ENT

Question 1

Deafness

1. Conductive - causes (5)
2. Sensorineural - causes (4)
3. Presbycusis - definition
4. Presbycusis - cause
5. Otosclerosis - definition
6. Otosclerosis - treatment
7. Ototoxic drugs (4)
8. Ototoxicity - symptoms

Answer 1

1. Wax, acute otitis media, otitis externa, otosclerosis, perforated ear drum
2. Presbycusis, noise induced, congenital, vestibular schwannoma (aka acoustic neuroma), ototoxicity
3. Deterioration in hearing as patients age (chronic sensorineural)
4. Loss of sensitivity of delicate hair cells in the cochlea
5. Abnormal bone formed around stapes foot plate
6. Stapedectomy
7. Aminoglycosides (e.g. streptomycin), cisplatin (chemo), furosemide, quinine
8. Deafness, vertigo

Question 2

Deafness - examination

1. Whisper test - how far away to stand
2. Weber - where to put tuning fork
3. Louder in one ear means
4. Dead ear finding
5. Rinne’s - tests what
6. AC > BC
7. BC > AC
8. Tympanometry test - tests what

Answer 2

1. 1m
2. Forehead
3. Conductive loss in same ear or sensorineural loss in opposite
4. False negative test
5. Checks air compared to bone conduction
6. Normal middle/outer ear function
7. Conductive deafness
8. The compliance of middle ear structures

Question 3

Hearing aids

1. Indication for bone anchored hearing aids (2)

Answer 3

1. Chronic infection, shape of the ear canal

Question 4

Emergency childhood ENT

1. Croup - AKA
2. Main management
3. Epiglottitis - usual cause
4. Don’t do what
5. Management

Answer 4

1. Acute laryngotracheobronchitis
2. Dexamethasone single dose, nebulised ventolin, paracetamol
3. Haemophilus influenzae B (HIB)
4. Persist in examining the child’s throat
5. Admit and give IV amoxicillin

Question 5

ENT history - key questions

1. Ear (5)
   Other (2)
2. Nose (5)
   Other (4)
3. Throat (5)
   Other (3)
4. Relevant systemic diseases

Answer 5

1. Otalgia, otorrhea, hearing loss, tinnitus, dizziness
   Ear blockage, ear itch
2. Nasal obstruction, anterior rhinorrhea, hyposmia, epistaxis, facial pain
   Post-nasal drip, nasal itch, ocular itch, sneezing
3. Dysphagia, sore throat, odynophagia, dysphonia, regurgitation
   Feeling of lump in throat, burning in throat, weight loss
4. Allergic chronic rhinosinusitis, DM, HTN, TB, sarcoid, GPA, type 2 neurofibromatosis

Question 6

Rhinitis

1. Pathophysiology
2. Chronic finding
3. Test
4. Management (1st line)
5. Treatment if non resolving small nasal polyps in rhinitis
6. Treatment if large polyps

Answer 6

1. Type 1 allergic reaction - release of inflammatory mediators
2. Nasal polyps
3. Radioallergosorbent test - detects allergis
4. Antihistamine and nasal steroid spray (takes 6m to take effect)
5. Prednisolone
6. Nasal polypectomy

Question 7

ENT - random definitions

1. Synechia
2. Epiphora
3. Myringoplasty

Answer 7

1. Adhesions in the nasal cavity
2. Damage to nasal lacrimal duct
3. Repair of the tympanic membrane perforation

Question 8

Otitis externa

1. Definition
2. Risk factors (4)
3. Common organisms
4. Symptoms (4)
5. Examination signs (3)
6. Management - if no infection signs
7. Management - if Pseudomonas
8. Early complications + sign (2)
9. Complication if chronic
10. Complication in immunocompromised
11. Malignant otitis externa - responsible organism
12. Risk factors
13. Symptoms
14. Management - medical
15. If ear closed up and need topical ABX
16. Monitoring requirements
17. Surgical

Answer 8

1. Diffuse inflammation of the skin lining the outer ear canal
2. Narrow external canal, trauma, eczema / psoriasis, swimming
3. Staphylococcus pyogenes, staphylococcus aureus, candida albicans, E.coli
4. Irritation, discharge, pain (tismus), mild deafness
5. Meatal tenderness, moist/purulent debris, smelly/keratotic, red desquamated skin
6. Analgesia
7. Topical flucloxacillin
8. Perichondritis (‘cauliflower ear’); cartilage inflammation, + facial cellulitis (if spreads to skin); otomycosis (following topical ABX use)
9. Canal stenosis with hearing loss
10. Osteomyelitis of temporal bone ‘malignant’
11. Pseudomonas aeruginosa
12. Immunosuppression, DM
13. CN 7 inflammation/weakness
14. Topical + IV ABX via in-dwelling cannula for 6 weeks
15. Use OTOWICK (ear stent) for 48 hours
16. Regular assessments: CRP/ESR, MRI skull base
17. Mastoidectomy

Question 9

Perforated ear drum

1. Causes (3)
2. Symptoms (4)
3. Management - surgical

Answer 9

1. Trauma, iatrogenic (grommet surgery), recurrent infections
2. Pain (transient), conductive deafness, tinnitus, vertigo
3. Myringoplasty

Question 10

Acute otitis media

1. Length
2. Causative organisms (2)
3. Symptoms
4. 1st line management
5. Considered recurrent when
6. OM - otoscope findings
7. OM with effusion - otoscope findings

Answer 10

1. 1-5 days
2. Streptococcus pneumonia, H. influenzae
3. Earache, conductive deafness, otorrhoea, systemic illness, no canal inflammation
4. Analgesics (usually self limiting) (if ABX later then 5 days amoxicillin)
5. 4+ episodes in 6 months
6. Bulging, red, inflamed membrane, maybe perf/fluid
7. Dull TM with air bubbles/fluid level behind it, or normal

Question 11

Cholesteatoma

1. Definition
2. Commonest cause
3. Symptoms
4. Commonest location
5. Potential complication
6. Investigation
7. Potential imaging (2) + indications
8. Management - if infection present
9. Management - definitive

Answer 11

1. Accumulation of squamous keratin epithelium
2. Chronic eustachian tube dysfunction
3. Painless unilateral hearing loss
4. Behind pars flaccida in middle ear
5. Cyst expansion into middle ear - ossicular erosion
6. Pure tone audiogram
7. CT if planning mastoid surgery, MI if expected intracranial complication
8. Topical ABX/steroid drops
9. Mastoidectomy

Question 12

Tonsillitis

1. Criteria to use to decide whether to give ABX
2. Components (4)
3. Bacterial - commonest organism + management
4. Complication of severe bacterial, + organism
5. Presentation (4)
6. Examination
7. Management

Answer 12

1. Centor
2. Tonsillar exudate, tender anterior lymphadenopathy or lymphadenitis, fever, NO cough (give if 3/4)
3. Group A strep, use Penicillin V (phenoxyethylpenicillin)
4. Peritonsillar abscess (Quinsy) - strep. pyogenes
5. Hot potato voice, fever, bad dysphagia, referred otalgia
6. Trismus, furred buccal mucosa, foetor (bad breath)
7. IV AB and drainage of the abscess

Question 13

Pharyngeal pouch

1. Location on neck
2. Specific feature
3. Presentation

Answer 13

1. Posteromedial
2. Gurgles on palpation
3. Dysphagia, regurgitation, aspiration, chronic cough

Question 14

Neck lump

1. History
2. Important risk factor questions (5)
3. Red flags (6)
4. Investigations
5. Midline if <20
6. Midline if >20
7. Midline, bony hard
8. Midline, below hyoid + moves up on tongue protrusion
9. Midline, moves up on swallowing
10. Lateral - general differentials
11. Submandibular triangle - differentials
12. Anterior triangle - differentials
13. Posterior triangle - differentials
14. If on left side and present from birth
15. Complication of this removal
16. Lymphadenopathy - infective causes

Answer 14

1. Preceeding symptoms (tonsillitis, pharyngitis, cold), duration, change in size, associated features (pain, redness, discharge), other lumps
2. Smoking/alcohol, recent foreign travel, HIV status, dental problems, TB contact
3. Dysphagia, hoarseness, odynophagia, weight loss, fevers, night sweats
4. USS neck, CT neck and chest, FNAC
5. Dermoid cyst
6. Thyroid isthmus mass
7. Chondroma
8. Thyroglossal cyst
9. Goitre
10. Lymph node, solitary thyroid nodule, lipoma, cystic hygroma /branchial cyst
11. Lymphadenopathy, salivary stone, sialadenitis
12. Branchial cyst (high, anterolateral, behind SCM), parotid tumour, laryngocoele (bigger on blowing), pulsatile (carotid artery pathology e.g. carotid body tumour, anterior)
13. Pancoast tumour, cervical rib, pharyngeal pouch, cystic hygroma (low, lymph filled, at base, seen in kids)
14. Cystic hygroma
15. Accessory nerve damage
16. Streptococcus, staphylococcus, EBV, CMV, TB, toxoplasmosis

Question 15

Goitre

1. Commonest cause of large
2. Goitre in Hashimoto’s
3. Goitre in Graves’

Answer 15

1. Diffuse multinodular
2. Small, firm
3. Smooth and soft +/- bruits

Question 16

Vertigo

1. Definition
2. Due to pathology of (2)
3. Inner ear - causes
4. CN 8 - causes
5. Test to confirm CN 8 pathology
6. Meniere’s disease - cause
7. Presentation
8. BPPV - cause
9. Diagnosis
10. Management
11. Acute labyrinthitis - symptoms
12. Cause (2)
13. Duration
14. Management

Answer 16

1. Illusion of rotatory movement
2. Inner ear, CN 8
3. BPPV, menieres, otitis media, labyrinthitis
4. Acoustic neuroma, ototoxic drugs, HZV
5. Caloric test - cold water in ear causes nystagmus
6. Fluid overload due to failure of endolymph reabsorption
7. Episodic vertigo, fluctuating deafness, tinnitus, recurrent attacks
8. Occurs on head movement due to disruption of debris in semicircular canal
9. Fatiguable nystagmus during Hallpike manoeuvre
10. Epley manoeuvres
11. Abrupt onset, severe vertigo, nausea, vomiting, prostration, no deafness or tinnitus
12. Virus, vascular lesion
13. Severe improves in days, full recover 3-4 weeks
14. Reassure, sedate

Question 17

Dizziness

1. Tests - bedside
2. Tests - blood
3. Tests - imaging

Answer 17

1. Lying and standing BP, ECG, obs, hearing tests
2. FBC, ESR
3. Brain scan

Question 18

Referred otalgia

Causes (5)

Answer 18

1. Sore throat (CN 9)
2. Temperomandibular joint
3. Chronic rhinosinusitis
4. Dental infection
5. Pharyngeal pathology

Question 19

Oral cavity exam

1. Eight steps

Oral squamous cell carcinoma

2. Metastasis sites (4)
3. Risk factors (6)
4. Red flax warranting maxfax referral (3)

Answer 19

1. Mucosa of cheeks
2. Roof of mouth
3. Dentition/gums
4. Dorsum of tongue
5. Lift tongue (mouth floor)
6. Move tongue (examine sides)
7. Sometimes palpate OC structures
8. Inspect oropharynx
9. Oral cavity, Larynx, EAC (chronic inflammation/previous irradiation), Nasopharynx (SE Asians)
10. Smoking, alcohol, HIV, EBV, GORD, betel nut
11. Red/white oral mucosa patches, oral mucosa ulceration > 3 weeks, unexplained tooth mobility

Question 20

Neck anatomy

1. Anterior triangle - borders
2. Important structures
3. Posterior triangle - borders
4. Neck exam - palpated structures

Answer 20

1. Midline of neck, SCM muscle, inferior mandible border
2. Carotid sheath, thyroid gland, submandibular gland, lymph nodes
3. SCM, anterior trapezius, middle 1/3 of clavicle
   Lymph nodes, accessory nerve (CN 11)
4. Tip of chin (submental/submandibular); Mastoid process (anterior SCM border); Thyroid and larynx (if pathology, assess water swallow); Posterior Triangle (up SCM to mastoid, then rest); Parotid gland; Fossae

Question 21

Ear examination

1. To do beforehand (3)
2. Outer - areas to examine
3. Outer - looking for what
4. Otoscopy - external auditory canal
5. Otoscopy - typanic membrane (what and how)

Answer 21

1. Sit patient sideways; Examine good ear first; Ask if bad ear is tender
2. Pinna, surrounding skin, post-auricular sulcus
3. Deformity, discharge, scars, sinuses, skin conditions
4. Diameter, debris, swelling
5. Examine TM in quadrants; include pas flaccida. Perforations, retractions, keratin, cavity

Question 22

Ear anatomy

1. Corda tympani branch of the facial nerve - function
2. Cochlear channels - aka (+ 3 channels)
3. Hair cells involved in cochlear nerve depolarisation
4. Neurotransmitter involved
5. Outer hair cells within Organ of Corti - function
6. Auditory cortex - location

Answer 22

1. PNS to lacrimal gland; taste from anterior 2/3 of tongue
2. Scala (Vestibuli, Tympani, Media)
3. Inner hair cells
4. Glutamate
5. Modulate the signal generated by the Organ of Corti
6. Superior temporal gyrus; extends to lateral sulcus and transverse temoral (Heschl’s) gyrus

Question 23

Chronic otitis media

1. Definition
2. What does this imply
3. Commonest causative organisms (4)
4. Types (2) + causes
5. Complications - extra-temporal (4)
6. Complications - intra-temporal (4)
7. How it may cause hearing loss (2)
8. Management - conservative
9. Management - medical
10. Management - surgical

Answer 23

1. Present for 3+ months
2. Perforated eardrum; failed to heal and ongoing infection
3. Pseudomonas aeruginosa, staphylococcus aureus, streptococcus, anaerobic bacteria (e.g. peptostreptococcus)
4. Mucosal (from perforated TM; dry); squamous (from cholesteatoma formation)
5. Meningitis (erodes through tegmen, exposes dura), subdural abscess, temporal lobe abscess (septic thrombi/RVS), sigmoid sinus thrombosis (direct infection/RVS)
6. Intermittent vertigo (vestibular inflammation), hearing loss, acute otitis externa (discharge and skin irritation), facial weakness (bony erosion - CN 7 exposure and damage)
7. Conductive (TM/ossicle damage), sensorineural (cochlear nerve inflammation)
8. Water precautions, regular aural toilet
9. Topical ciprofloxacin
10. Myringoplasty (surgical TM repair)

Question 24

Glomus jugulaire

1. What it is
2. Commonest symptom
3. Otoscopy finding

Answer 24

1. Vascular tumour in middle ear
2. Pulsatile tinnitus
3. Red mass behind TM

Question 25

Structure perforated in barotrauma

Answer 25

Round window (part of medial wall of inner ear)

Question 26

Tympanic membrane 1. Parts (2) 2. PF - location 3. PT - location 4. Typanosclerosis - what is it, cause

Answer 26

1. Pars tensa, pars flaccida 2. Above malleus lateral process 3. Below malleus lateral process 4. Calcium deposits following healing of previous infection

Question 27

Impacted wax- symptoms (3)

Answer 27

Hearing loss, visible wax, no pain/discharge

Question 28

Otorrhoea 1. What it is 2. Causes (2) 3. History

Answer 28

1. Discharge 2. Inflammation, infection 3. Duration Associated otalgia, hearing loss, dizziness, tinnitus Treatment so far PMH: water in ear, surgery to ear, allergic chronic rhinosinusitis, asthma, DM

Question 29

Salivary gland 1. Acute swelling - differentials 2. Chronic bilateral swelling - co-existing symptoms 3. Chronic bilateral swelling - differentials

Answer 29

1. Mumps, HIV (bilateral), stone (unilateral, recurrent, pain/swelling on eating) 2. Dry eyes/mouth, autoimmune disease 3. Hypothyroidism, Sjogren's syndrome, fixed (ALL, other tumour, sarcoid, amyloid, GPA)

Question 30

Dysphonia 1. History 2. Examination - areas (4) 3. Vocal fold paralysis - causes (4)

Answer 30

1. Problems/pain swallowing, weight loss, GORD symptoms, nasal symptoms (e.g. PND), systemic upset 2. Oral cavity, oropharynx, larynx (flexible endoscope), oropharynx, neck (lymphadenopathy/thyroid disease) 3. Reinke's oedema, GORD, SCC (white keratin lesions), polyps

Question 31

Nasal obstruction 1. Causes (3 groups) 2. History - questions 3. Deviated septum - management 4. Potential complication

Answer 31

1. Structural (e.g. septal deformity), inflammatory (e.g. chronic rhinosinusitis), infective 2. Unilatera/bilateral, duration, intermittent/constant, PMH (trauma/nasal surgery), orther nasal symptoms 3. Septoplasty 4. Maxillary nerve branch damage - upper teeth/nose floor numbness

Question 32

Chronic rhinosinusitis 1. Diagnostic criteria 2. Signs/symptoms within criteria 3. Symptoms 4. Blood test to identify allergies to specific allergens 5. Management - medical (3) 6. Management - associated infection 7. Management - surgical 8. Surgical management - complications 9. Nasal polyps - medical management 10. Bacterial cause

Answer 32

1. EPOS criteria 2. Nose/paranasal sinus inflammation and nasal blockage, with 1 of (facial pain/pressure, hyposmia/anosmia, polyps, mucopurulent discharge, CT changes) 3. Bilateral nasal obstruction, anterior rhinorrhoea - watery discharge, sneezing, nasal mucosa oedema 4. RAST (radioallergosorbent) 5. Topical nasal steroid (e.g. flixonate beconase) if >10 days, saline nasal irrigation, antihistamines 6. Macrolide e.g. clarithromycin 7. Sinus surgery 8. Blindness (ethmoidal air cell can wrap around CN 2), CSF leak/meningitis, epiphora (damage to nasolacrimal duct), orbital injury, synechiae, hyposmia/anosmia 9. Short course prednisolone 10. Streptococcus pneumoniae

Question 33

Mucocilliary function 1. Test used to assess 2. How it is performed

Answer 33

1. Saccharine test 2. Placed 1cm behind anterior end of inferior turbinate Usually swept backwards and tasted after 10-20 minutes

Question 34

Epistaxis 1. Causes (4) 2. Commonest origin (85%) 3. Other origin 4. History 5. Recurrent chronic epistaxis - medical management 6. How it works 7. How to use Severe epistaxis - management 8. Stage 1 9. Stage 2 10. Stage 3 11. Stage 4 12. Risk of bilateral SNC 13. PP - length of time 14. PP - additional drug given

Answer 34

1. Idiopathic (85%), trauma, nasal mucosa inflammation / malignancy (SCC), haematological (DIC, ICP) 2. Little's area/Kiesselbach plexus (ant. nasal septum) 3. Woodruff's plexus (posterior end of middle turbinate) 4. Frequency, duration, side affected Dripping - down nose/throat/both What do they do when it starts e.g. apply pressure PMH - previous bleeds, HTN, rhinitis, bleeding disorders, GPA, sarcoidosis DH - warfarin, aspirin, clopidogrel, clexane (LMWH) 5. Naseptin (bactroban) ointment 6. Treats staph colonisation causing inflammation 7. Use for 1-2 weeks - stops crust forming (contains peanuts) 8. Visualise bleeding point 9. Cauterise or anterior pack 10. If AP, then posterior pack (foley catheter) 11. Surgery (Artery ligation - mainly sphenopalatine or anterior ethmoidal) 12. Septal perforation 13. 48 hours 14. Prophylactic PO antibiotics