2019 RC Specialties > ENT > Flashcards

ENT Flashcards

(128 cards)

Study These Flashcards
1
Q

What is the last sinus to develop?

A

Frontal

**Ego Means SelF
= Ethmoid - Maxillary - Sphenoid - Frontal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Tell me when the sinuses develop.

A

Ego means SelF

= Ethmoid= air @ birth
= Maxillary= present at birth; air @ 4
= Sphenoid= present at 5
= Frontal= start @ 7-8 but not fully done till teens

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Most common long-term sequelae associated with congenital CMV?

A

Hearing loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

T or F: kids with congenital CMV can pass newborn hearing test.

A

True!

50% will pass but develop loss later.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the leading cause of acquired hearing loss?

A

Bacterial meningitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Please list min. 5 non-infectious RF for neonatal sensorineural hearing loss.

A 
Preg: *in utero infectxn (i.e. CMV)
Post Natal
- Apgar 0-4 @ 1 min or 0-6 @ 5min
- *BW < 1500 g
- *Craniofacial anomalies (involving external ear)
- NICU > 2d
- *ECMO
- mechanical vent 5+ days
- *ototoxic meds (gent, tobra), diuretics (lasix)
- *hyperbili needing exchange
PMHX
- *congenital bacterial meningitis
- *syndromes: NF, Alport, Jervell and Lange-Nielson syndromes
- Neurodegenerative (Hunter)
- Sensory motor neuropathies (Charcot-Marie Tooth Syn)
- Recurrent or persistent AOM x 3 mon.
Meds: chemo
HPI: *trauma, noise level
Development: GDD, SLP delay
FHX: *fhx of permanent hearing loss
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

1.5 year old boy with sudden fall with normal LOC that has nystagmus. What is dx?

A

Benign Paroxysmal Vertigo

Associated: Migraines.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is vertigo?

A

rotation or spinning component

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

T or F: true vertigo is associated with LOC.

A

False

  • No LOC
  • association= N/V, pallor, diaphoresis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Do you teens have benign paroxysmal or position vertigo?

A

Positional!

Paroxysmal usually resolve by 6 y.o.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How can you tell peripheral or central vertigo?

A

Central= constant, any direction nystagmus, neuro signs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

List common reasons for acute vertigo:

A
  • AOM
  • benign paroxysmal vertigo (1-2 y.o.; short period; may get migraine later, tx gravol symptoms)
  • benign positional vertigo (~6 y.o., free debris in canal, sudden vertigo btwn episodes)
  • labyrinthitis (infection of inner ear; infection preceding; resolve over day)
  • vestibular neuritis (teens; after resp infection; postural imbalance w/ ear pain)
  • basilar artery migraine (teen F; episodic vertigo; h/a after)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

List reasons for chronic vertigo:

A
  • NF2 neuromas
  • posterior fossa tumours
  • meds: aminoglycosides
  • cerebral infarct
  • MS (demyelinating process)
  • endo/metabolic (DM, thyroid)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What test must all people with vertigo undergo?

A

Hearing test.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What maneuver can you do for Benign POSITIONAL vertigo?

A

Epley test.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How do you treat vertigo?

A

Symptomatic if no RED flags

  • If persistent= W/U
  • If neuro= imaging
  • If LOC= EEG

Most recover w/out intervention over wk-months.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is the most objective test for middle ear effusion?

A

Tympanometry.

Fluid= non compliant TM = flattened tympanogram tracing. Test limited by pt cooperation.
Does not distinguish btwn OME vs. AOM.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Facial nerve is which cranial nerve?

A

7

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Most common causes of facial nerve palsy?

A

AOM
Bell’s palsy
Lyme disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

List 3 congenital causes of facial nerve palsy

A

CONGENITAL
1. Congenital Traumatic (LGA, forcep, prem)

  1. Moebius syndrome (CN 7 and 6)
  2. Asymmetric crying facies (loop-sided lip)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

List 3 acquired causes of facial nerve palsy

A

ACQUIRED

  1. Tumour or Trauma
    - cholesteatoma
    - CA invasion
    - Basal skull #
  2. Infection
    - chronic AOM
    - parotitis or mastoiditis
    - Bell’s palsy (whole side)
    - Ramsay Hunt Syn (Herpes Zoster)
    - Lyme disease
  3. Systemic
    - sarcoidosis (esp if bilateral)
    - MS
    - Hyperthyroidism
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is the most common cause of unilateral facial weakness?

A

Bell’s Palsy

CC: usually abrupt loss of control + sensation on one side
~2 wk after infection
Dx of exclusion
Tx: steroids +/- valacyclovir

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Describe the Ramsay Hunt Triad:

A
  1. Ipsilateral facial palsy
  2. Ear pain
  3. Vesicles (auditory canal, palate, tongue)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

How do you tell the difference btwn central vs. peripheral lesions causing facial palsy?

A

Central =

  1. contralateral side from lesion
  2. spare upper 1/2 of face (wrinkle forehead)
    * see wkness if ask “show your teeth”
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Describe areas you look at when assessing palsy?
1. Forehead + Brow (lose mvmt) 2. Eyes (can't close or drooping or eyelid) 3. Nasolabial folds (lost) 4. Lip (drooping)
26
Tx of facial palsy:
Corticosteroids (prednisone x 1 week w/ taper) +/- Antiviral (valacyclovir if severe or Ramsay Hunt) PT EBM unclear Surgical: rare Remember: If can't close their eyes= artificial tears w/ ophthalmic ointment + patch at night
27
What is the prognosis for Bell's Palsy?
Excellent >85% full recovery (95% in some sources)
28
What is the consequence of withholding treatment x 48hr in child w/ AOM?
Prolonged duration of overall symptoms (including fever) NOT: pain, mastoiditis
29
Give three indications for tympanostomy tubes.
1. Recurrent AOM with MEE (middle ear effusion) 2. OME + symptoms (hearing loss or school behav) 3. OME (otitis media w/ effusion) > 3 month (w/ hearing loss or symp or high risk pop'n) High risk pop'n: ASD, T21, cleft palate, DD, blind, craniofacial abnormalities, SLP delay, permanent hearing loss 4. Hammer: B/L OME > 3 mon. + conductive hearing loss 5. Hammer: other uncommon (complications of AOM like mastoiditis, lack of med tx response, chronic retraction of TM)
30
How do you diagnose AOM?
1. Acute Symptoms - otalgia, irritability 2. Middle Ear Effusion - immobile TM or otorrhea 3. Significant middle-ear inflammation - bulging TM - discoloured TM
31
List risk factors for AOM
1. orofacial anomalies (i.e. cleft palate) 2. short duration of BF 3. prolonged bottle feeding while supine 4. household crowding 5. exposure to cig smoke 6. (+) FHX AOM 7. First Nations or Inuit Other CPS: young age, pacifier use, low IgA, CF
32
When do you do watchful waiting in AOM?
``` Min 6 mo. old + Well (no immuno, cardiac, pul., T21) + Mild (fever < 39, mild pain) + do not meet full criteria = wait x 48 hr ``` If not improve or worsen = Tx
33
When do you treat AOM?
Unwell OR febrile (min. 39) + mod-severe or severe otalgia OR min. 48hr wait = Tx Note: AAP also says < 2 y.o. w/ bilateral to treat.
34
What are risk factors for Abx resistant S. pneumonia for AOM (which is why we do high dose)?
< 2 y.o. daycare frequent/recent (w/in 3 mo.) failed initial Abx
35
Which Abx can you use for AOM?
1. Amoxicillin 90 divided BID 2. Amox-Clav - amox in last 30 days - If unimmunized - AOM + purulent conjunctivitis as more likely H. influx + M. catarrhalis 3. Cefprozil or Cefuroxime - non IgE rxn - Note only Ceftriaxone if PO not tolerated or Amox-Clav fail 4. Clarithromycin or Azithro x 5d - IgE Rxn 5. Clindamycin - IgE Rxn (not as good w/ s. pneumonia or H. Influ)
36
How long do you treat AOM for?
5 DAY= > 2 y.o. = 5 day 10 DAY = < 2 or frequent or perf TM or failed initial Tx
37
List some serious complications of AOM?
1. *Mastoiditis 2. Sub-periosteal abscess 3. Facial Nerve Palsy 4. Venous Sinus Thrombosis 5. Meningitis Other: labyrinthitis, Bezold's absces, * cholesteatoma etc.
38
How do you treat AOM w/ tube otorrhea
Ciprodex (steroids + Abx)
39
How do you treat AOM + perf TM/otorrhea
PO Amox x 10 d
40
When do you refer a perforated TM to ENT?
Does not heal in 6 wk - heal usually w/out intervention - keep out water + cotton tips - eval hearing
41
List three possible Abx for a pt w/ AOM treated with Clarithro a few weeks ago for resp infection.
1. high dose amox 2. amox-clav 3. cefuroxime or cefprozil
42
How do you prevent AOM?
1. Hygiene (reduce virus) 2. Exclusive BF until min. 3 mon (reduce chance for 4-12 mo. after BF ceases) 3. Avoid pacifier 4. No smoking 5. Pneumococcal conjugate vaccine for all as per schedule. 6. Recommend annual flu vaccine.
43
When do you suspect primary ciliary dyskinesia?
PCD= immotile cilia syn; AR dx 50% situs inversus= Kartagener's Syn - chronic or recurring URTI or LRTI - bronchiectasis of RML or lingula - chronic AOM - rhinosinusitis - nasal polyps - heterotaxy (TGA common) - infertility Consider: CXR, CT lung, PFT Dx: nasal nitric oxide (low in PCD), nasal bx (ciliary motion)
44
Most common cause of epistaxis?
picking the nose
45
List a brief list of aetiologies for epistaxis:
- trauma (nose picking, acute facial trauma causing septal hematoma) - rhinitis - sinusitis - FB - polyp, tumours - vascular malformations/telangiectasia - bleeding dx (vWF, hemophilia) - irritant (Smoke) - meds (anticoag, NSAID, topical corticosteroids)
46
How do you manage epistaxis
1. Sit child upright 2. Tilt head fwd 3. compress nare x 5-10 min. 4. cold compress to nose if does not work - oxymetazole - anterior pack + cauterize site - tx underlying coagulopathy
47
When do you refer to ENT for epistaxis?
- b/l nasal bleeding | - posterior hemorrhage (not from Kiesselbach plexus)
48
How do you prevent epistaxis?
Humidify + Lubricate! - humidifier - nasal saline drops - vaseline to septum
49
What is Otrivin?
Oxymetazoline= vasoconstrictor - nose bleed - topical decongestant for rhinitis - only use max 3-5d
50
What is rhinitis medicamentosa?
= Rebound nasal rhinitis after Otrivin = rebound nasal hypertrophy, congestion, inflam. - resolve in 1-2 wk - can use IN steroids to tx
51
What is obstructive sleep apnea?
Sleep disruption + Hypoxemia + Daytime symptoms
52
What is the most common cause of OSA?
Adenotonsilar Hypertrophy
53
List 5 daytime symptoms of OSA:
- *difficult to wake in am - *morning h/a - mouth breathing - chronic nasal congestion - *hyponasal speech - *somnolence= excess daytime sleepiness/ naps - *neurobehav issues= poor mood, behav difficulties
54
What are the paradise criteria recommendations for tonsillectomy in cases of recurrent tonsillitis? How many episodes are too much?
Relative indication "7 in 1 5 in 2 3 in 3" ( # of episode go down by 2 while year go up by 1) - 7 episode sore recurrent throat infctxn in pvx year - min. 5 episodes in each of pvx 2 yrs - min. 3 episodes in each of past 3 yrs
55
List the paradise criteria for recurrent tonsillitis and T&A
7 in 1 5 in 2 3 in 3
56
1 y.o. w/ exudative pharyngitis- likely dx?
Viral! - strep uncommon before 2-3 y.o. - virus predominate over bacterial - Mono < 4 y.o. usually asymptomatic
57
Triad for EBV in teens
Fatigue + Pharyngitis + Generalized lymphoadenopathy
58
At which age group is GAS pharyngitis more common?
5- 15 y.o.
59
How do you treat GAS pharyngitis:
Pen PO x 10 d
60
When is EBV symptomatic?
Teens
61
Tell me about splenic hemorrhage.
- highest risk during 2nd week of dx | - avoid contact sport + strenuous athletic activities during 2-3 wk of illness or while splenomegaly there
62
What are absolute indications for tonsillectomy?
- acute airway obstruction - cor pulmonale - suspected CA or TB - acute hemorrhagic tonsillitis - severe dysphagia VS. Relative indication= recurrent tonsillitis (paradise criteria), tonsillitis complications (peritonsillar abscess, sleep apnea, hard swallowing), tonsilloliths and halitosis
63
List two contraindications to T&A
1. repaired cleft palate | 2. hemophilia.
64
What condition is pathognomonic for bifid uvula?
Loeys-Dietz Syn = AD connective tissue dx Primary CC: arterial tortuosity + wide spaced eyes (hypertelorism) + bifid uvula + aortic root aneurysm ``` Other: Cardiac- PDA, ASD Aneurysm Midface cleft palate MSK scoliosis, club foot Skin bruising, scar ```
65
Q: RPA with Sx decompression. New H/A. Likely cause?
Internal jugular vein thrombosis. * HENT infection most common cause of cerebral venous sinus thrombosis Other Complications of RPA: - obstruction - rupture leading to aspiration pneumonia - erosion of carotid sheath
66
What are some differences between peritonsillar abscess vs. retropharyngeal abscess
``` Peritonsillar= Teens GAS TRIMUS + Dsyphagia CT Sx ``` ``` RPA= < 5 y.o. (RP nodes involute) Polymicrobial Throat pain + muffle TORTICOLLIS 1/3 have trismus Inspiration XR +/- CT IV Abx + Sx ```
67
Recurrent stridor often need what type of test?
Bronchoscopy DX: - allergic/spasmodic croup - resp infection w/ narrow airways - laryngomalacia
68
T or F: cool mist in ED is helpful in helpful in tx croup.
False. - Cochrane shows no evidence despite observational comments.
69
What is the #1 tx for croup?
Oral corticosteroids + Nebulized epinephrine. * should respond w/in 10-30 min. Note: heliox considered if thinking intubation (but evidence inconclusive)
70
2 mon. old w/ noisy breathing but well. Dx and maneuver?
Laryngomalacia. Maneuver: improve w/ prone.
71
T or F: laryngomalacia is most common cause of stridor in infants AND chidlren
True.
72
What is the natural course of laryngomalacia?
Present by 1st mo. Worsen up 6-8mo. Resolve by 2 y.o.
73
Treatment for laryngomalacia
Reassurance. If severe (resp failure, growth, FTT, DD) = Sx
74
List a DDX for noisy breathing:
THINK ANATOMY (Nose -> Oro -> Larynx -> Subglottic -> Tracheobronchial) OR CATEGORIES - Congenital: chonanal atresia, laryngomalacia, laryngeal cleft, tracheomalacia - Trauma: FB, hematoma - Inflammatory: polyps, tonsil hypertrophy, RPA, laryngitis, croup, asthma - Neoplastic: hemangioma, tumour, thyroid - MSK: hypotonia, Vocal cord paralysis
75
What is paradoxical vocal cord dysfunction?
- inappropriate closing during inspiration = stridor or wheeze w/ activity (not working w/ asthma meds) * Think if truncated (flattened at bottom) or inconsistent (vs. asthma is scooped top) PFT flow-vol loop
76
How do you treat paradoxical vocal cord dysfunction?
Rx: speech training + behaviour therapy (relaxation), +/- heliox if acute
77
Swollen red midline neck mass = ?
Thyroglossal duct cyst.
78
What is the pathognomonic sign for thyroglossal duct cyst?
Vertical elevation of mass w/ swallowing and tongue protrusion.
79
Why do we not do Sx while thyroglossal duct cyst infected?
- increase risk of recurrence | - increased chance of seeding infected cell outside
80
List 2 DDX for congenital torticollis that are NOT a SCM tumour.
1. Positional deformity 2. Unilateral absence of SCM 3. Vertebral anomalies (failure segmentation) ... Acquired DDX: - trauma (muscular injury to cervical muscle) - cervical inflame - - RPAbscess - JIA - Dystonic drug rxn - Cervical cord tumour - Sandifer syndrome (GERD, hiatal hernia) - Benign paroxysmal torticollis
81
What is Sturge Weber Syndrome?
Sporadic neurocutaneous vascular dx.
82
What are the three main components of Sturge Weber Syndrome?
Skin-Brain-Eye 1. Port-Wine Stain 2. Leptomeningeal angioma - abN blood vessel in brain= Sz DD, hemiparesis, stroke 3. Glaucoma - abN vessel in eye or others
83
Cyst in salivary gland in sublingual area called what? What do you do?
Ranula. Refer to Sx for excision!
84
What is the gold standard for testing obstructive sleep apnea?
Nocturnal Polysomnography.
85
Sequelae of Untreated OSA?
- pulmonary HTN - R and LVH - Cor Pulmonale
86
What are common trach complications
- Obstruction - Accidental decannulation - Recurrent tracheitis - Tracheal ulceration - Tracheal granuloma - Hemorrhage
87
What are key teaching points for families w/ Trach?
- CPR - ABC/ need to be able to assess resp status - trach hygiene - suction - tube change - emergency trach + back up kit - back up power
88
Common causes of stridor in TEF post-op:
- tracheomalacia (associated w/ TEF) - GERD w/ laryngospasm - tracheal structure - vocal cord paralysis
89
How long does it take for an effusion to clear after an AOM?
12 weeks (90% resolved)
90
Teen w/ chronic left ear drainage - likely?
Cholesteatoma. - unilateral - foul - persistent - respond to tx but recur
91
What is the most common congenital birth defect?
Sensorineural hearing loss.
92
What is the most common genetic/hereditary cause of congenital sensorineural hearing loss?
Connexion 26 - AR - non syndromic kids Other: Waardenburg (AD), NF2 (AD), Treacher Collins (AD), Jervell/Lange-Nielsen (AR), Alport (X)
93
How many of congenital CMV have symptoms?
5-10% and 50% of those have SNHL. vs. 90-95% asymptomatic but later 5-15% of those have SNHL.
94
What most common non-genetic cause of hearing loss?
Congenital CMV - newborn screen miss 50% - high frequency sound - progressive (>50% in first 5 yr) - unilateral loss in most
95
Most common cause of bilateral nasal obstruction in child?
Adenoid hypertrophy
96
Most common cause of new foul persistent unilateral nasal d/c?
Nasal FB
97
What do you worry about in nasal trauma or #?
septal hematoma - no XR needed; clinical exam - closed reduction b4 2 wk
98
List complications of sinonasal infections?
- Osteomyelitis - Sinovenous thrombosis - Brain abscess
99
List signs of orbital cellulitis:
``` H/A or severe pain Diplopia Vision change Proptosis LOC change ```
100
How do you manage sinonasal infections?
Abx Nasal corticosteroids Decongestants Sx: abscess drainage, source control
101
Which is false: secondary indications of OSA include daytime somnolence, FTT, ADHD, enuresis.
Trick- they're all true!
102
What is enlarged soft tissue space in RPA or RP cellulitis?
Pre vertebral soft tissue > 1x width of vertebral body. - Or > 7mm @C2 - Or > 14mm @C6 Other signs on XR: loss of cervical lordosis
103
Describe the airway involved: - inspiratory stridor - biphasic - expiratory stridor
Insp= supra glottis ... laryngomalaia.. epiglottitis Biphasic= VC/ Subglottis ... B/L VC paresis, subglottic hemangioma, croup Exp= Trach + Bronchi ... tracheomalacia, TEF , complete trach ring
104
What type of stridor do you get with FB?
ANY! can be anywhere. - supraglottis= insp - VC= biphasic - trach/bronchi= exp
105
What are Stridor Red Flags (when to refer):
- Eating/Feeding - Cyanosis - Progression - Severe - biphasic stridor - parental concern - dx question
106
Beard distribution hemangioma =
Subglottic hemangioma - "Croup" too early - tx: propanolol - +/- steroid +/- laser/Sx
107
Tell me the diff btwn stridor in laryngomalacia vs. tracheomalacia.
Laryngomalacia = INSP Tracheomalacia= EXP
108
What type of malacia is associated w/ TEF repair?
Tracheomalacia.
109
When do a bronchoscopy with FB?
Object-Exam-XR - high density food: peanut, carrot, apple - P/E: wheeze, prolonged expiration, low AE - XR: air trapping or consolidation
110
Most common FB?
Food | 1/3= nuts (esp peanuts).
111
What CC is usually suggestive of FB?
abrupt choking/coughing w/ new onset wheeze Consider also in recurrent pneumonia
112
What type of XR do you order if FB suspected?
Inspiratory + Expiratory (doesn't deflate) If can't cooperate= Left + R lateral decubitus
113
If you see a double ring circulator object on AP CXR or step on lateral? What is that?
Esophageal Button Battery
114
Does OAE tell you about degree of hearing loss?
No! - objective test best in BB w/ no RF with clear middle ear that tell you if loss present
115
What type of hearing screen do you do for newborns:
No RF and well: OAE (otoacoustic emission) If (+) or BB has RF: AABR (Auditory brainstem response)
116
Neck Masses Etiology Categories
COIN - Congenital - Other - Infectious/Inflam - Neoplasm
117
List 2 acute and 2 chronic infectious causes of neck masses:
Acute 1. Viral: EBV, CMV 2. Bacterial: GAS, Staph 3. PFAPA lymphadenitis Chronic 1. HIV lymphadenitis 2. Cat scratch (Bartonella) 3. TB 4. Atypical mycobacteria
118
List two inflammatory conditions causing neck masses?
1. KD | 2. Sarcoidosis
119
List 2 Benign and two malignant neoplastic causes of neck masses
Benign: hemangioma, neurofibroma Malignant: lymphoma, neuroblastoma, thyroid malignancy
120
List two causes each of midline neck masses vs. lateral
Midline: - thyroglossal duct cyst - dermoid cyst - cervical cleft Lateral - branchial cleft cyst - thymic cyst Vascular malformation can be either.
121
Node is >1cm and round with high resistive index on U/S. Reactive or malignant?
Malignant! ``` >1cm round (S/L > 0.5 cm) no echogenic hilus coagulative necrosis high resistance index of blood flow extracapscular spread ```
122
If you see midline Ca2+ on neck on plain film=
Dermoid cyst
123
If you have lateral smooth neck mass along SCM border
Branchial cleft cyst
124
If you have neck mass that enlarges w/ valsalva?
Laryngocele
125
If you have neck mass present at birth but grow then plateau and blue-
Hemangioma
126
Compressible or transilluminate neck mass?
Lymphatic malformation
127
Neck mass w/ torticollis
SCM tumour
128
When do you Bx neck adenopathy
``` Node > 2cm Neonate Firm, hard, fixed CN abN supraclavicular ``` No change x 4wk 'B' symptoms PMHX cancer FHX of cancer
2019 RC Specialties
flashcards
Decks in class (31)
# Cards
Brainscape helps you reach your goals faster, through stronger study habits.
© 2026 Bold Learning Solutions. Terms and Conditions