycusis (age-related high-frequency loss), noise trauma, Ménière disease, ototoxic drugs (aminoglycosides, cisplatin), Vestibular Schwannoma

Sudden Sensorineural Hearing Loss (SSNHL):

Definition: Loss of ≥30 dB across ≥3 contiguous frequencies occurring over ≤72 hours .

Management (Otologic Emergency): Immediate initiation of High-Dose Oral Corticosteroids (Prednisone 60 mg/day tapered over 14 days) or intratympanic steroid injections; greatest recovery occurs when treated within 1–2 weeks.

Diagnostic Requirement: Contrast-enhanced Brain MRI with Internal Auditory Canal (IAC) protocol to rule out Vestibular Schwannoma (Acoustic Neuroma) in all patients with unilateral sensorineural hearing loss or asymmetric tinnitus.

Acute Otitis Externa vs. Malignant (Necrotizing) Otitis Externa

Clinical Parameter Acute Otitis Externa (AOE / "Swimmer's Ear") Malignant (Necrotizing) Otitis Externa (MOE)

Etiology Pseudomonas aeruginosa (40–50%) and Staphylococcus aureus (20–30%) Pseudomonas aeruginosa (>95% of cases) causing invasive osteomyelitis of skull base

Host Demographics Swimmers, humid environments, mechanical cleaning with cotton swabs Elderly patients with diabetes mellitus (90%) , immunocompromised, HIV, post-chemotherapy

Clinical Symptoms Rapid onset of severe otalgia, intense tragal and pinna tenderness , canal pruritus, discharge Excruciating, deep-seated nocturnal otalgia radiating to temporomandibular joint, persistent foul-smelling purulent otorrhea

Physical & Otoscopic Exam Erythematous, edematous ear canal with moist debris; intact tympanic membrane Granulation tissue on the floor of the external auditory canal at the osseocartilaginous junction; mucosal ulceration

Neurological Complications Absent Cranial Nerve Palsies : CN VII (Facial nerve) most common (ipsilateral facial droop in 50%), progressing to CN IX, X, XI (jugular foramen syndrome) and CN XII

Diagnostic Workup Clinical diagnosis Markedly elevated ESR and CRP (used to track treatment response); High-Resolution Temporal Bone CT (cortical bone erosion and demineralization); Technetium-99m / Gallium-67 bone scans; deep tissue biopsy

Treatment Regimen Thorough ear canal debridement + Topical Otic Fluoroquinolone Drops ( Ciprofloxacin 0.3% - Dexamethasone 0.1% or Ofloxacin 0.3% drops for 7–10 days).; Warning: Avoid ototoxic neomycin/polymyxin drops if tympanic membrane perforation cannot be excluded. EMERGENCY Hospitalization: Prolonged Systemic IV Antipseudomonal Antibiotics for 6 to 8 weeks ( IV Cefepime 2 g q8h , IV Piperacillin-Tazobactam 4.5 g q6h , or IV/Oral Ciprofloxacin 750 mg BID if confirmed susceptible); strict glycemic control; surgical debridement of necrotic bone for refractory cases

6. Meniere Disease, Cholesteatoma & Other Disorders of the Ear

The blueprint enumerates benign paroxysmal positional vertigo, vestibular neuronitis and acute labyrinthitis, Meniere disease, acoustic neuroma, presbycusis and other hearing loss, otitis media and externa, cholesteatoma , and other disorders of the ear and mastoid.

Meniere disease

Endolymphatic hydrops producing a distinctive four-symptom complex:

Episodic vertigo lasting 20 minutes to several hours — long enough to distinguish it from the seconds of benign paroxysmal positional vertigo, short enough to distinguish it from the days of vestibular neuronitis

Fluctuating sensorineural hearing loss , initially low-frequency , becoming permanent over years
Tinnitus , often a low roaring sound
Aural fullness in the affected ear

Attack duration is the highest-yield discriminator:

Disorder Duration of vertigo Hearing loss
Benign paroxysmal positional vertigo Seconds , positional No
Meniere disease 20 minutes to hours , spontaneous Yes, fluctuating
Vestibular neuronitis Days , continuous No
Labyrinthitis Days, continuous Yes
Vertebrobasilar ischemia Minutes, with other neurologic signs Variable

Diagnosis is clinical, supported by audiometry showing low-frequency sensorineural loss . MRI is obtained to exclude vestibular schwannoma , particularly with asymmetric loss. Management begins with sodium restriction and avoidance of caffeine, alcohol and nicotine , with diuretics, betahistine (outside the United States) and vestibular rehabilitation; intratympanic corticosteroid or gentamicin and surgical procedures are reserved for refractory disease.

Cholesteatoma

An expanding sac of keratinizing squamous epithelium in the middle ear or mastoid. It is not a neoplasm , but it behaves destructively, eroding the ossicles and surrounding bone.

Suspect it with chronic, painless, foul-smelling otorrhea that does not resolve with topical or oral antibiotics , together with conductive hearing loss. Otoscopy may show a retraction pocket, a perforation with white keratin debris, or a granulation-covered mass in the attic.

Complications result from bone erosion: conductive then sensorineural hearing loss, facial nerve palsy , labyrinthine fistula with vertigo, mastoiditis, and intracranial extension causing meningitis or brain abscess.

Treatment is surgical — antibiotics and drops do not resolve it — so the internist's task is to recognize chronic malodorous otorrhea unresponsive to medical therapy and refer promptly.

Other ear conditions

Acoustic neuroma (vestibular schwannoma) — asymmetric sensorineural hearing loss with poor speech discrimination out of proportion to the pure-tone loss , tinnitus and unsteadiness; diagnosed by gadolinium-enhanced MRI of the internal auditory canals . Bilateral tumors indicate neurofibromatosis type 2 .

Otitis media with effusion in an adult — a unilateral effusion in an adult, particularly of Southeast Asian ancestry, requires nasopharyngeal evaluation for nasopharyngeal carcinoma obstructing the eustachian tube.

Tympanic membrane perforation — most heal spontaneously; keep the ear dry and avoid ototoxic drops.

Cerumen impaction — a common, immediately reversible cause of hearing loss that should be excluded before audiometry.