ENT-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal
Dear Plabber,
•
•
This first ever System Wise 1700 document was created thanks to 3 months of daily hard
work by the PLAB Skype group ‘Unity’ which was brought together by Dr Susmita
Chowdhury.
Please ignore the old versions posted by my new skype member Murtaza as he did so
without permission.
The team members were:
& Susmita (Lead/most ignorant as she is working full time in public health for 13 years)
& Asad (Invaluable in IT and all types of support/the heart of the group)
& Manu (Volunteered to solve more questions/pathologist/amazing genuine person)
& Saima (Most concise clear notes/ photographic memory)
& Zohaib (Great research/a surgeon)
& Savia (Great research/multi-tasker with two little ones)
& Shanu (Very helpful after her March exam for those appearing in June)
& Mona (Great contributor in discussions)
& Manisha (Gyne/great discussion contributor)
& Sitara (Good discussion contributor)
& Samreena (Stayed a shorter time but great)
& Sami (Contributed the most early on but too brilliant for the group/still great friends)
& Komal (Knowledgeable sweet supportive girl)
•
The main purpose was to break down the 1700 Q Bank System wise.
•
We did our own reliable research for the options (OHCM/Patient info etc.) and concluded
these keys below on skype. This can save you 100s of hours of research. But I suggest you
also do your own.
•
90% of the document consists of Unity research. We also added information from other
circulating documents and they are referenced as Dr Khalid/Dr Rabia (and her Team).
•
However, several keys may be ‘incorrect’ and so please use your own judgment as we take
no responsibility. I suggest cross checking with Dr Khalid’s latest keys (a few of which are still
debatable). Finally decide on your own key.
•
Sorry if some members failed to make their answers thorough. The highlights are mostly as
per what the team members wanted to highlight. Blank tables to be ignored.
•
Note that some 1700 Questions are missing from here (when members did not do their
share). Questions may not be in order due to merging of documents and there is excess
information than required. Read as much as needed.
•
This has been circulated by our team as a generous contribution to the Plabbers’ success and
must not be ‘sold’.
1
Good luck and best wishes: Sush and Team
ENT-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal
Q: 51
A 5yo girl had earache and some yellowish foul smelling discharge, perforation
at the attic and conductive hearing loss. She has no past hx of any ear
infections. What is the most appropriate dx?
a. Acute OM
b. OM with effusion
c. Acquired cholesteatoma
d. Congenital cholesteatoma
e. Otitis externa
Clincher(s)
A
B
C
D
E
KEY C
Foul smelling discharge , hearing loss, perforation at the attic
No discharge except pus and blood exudate in canal
Correct answer (perforated tympanic membrane)
Foul smelling discharge indicates Cholesteotoma ! lead to Conductive
hearing loss
Additional
Information
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ENT-System Wise 1700-by Sush and Team. 2016
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ENT-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal
Reference
Dr Khalid/Rabia
GP Notebook and DOK Notes
Q. 1. What is the key?
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ENT-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal
Q.2. What are the points in favour of your diagnosis?
Ans. 1. The key is c. Acquired cholesteatoma.
Ans. 2. Ans. 1. The key is c. Acquired cholesteatoma.
Ans. 2. acquired cholesteatomas develop as a result of chronic middle ear
infection and are usually associated with perforation of the tympanic
membrane at the attic (mass is seen in attic with perforation at pars flaccidain contrast to medial to tympanic membrane which is in congenital). Clinical
presentation usually consists of conductive hearing loss, often with purulent
discharge from the ear
In congenital
• mass medial to the tympanic membrane
• normal tympanic membrane
• no previous history of ear discharge, perforation or ear surgery.
Q: 246
Clincher(s)
A
B
C
D
E
KEY A
Additional
Information
A man has discharge from his left ear after a fight. Where is the discharge
coming from?
a. CSF
b. Inner ear
c. Outer ear
d. Brain
Perforation (likely fracture base of skull during fight)
Due to infection discharge occur
Due to Viral or Bacterial infection
Base of skull fracture ! CSF discharge via ear
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no history of swimming or anything ! because history of swimming means
liquid into the ear ! developing ear infection
Reference
Dr Khalid/Rabia
Patient.co.uk
Ear Discharge & Their Source:
External ear: Inflammation, ie otitis externa produces a scanty watery
discharge, as there are no mucinous glands— Blood can result from trauma to
the canal. Liquid wax can sometimes ‘leak’ out.
• Middle ear: Mucous discharges are almost always due to middle ear
disease.Serosanguinous discharge suggests a granular mucosa of chronic otitis
media. An offensive discharge suggests cholesteatoma.
• CSF otorrhoea: CSF leaks may follow trauma: suspect if you see a halo sign
on filter paper, or its glucose is increased , or Beta2 (tau) transferrin is present.
Q: 324
A man presents with muffled hearing and feeling of pressure in ear with
tinnitus and vertigo. He also complains of double vision when looking to the
right. What is the most appropriate dx?
a. Meniere’s disease
b. Acoustic neuroma
c. Acute labyrinthytis
d. Meningioma
e. Otosclerosis
Clincher(s)
A
B
C
D
E
KEY B
Additional
Information
Muffled hearing, vertigo, tinnitus, double vision
Doesn’t effect vision (right abducens nerve)
Matches with the symptoms of this disease
Problem of inner ear -> vertigo, hearing loss, ringing in ears, nystagmus
All symptoms match Acoustic Neuroma
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ENT-System Wise 1700-by Sush and Team. 2016
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ENT-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal
Reference
Dr Khalid/Rabia
Q. 1. What is the key?
Q. 2. Justify the key.
Ans. 1. The key is B. Acoustic neuroma.
Ans. 2. Hearing loss, feeling of pressure in the ear with tinnitus, vertigo and
involvement of cranial nerve i.e. right abducent nerve are suggestive of
acoustic neuroma.
Q: 342
An 8yo returned from Spain with severe pain in one ear. Exam: pus in auditory
canal, tympanic membrane looks normal. What is the tx option?
a. Gentamicin topical
b. Amoxicillin PO
c. Analgesia
d. Amoxicillin IV
Clincher(s)
A
B
C
D
E
Pus in auditory canal, tympanic membrane normal
Correct answer
Given if pus in tympanic membrane
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KEY A
Additional
Information
Gentamcin Topical
Reference
Dr Khalid/Rabia
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Q: 373
A mentally retarded child puts a green pea in his ear while eating. The
carer confirms this. Otoscopy shows a green colored object in the ear
canal. What is the most appropriate single best approach to remove this
object?
a. By magnet
b. Syringing
c. Under GA
d. By hook
e. By instilling olive oil
Clincher(s)
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia
Q:1300
Pea
Cant remove pea via magnet
May swell up
Best to avoid injury
May push pea deeper
Not useful
Best tactic to avoid injury
A 45yo man has noticed difficulty hearing on the telephone. He is concerned
because his father has been moderately hard of hearing since middle age.
BC=normal. An audiogram showsmoderate hearing loss in both ears across all
frequencies. What is the single most likely
dx?
a. Acoustic neuroma
b. Menieres’ disease
c. Noise induced deafness
d. Otosclerosis
e. Presbyacusis
Clincher(s)
A
B
C
TWO TYPES:
.PTS (Permanent Threshold Shift): the part of the hearing loss subsequent to
an acoustic trauma that will never be recovered. PTS is measured in decibels.
•
•
TTS (Temporary Threshold Shift): the hearing loss that will be recovered
after a couple of days. Also called auditory fatigue. TTS is also measured
in decibels.
SYMPTOM: The first symptom of noise-induced hearing loss is usually
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difficulty hearing a conversation against a noisy background
In addition to hearing loss, other external symptoms of an acoustic trauma can
be:
•
•
•
•
D
E
KEY
Additional
Information
Tinnitus
Some pain in the ear
Hyperacusis
Dizziness or vertigo; in the case of vestibular damages, in the inner-ear
D
Presbycusis is after age of 60 due to degenerative changes..... It's otosclerosis
cox it has strong family history in about 50 to 60 percent of cases....secondly
it's ...bilateral ....negative rinne's test. autosomal dominant
Age - it usually presents between teen years and middle age (typically
between the ages of 15 and 35). However, the average age for having surgery
is rising Positive family history - there is approximately 1/4 risk if one parent is
affected; 1/2 risk if both parents are affected.
Patients may have low-volume speech (enhanced bone conduction leads to
the perception of their own speech as 'loud').
· Schwartze's sign - reddish-blue discolouration over promontory and oval
window niche, due to vascular hyperaemia of immature abnormal bone.
· Tuning fork tests (Rinne's and Weber's tests) reveal conductive pattern
deafness in the majority of cases.
Audiometry is the primary investigation of choice. Bone and air conduction
must be tested and typically reveal a purely conductive
PRESBYCUSIS
· Problems are often first noted in noisy environments; there is usually a slow,
insidious onset of symptoms with gradual progression.
· The ability to understand speech is often the earliest symptom as highfrequency hearing loss predominates. It may be the patient's friends/relatives
who note the problem, rather than the patient.
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· When assessing elderly patients with depression or cognitive impairment,
consider hearing loss as a cause of the symptoms. Tinnitus may be a feature of
Presbyacusis when the hearing impairment becomes marked.
ACOUSTIC NEUROMA
Unilateral hearing loss or tinnitus ,Impaired facial sensation ,Balance problems
Reference
Dr Khalid/Rabia
rabia
Q:1327
A 34yo man has supra-orbital pain and tenderness and developed
tenderness over the maxilla. He also has mild fever. What is the single likely
cause for these symptoms?
a. Acute sinusitis
b. GCA
c. Trigeminal neuralgia
d. Maxillary carcinoma
Clincher(s)
A
B
Supraorbital pain,tenderness on maxilla
The most common symptom of giant cell arteritis (GCA) is a
headache, although some people also experience jaw pain and
vision problems
•
•
•
•
•
mild fever, with a temperature of 37-38C (98.6-100.4F)
extreme tiredness
loss of appetite
weight loss
depression
investigation temporal artery biopsy is gold standard
The management regime consists primarily of systemic corticosteroids
(e.g. prednisolone), commencing at a high dose
Polymyalgia rheumatica
Around half of people with giant cell arteritis also develop a condition
that causes inflammation of the muscles called polymyalgia rheumatica.
If you have giant cell arteritis, you therefore may also have symptoms of
polymyalgia rheumatica, such as shoulder, neck and hip pain, and
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muscle stiffness
C
Trigeminal neuralgia usually only affects one side of your face. In rare
cases it can affect both sides, although not at the same time. The pain
can be in the teeth, the lower jaw, upper jaw, cheek and, less commonly,
in the forehead or the eye
There will be trigerring event like brushing ,vchewing,smiling etc
Dental xray is done to look for any dental infection
An MRI can also sometimes detect whether a blood vessel in your head
is compressing one of the trigeminal nerves, which is one of the main
causes of trigeminal neuralgia.
D
E
KEY
Additional
A
Sinusitis describes an inflammation of the mucous membranes of the
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Information
paranasal sinuses. The sinuses are usually sterile - the most common
infectious agents seen in acute sinusitis are Streptococcus pneumoniae,
Haemophilus influenzae and rhinoviruses.
Predisposing factors include: · nasal obstruction e.g. Septal deviation or
nasal polyps
· recent local infection e.g. Rhinitis or dental extraction
· swimming/diving
· smoking
Features :· facial pain: typically frontal pressure pain which is worse on
bending forward
· nasal discharge: usually thick and purulent
· nasal obstruction: e.g. 'mouth breathing'
· post-nasal drip: may produce chronic cough
Management of acute sinusitis
· analgesia
· intranasal decongestants
· oral antibiotics are not normally required but may be given for severe
Reference
Dr Khalid/Rabia
Q:1328
presentations. Amoxicillin is currently first-line
nhs
rabia
8. A 51yo woman presents with painful tongue and complains of
tiredness. She is pale and has angular stomatitis and a smooth red tongue.
There is no koilonychea. Choose the single cell type you will find on the blood
film.
a. Numerous blast cells
b. Oval macrocytes
c. Spherocytes
d. Microcytic hypochromic
e. Mexican hat cells
f. Erythrocytes
Clincher(s)
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A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
These are the features of vit. b12 and folic acid deficiency. Angular stomatitis is
the
clincher here.
B
Q:1346
An 89yo man presents with carcinoma of posterior oropharynx. Which
is the single most appropriate LN involved?
a. Pre-aortic LN
b. Aortic LN
c. Submental LN
d. Submandibular LN
e. Deep cervical LN
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Ca posterior oropharynx
e
Oropharyngeal Lumphatics >>> Retropharyngeal Ln >> Deep cervical LN
Reference
Dr Khalid/Rabia
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Q:1365
5. A 27yo female who had a RTA 7m back now complaints of attacks of
sudden onset rotational vertigo which comes on with sharp movements of the
head and neck. Which of the following would be most helpful?
a. Caloric testing
b. Hallpikes maneuver
c. Gutenbergers test
d. Meniere’s test
e. Otoscopy
Clincher(s)
A
Sudden onset of rotational vertigo
COWS: PNEUMONIC
To test the function of peripheral vestibular system
•
•
B
C
D
If the water is warm (44°C or above) endolymph in the ipsilateral
horizontal canal rises, causing an increased rate of firing in the
vestibular afferent nerve. This situation mimics a head turn to the
ipsilateral side. Both eyes will turn toward the contralateral ear, with
horizontal nystagmus (quick horizontal eye movements) to the
ipsilateral ear.
If the water is cold, relative to body temperature (30°C or below), the
endolymph falls within the semicircular canal, decreasing the rate of
vestibular afferent firing. The eyes then turn toward the ipsilateral ear,
with horizontal nystagmus to the contralateral ear
Meniere’s disease TESTING
http://www.mayoclinic.org/diseases-conditions/menieresdisease/basics/tests-diagnosis/con-20028251
•
MRI Test
The main TEST is an overall picture or scan, using CAT (Computed
Axial Tomography) or MRI (Magnetic Resonance Imaging). It is done to
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detect any abnormality in the head, specifically the inner ear. Any
abnormality that shows up in this picture can then be evaluated further.
The MRI provides detailed images of the brain in multiple layers without
any blockage by the dense bone/skull.
•
ECOG Test
Transtympanic electrocochleography (ECOG Test) is done to measure
inner ear pressure. The sufferer complains of inner ear congestion or
pressure.
•
ENG Test
Electronystagmography “ENG“. This evaluates the reaction of the
hearing nerve and the eye (optic) nerve to assess predetermined
involuntary reactions. There are two versions of this test: ENG and
Caloric.
•
Audiology Test
Baseline Audiology testing is measured against normal values. Any the
testing will have a specific purpose. Audiometry: “audio” means sound.
So “Audiometry” (measures the sound, ability to hear.) and Audiogram
(plots the sound on a graph) Audiography is another name for
Audiometry.
One other aspect of this hearing is also measured by fluctuating hearing.
That means you can hear at some point, then lose the hearing, then
regain it. And this can happen over a period of time,s
E
KEY
Additional
Information
Dix–Hallpike test. The Dix–Hall pike test — or Nylen–Barany test — is a
diagnostic maneuver used to identify benign paroxysmal positional vertigo
(BPPV).
Benign paroxysmal positional vertigo (BPPV) is one of the most common
causes of vertigo encountered. It is characterised by the sudden onset of
dizziness and vertigo triggered by changes in head position. The average age
of onset is 55 years and it is less common in younger patients.
Features:
vertigo triggered by change in head position (e.g. rolling over in bed or gazing
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upwards) · may be associated with nausea
· each episode typically lasts 10-20 seconds
· positive Dix-Hallpike manoeuvre
BPPV has a good prognosis and usually resolves spontaneously after a few
weeks to months. Symptomatic relief may be gained by:
· Epley manoeuvre (successful in around 80% of cases)
· teaching the patient exercises they can do themselves at home, for example
Brandt-Daroff exercises
Medication is often prescribed (e.g. Betahistine) but it tends to be of limited
value.
Reference
Dr Khalid/Rabia
Q:1374
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
A 2yo girl is brought to the ED by her mother. The child is screaming
that there is something in
her ear and she appears agitated. Exam: a plastic bead is seen inside the
ear. What is the best
method of removal?
a. Forceps
b. Hook
c. Under general anesthesia
d. Syringing
e. Magnet
C as kid is irritable
Presentation
· Most older children and adults will know that there is something in their
ear but sometimes a foreign body may get into the external ear canal
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without the patient realising
The patient may present with pain, deafness or discharge. Live insects may
cause a buzzing in the ear
The appearance will vary according to the object and length of time it has
been in the ear:
· An inanimate object that has been in the ear a very short time presents
with no abnormal finding other than the object itself.
·Pain or bleeding may occur with objects that abrade the ear canal, from
rupture of the tympanic membrane, or from the patient's attempts to
remove the object.
·With delayed presentation, erythema and swelling of the canal and a
foul-smelling discharge may be present.
Management
A great deal of care is required in order not to push the object deeper into
the ear canal and not to damage the ear canal. There is a high failure rate in
removal of foreign bodies from the ear.
Insects should be killed prior to removal, using 2% lidocaine.
· Remove batteries or magnets as soon as possible to prevent corrosion or
burns. Do not crush a battery during removal.
· Adhesives (eg, Super Glue®) may be removed manually within 1-2 days
once desquamation has occurred. Referral to an ear, nose and throat
specialist is required if an adhesive is in contact with the tympanic
membrane.
Methods of removal :
Forceps or hook: grasp the object with forceps, or place a hook behind the
object and pull it out. Irrigation is often effective. Irrigation with water is
contra-indicated for soft objects, organic matter or seeds (which may swell
and increase the level of pain and difficulty to remove if exposed to water).
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Suction with a small catheter held in contact with the object may be affective
Reference
Dr Khalid/Rabia
Q:857
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
857. A 13yo girl complains of a 2d hx of hoarseness of voice a/w dry cough. She
feels feverish. On direct laryngoscopy, her vocal cords are grossly edematous.
What is the single most appropriate inv?
a. None req
b. Sputum for AFB
c. Laryngoscopy
d. Bronchoscopy
e. XR cervical spine
None req
Sputum for AFB- For tuberculosis
Laryngoscopy- already done
Bronchoscopy- Not required
XR cervical spine- Not required
A
Laryngitis: This is often viral and self-limiting, but there may be secondary
infection with streps or staphs. It can also be secondary to GORD (see
above) or autoimmune disease, eg rheumatoid arthritis. NB: in chronic
laryngitis (lasting >3 wks),any bacteria found are likely to be colonizers
only.185 Symptoms: Pain (hypopharyngeal, dysphagia;pain on phonation),
hoarseness; fever. : Supportive.If necessary, give penicillin V 500mg/6h
PO for 1 week. Steam inhalation may help. Chronic cord irritation from
smoking } chronic voice abuse may cause Reinke’s oedema (a gelatinous
fusiform enlargement of the cords, also associated with hypothyroidism—if
conservative treatment fails,laser therapy may help).
Functional disorders of speech articulation: (ie cause unknown). Aphonia:
Phonation yields no response (or a whisper) in seemingly normal cord
adductors, eg in young women at times of stress (NB: there are many
functional voice disorders which may result in laryngeal oedema } nodules.) A
good diff erentiating test is to ask patients to cough (needs functional
adductors).
It is a diagnosis by exclusion, eg allergic reactions may cause sudden aphonia,
so don’t assume a functional disorder without laryngoscopy. Treatment:
Speech therapy is the best, with attention to emotional factors which may be
present. Spasmodic dysphonia: Strained, eff ortful, hoarse voice + tremors,
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jerky voice onset, intermittent voice breaks, breathy spasms, hypernasality,
failure to maintain voice.186 Children with functional speech disorders have
diffi culty with specifi c speech sounds (eg /r/, /s/, /z/, /r/, /l/ and/or ‘th’). Try
to distinguish articulation disorders from phonological delay, consistent and
varying (‘inconsistent’) phonological disorders and speech dyspraxia.
Differential: Before saying ‘no cause can be found’, consider generalized
infiltrating entities of the larynx, such as hyperkeratosis ( smoking, alcohol
abuse, pollution), leukoplakia, also granulomata, papillomata, polyps, and
cysts.
Reference
Dr Khalid/Rabia
Acute laryngitis
• Investigations are rarely helpful in primary care. A swab for
microbiological analysis may be contributory if excessive exudate is
present.
• Clinicians with the skill to perform indirect laryngoscopy will
typically find redness and small dilated vasculature on the inflamed
vocal folds.
Q:874
874. A middle aged man who has had a hx of chronic sinusitis, nasal
obstruction and blood stained nasal discharge. He now presents with cheek
swelling, epiphora, ptosis, diplopia, maxillary pain. What is the single most
likely dx?
a. Nasopharyngeal ca
b. Pharyngeal ca
c. Sinus squamous cell ca
d. Squamous cell laryngeal ca
e. Hypopharyngeal tumor
Clincher(s)
A
Sinusitis, nasal obstruction, blood stained nasal discharge, maxillary pain
Nasopharyngeal ca
B
C
D
E
KEY
Additional
Information
Pharyngeal ca- no nasal symptoms
Sinus Squamous cell ca- Blood-stained nasal discharge and nasal obstruction
Squamous cell laryngeal ca- nasal obstruction
Hypopharyngeal tumor, cheek, nasal, epiphora,
C
Oropharyngeal carcinoma is often advanced at presentation. : ≈5:1.
Histol ogy: 85% are squamous. Typical older patient: Smoker with sore throat,
sensation of a lump, referred otalgia, and local irritation by hot or cold foods,
with risk factors: chewing or smoking tobacco (alcohol alone is not a risk factor
but is synergistic with smoking). 30% of squamous pharyngeal tumours
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will have a 2nd primary within 10yrs. 20% are node +ve at presentation.
Reference
Dr Khalid/Rabia
Q:875
875. A 60yo man with a long hx of smoking and alcohol presents with nasal
obstruction, epistaxis, diplopia, otalgia and conductive deafness. What is the
single most likely dx?
a. Nasopharyngeal ca
b. Pharyngeal ca
c. Sinus squamous cell ca
d. Squamous cell laryngeal ca
e. Hypopharyngeal tumor
Clincher(s)
Smoking, alcohol, nasal obstruction, epistaxis, diplopia, otalgia, conductive
deafness
Nasopharyngeal carcinomaDiplopia, conductive deafness (Eustachian tube affected), cranial nerve palsy
(not I, VII, VIII), nasal obstruction, or neck lumps.
Pharyngeal –no conductive deafness
Sinus squamous cell carcinoma- Blood-stained nasal discharge and nasal
obstruction
Sq laryngeal carcinoma- Typical older patient: Male smoker with progressive
hoarseness, then stridor, difficulty or pain on swallowing} haemoptysis ear
pain (if pharynx involved). Regular cannabis users are at risk.
Typical younger patient: HPV +ve.1
Sites: Supraglottic, glottic, or subglottic. Glottic tumours have the best
prognosis as they cause hoarseness earlier (spread to nodes is late).
Hypopharyngeal tumor- lump in throat, dysphagia for solids then fl uids, or as
neck lumps.
A
Sinus squamous cell cancer (~1% of all tumours)
Typical patient: Middle aged or elderly. Suspect when chronic sinusitis
presents for the first time in later life.
Early signs: Blood-stained nasal discharge and nasal obstruction.
A
B
C
D
E
KEY
Additional
Information
Later: Cheek swelling, swelling or ulcers of the buccoalveolar plate or palate,
epiphora due to a blocked nasolacrimal duct, ptosis and diplopia as the floor of
the orbit is involved, and pain in maxillary division of the trigeminal nerve.
Local spread may be to cheek, palate, nasal cavity, orbit, and pterygopalatine
fossa. Patients present late because epistaxis, obstruction and
headache only occur with large tumours. Images: MRI/CT endoscopy (with
biopsy) is best. NB: coronal CT is needed to show bone erosion (esp. around
the cribriform plate).
Differential histology: Squamous cell (50%), lymphoma (10%),
adenocarcinoma, adenoid cystic carcinoma, olfactory neuroblastoma,
or chondrosarcoma, benign tumours.2 Treatment: Radiotherapy } radical
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surgery.
5-yr and 10-yr overall survival rates are 77% and 66% respectively
Squamous cell laryngeal cancer ( Incidence: 2000/yr (UK).
Typical older patient: Male smoker with progressive hoarseness, then stridor,
difficulty or pain on swallowing} haemoptysis ear pain (if pharynx involved).
Regular cannabis users are at risk.
Typical younger patient: HPV +ve.1
Sites: Supraglottic, glottic, or subglottic. Glottic tumours have the best
prognosis as they cause hoarseness earlier (spread to nodes is late).
Diagnosis:
Laryngoscopy +biopsy. HPV status; MRI staging: Radical radiotherapy (eg
IMRT above) or total laryngectomy.
Nasopharyngeal cancer 25% of all cancers in China vs 1% in UK. Associations:
• HLA A2 allele survival with B17 & BW46) • HPV 1 • Epstein–Barr
(EBV) • Tobacco, formaldehyde, wood dust exposure • Weaning on to salted fi
sh (?N-nitroso carcinogens).
Signs: Diplopia, conductive deafness (Eustachian tube affected), cranial nerve
palsy (not I, VII, VIII), nasal obstruction, or neck lumps. Endoscopy/biopsy; PCR
for EBV. NB: submucosal spread may mean the area looks normal.
Oropharyngeal carcinoma is often advanced at presentation. ≈5:1.
Histology: 85% are squamous.
Typical older patient: Smoker with sore throat, sensation of a lump, referred
otalgia, and local irritation by hot or cold foods, with risk factors: chewing or
smoking tobacco (alcohol alone is not a risk factor but is synergistic with
smoking). 30% of squamous pharyngeal tumours will have a 2nd primary
within 10yrs. 20% are node +ve at presentation.
Hypopharyngeal tumours are rare and are usually a disease of the elderly.
They can present as a lump in throat, dysphagia for solids then fl uids, or as
neck lumps. The anatomic limits of the hypopharynx are the hyoid bone to
the lower edge of the cricoid cartilage: the 3 main sites are piriform fossa post
cricoid region, and the posterior pharyngeal wall. Note premalignant
conditions: leuko plakia and Patterson–Kelly–Brown syndrome (Plummer–
Vinson)—in which a pharyngeal web is associated with iron defi ciency, angular
stomatitis, glossitis, and koilonychia: 2% risk postcricoid cancer. They are
associated with previous irradiation, smoking and alcohol, but not as clearly as
laryngeal carcinoma. Treatment options are radiotherapy and surgery in
various combinations. The prognosis is poor with 60% mortality at 1 year.
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Reference
Dr Khalid/Rabia
Q:882
882. A 34yo man had a cold 2d back. He now presents with right sided facial
pain. What is the single most likely dx?
a. Maxillary sinus
b. Ethmoid sinus
c. Septal hematoma
d. Septal abscess
e. Allergic rhinitis
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Cold, right sided facial pain
Maxillary sinus
Ethmoid Sinus
Septal Hematoma (infection> hematoma>absecess)
Septal Abscess
Allergic Rhinitis
A
Key : a
Clincher : age, h/o cold, facial pain
Ethmoid sinus ... it is more common in children
Septal hematoma ... collection of blood within the septum of the nose, it
doesnt cause facial pain
Septal abcess ... a serious condition that is caused by bacteria. Trauma to the
nose, or even nasal surgery, can leave the patient prone to develop a nasal
abscess, which is basically a pocket filled with blood (haematoma) which has
become affected by bacteria. Symptoms include nasal blockage, pain, redness
over the nasal bridge, difficulty in breathing and fever.
Allergic rhinitis ... doesnt cause facial pain
MAXILLARY SINUS (source : patient.co.uk)
The sinuses are small, air-filled spaces inside the cheekbones and forehead.
They make some mucus which drains into the nose through small channels.
Sinusitis means inflammation of a sinus. Most bouts of sinusitis are caused by
an infection. The cheekbone (maxillary) sinuses are the most commonly
affected.
Acute sinusitis means that the infection develops quickly (over a few days) and
lasts a short time. Many cases of acute sinusitis last a week or so but it is not
unusual for it to last 2-3 weeks.
Chronic sinusitis means that a sinusitis becomes persistent and lasts for longer
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than 12 weeks. Chronic sinusitis is uncommon.
Risk factors :
Cold/flu
Dental infection
Allergic rhinitis
Nasal polyp
Facial injury or surgery
Foreign body
Smoking
Asthma
Pregnancy
Poor immune system
Symptoms :
The most typical symptoms are headache and pain in the face, with the latter
increasing when the patient bends down, lifts something, coughs etc., that is,
when pressure increases in the sinuses. In case of acute maxillary sinusitis pain
is much stronger than in the case of the chronic type.
Blocked/runny nose
Toothache
Fever
Headache
Cough
Tiredness
Treatment :
Antibiotics are needed only :If your symptoms are severe or if you are very
unwell.If you have another illness such as cystic fibrosis, heart problems or a
weakened immune system.If your symptoms are not settling within seven
days, or are worsening.
Treatment to relieve symptoms :
Painkillers
Decongestant nasal spray or drop
Keeping hydrated
Warm face packs
Saline nasal drops
Steam inhalation
Q:1017
A 20yo woman with no prv hx of ear complains, presents with 1d hx of severe
pain in the right ear which is extremely tender to examine. What is the single
most likely dx?
a. Chondromalasia
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b. Furuncle
c. Myringitis
d. OE
e. OM
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
No prv hx , I day hx, severe pain ear, teder
Chondromalacia
Furuncle
Myringitis
OE
OM
D
Chondrodermatitis nodularis chronica helicis et antihelicis This Latin
describes an exquisitely tender cartilaginous infl amed nodule dwelling on the
upper helix or antihelix (fi g 2). A more convenient name is Winkler’s
disease. It is commoner in men who work outdoors. Causes: ?poor blood fl ow
(avascular chondritis) from pressure (eg phone addicts) or vasoconstriction
from cold. A pressure-relieving prosthesis may help.If not, excise skin and
underlying cartilage (eg ‘wide excision’ or ‘deep shave’).
Furunculosis This is a very painful staphylococcal abscess arising in a hair
follicle. Pathologically it is identical to a boil anywhere else; if there is cellulitis
consider fl ucloxacillin. Diabetes is an important predisposing factor
Bullous myringitis These are very painful haemorrhagic blisters on deep
meatal skin and on the drum ( } serosanginous fl uid behind it). Classically
associated with infl uenza infection, but Mycoplasma pneumoniae has also
been implicated as have a variety of other organisms. It may simply represent
a variant of acute otitis media. Sensorineural hearing loss is much more
frequent than previously thought. Treatment is generally supportive only, eg
pain relief; oral antibiotics can be considered in cases with middle ear eff
usions.
Barotrauma (aerotitis) If the Eustachian tube is occluded, middle ear pressure
cannot be equalized during descent in an aircraft or diving, so causing
damage. Risk factors: Conditions inhibiting function of the Eustachian tube eg
infl ammation/infection. Symptoms: Severe pain as the drum becomes
indrawn,eg from transudation or bleeding into middle ear. Barotrauma to the
inner ear causes vertigo, tinnitus, and deafness. Prevention: Not fl ying with a
URTI, decongestants into the nose (eg xylometazoline every 20min), repeated
yawns, swallows/jaw movements. Infl ating an OtoventR device is eff ective (it
is recommended to air passengers with problems clearing the ears.)29 Positive
pressure (higher than Eustachian tube resistance) through mask to the
nasopharynx can also help.30 : Supportive if simple barotrauma; eff usions
usually clear spontaneously, and most perforations heal.
Otitis externa (OE) Minimal discharge, itch, pain and tragal tenderness due to
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an acute infl ammation of the skin of the meatus, eg caused by moisture
(swimming),trauma eg fi ngernails (a consequence from conditions causing
itch, eg eczema/ psoriasis), high humidity, an absence of wax, a narrow ear
canal, and hearing aids.28 Pseudomonas is the chief organism involved, though
Staphylococcus aureus is another common off ender. Hearing loss and canal
stenosis (making hearing aids diffi cult to wear) can be sequelae. : Contact
eczema (fi g 1).
Aural toilet is the key to treatment. If severe, the meatus is narrowed. A thin
Pope wick can be inserted and hydrated with eardrops, eg SofradexR
(framycetin + dexametasone). An alternative is a strip of ribbon gauze soaked
in ichthammol glycerine (very soothing) or aluminium acetate (astringent).
After a few days, the meatus will open up enough for either microsuction or
carefulcleansing with cotton wool. Commercial QtipsR or cotton buds
shouldn’t beused: they are too large; instead thin out or make one yourself by
wrapping a small piece of cotton wool gently around an orange stick. Use
drops only short-term, as troublesome fungal infections can arise. Nonspecialists should not syringe the ear.
Beware persistent unilateral otitis externa in diabetics/immunosuppressed/
the elderly: the risk is malignant/necrotizing otitis externa .
OE which is resistant to treatment can be a sign of malignancy. Do biopsy.
Reference
Dr Khalid/Rabia
Ans: D
Reason : Acute Otitis Externa
his produces a similar temperature and lymphadenopathy. Swelling is more
diffuse and pain is variable with possible pruritus. Moving the ear or jaw is
painful. The canal, external ear, or both, are red, swollen, or eczematous, with
shedding of the scaly skin. There may be little,but thick, discharge in the acute
stage but it can become bloody if chronic. Hearing is often impaired
Management:
clean ear canal, keep it dry,
Acetic acid 2% ear drops can be very effective against both bacterial and fungal
infection
Antibiotic drops may be used if infection is present. These are often given in
combination with steroids
Q:1025
1025. A 34yo man was slapped over his right ear in a fight. There is blood
coming from his external auditory canal and he has pain, deafness and ringing
in his ears. What is the most appropriate initial inv?
a. CT
b. MRI
c. Otoscopy
d. Skull XR
e. Facial XR
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Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
C
Ans: C
Reason : traumatic perforation of the tympanic membrane can causes
pain,bleeding,hearing loss,tinnitus and vertigo. Diagnosis is based on otoscopy
,treatment often is unnecessary.
Traumatic causes of preparation include
Insertion of objects
Concussion caused by an explosion or open handed slap across the ear
Head trauma with or without Mozilla fracture
Sudden negative pressure
Barotrauma
Diagnosis: otoscopy , audiometry
Management: often no treatment required ,for dirty injuries prescribe
antibiotics amoxicillin 500 mg tid 8 days.most perforation close spontaneously
,those persisting more than 2 months require surgery
Q:1091
A 41yo man presents with long standing foul smelling ear discharge and
progressive hearing loss. Otoscopy showed perforation of the pars flaccida and
a mass in the upper part of the middle ear. What is the most likely dx?
a. ASOM
b. CSOM
c. Acquired cholesteatoma
d. Congenital cholesteatoma
e. BarotrauMA
Clincher(s)
41 year,foul smelling ear discharge and mass,perforation of tympanic
membrane
A
B
C
Mass in the ear excludes ASOM and CSOM
Otoscopic findings of perforation and mass point towards acquired
choleastoma which can also be a complication of asom.
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D
E
KEY
Additional
Information
C
.Secondary acquired cholesteatoma This arises as a result of insult to
the tympanic membrane, such as perforation secondary to acute otitis
media or trauma, or due to surgical manipulation of the drum. Squamous
epithelium may be inadvertently implanted by the insult so triggering the
process of cellular growth resulting in cholesteatoma formation.
* Frequent or unremitting painless otorrhoea which may be foul-smelling.
* Recurrent otitis, poorly responsive to antibiotic treatment.
* Progressive, unilateral conductive hearing loss.
* Tympanic membrane perforation (~90% of cases) or retracted
tympanum.
* The only finding may be a pusfilled canal with granulation tissue
CT imaging is the investigation of choice if there is a need for
assessment of the extent of the lesion and to assess subtle bony
defects.
Treatment
Surgery:
Open technique: tympanomastoidectomy
Closed technique : tympanoplasty
Reference
Dr Khalid/Rabia
Q.1093(HEMA)
A young boy has a hx of epistaxis. CBC=normal, except APTT=47s. What is the
most likely dx?
a.Hemophilia
b.ITP
c.Sickle cell
d.HUS
e.Thalassaem
Clincher(s)
A
Epistaxis and raised APTT
Epistaxis and prolonged APTT point toward intrinsic pathway defect ,
B
C
D
E
KEY
Additional
Information
Normal CBC excludes all other options
A
Hemophilia A IS A FACTOR 8 Deficiency inherited in a x linked recessive
pattern.
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Presentation early in life or after trauma/surgery. Bleeding into joints leading to
crippling
arthropathies and muscle causing hematomas with nerve compression and
compartment syndrome. Diagnosed by inc APTT and dec factor 8 assay.
Treatment with
desmopressin which inc factor 8 levels and recombinant factor 8 in major or
life threatening bleeds.
Hemophilia B is a similar condition arising due to deficiency of factor 9. Also
inherited in
x linked recessive pattern. Behaves clinically like hemophilia A.
Reference
Dr Khalid/Rabia
Q:1096
A 52 yo male with poorly controlled DM has now presented to his GP with pain
in the ear. Exam: skin around the ear is black in color and there was foul
smelling discharge from the ear. Pt also had conductive hearing loss. What is
the most probable dx?
a. Carbuncle
b. Folliculitis
c. Malignant OE
d. Cholesteatoma
e. Furuncle
Clincher(s)
Poorly controlled diabetes,black discolouration of skin around ear,foul
smelling discharge
Carbuncles are clusters of furuncles connected subcutaneously, causing deeper
suppuration and scarring. They are smaller and more superficial than
subcutaneous abscesses
A
B
C
D
E
KEY
Additional
Information
this is small with severe pain in the ear and local swelling of the canal.
Pyrexia is moderate (less than 38°C). There may be posterior auricular
lymphadenopathy. Examination with an auriscope can be very painful. If the
lesion bursts there is sudden relief of pain.
C
Necrotising or malignant otitis externa
This is rare but is a life-threatening extension of otitis externa into the
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mastoid and temporal bones. It is usually due to Pseudomonas aeruginosa
or S. aureus. It usually affects elderly patients with diabetes or patients
who are immunocompromised. It produces pain and headache of greater
intensity than clinical signs would suggest. Facial nerve palsy is a red flag
sign but is not necessarily associated with a poorer prognosis.[5] Obligatory
criteria for diagnosis include:[6]
•
•
•
•
•
•
Pain
Oedema
Exudate
Granulation tissue (may be present at the junction of bone and
cartilage)
Microabscess (when operated upon)
A positive bone scan or failure of local treatment and possibly
Pseudomonas spp. in culture
The occasional criteria are:
•
•
•
•
•
Diabetes
Cranial nerve involvement
A positive radiograph
A debilitating condition
Old age
Reference
Dr Khalid/Rabia
Patient.info
Q:1154
1154. A 10yo child has got progressive bilateral hearing loss. He has started to
increase the TV volume. All other examination is normal. What is the most
likely dx?
a. Wax
b. Foreign body
c. Bilateral OM with effusion
d. SNHL
e. Meningitis due to meningococcus
Clincher(s)
A
B
10yr old,progressive bilateral hearing loss
Wax would have been found on examination(normal examination)
Normal examination excludes forign body(forign body can’t be present in both
ears)
Fluctuating conductive hearing loss nearly always occurs with all types of otitis
media. In fact it is the most common cause of hearing loss in young children.
C
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D
E
KEY
Additional
Information
No history of meningitis(hearing loss is complication of meningitis).
C
Otitis media is an inflammation in the middle ear (the area behind the
eardrum) that is usually associated with the buildup of fluid. The fluid
may or may not be infected.Symptoms, severity, frequency, and length of the condition vary. At one
extreme is a single short period of thin, clear, noninfected fluid without any pain or fever but with a slight decrease
in hearing ability. At the other extreme are repeated bouts with infection,
thick "glue-like" fluid and possible complications such as permanent
hearing loss.-Fluctuating conductive hearing loss nearly always occurs
with all types of otitis media. In fact it is the most common cause of
hearing loss in young children.
Reference
Dr Khalid/Rabia
Q:1165
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
A 2d baby’s mother is worried about the baby’s hearing. Mother has a hx of
conductive hearing loss. What is the most appropriate test?
a. Brain stem evoked response
b. CT
c. Fork test
d. MRI
e. Reassure
Auditory brainstem response (ABR) technology is used in testing newborns.
Approximately 1 of every 1000 children is born deaf; many more are born with
less severe degrees of hearing impairment, while others may acquire hearing
loss during early childhood.
A
Audiologicalbrainstem responses (ABR): The ears are covered with
earphones that emit
a series of soft clicks. Electrodes on the infant’s forehead and neck
measure brain
wave activity in response to the clicks. ABR tests the auditory pathway
from the
external ear to the lower brainstem.used as a screening test in newborns.
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.
Reference
Dr Khalid/Rabia
Ohcs
Q:1299
A 16yo boy presents with acute pain in the right ear and little bleeding from
the
same ear. He had been in a boxing match and had sustained a blow to the ear.
There is little amount of blood in the auditory canal and a small perforation of
the eardrum. What is the most appropriatemanagement?
a. Admission for parental
antibiotics
b. Nasal decongestant
c. Oral amoxicillin
d. OPD review
e. Packing of ear
f. Surgical intervention
g. Syringing EN
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Pain and bleeding from ear after being hit in a boxing match
Risk of infection due to bleeding
C- or skype: OPD reiew? No treatment?
A torn (perforated) eardrum will usually heal by itself within -8 weeks. It
is a skin-like structure and, like skin that is cut, it will usually heal. In
some cases, a doctor may prescribe antibiotic medicines if there is an
infection or risk of infection developing in the middle ear whilst the
eardrum is healing.
Management•no treatment is needed in the majority of cases as the
tympanic membrane will usually heal after 6-8 weeks. It is advisable to
avoid getting water in the ear during this time•
it is common practice to prescribe antibiotics to perforations which occur
following an episode of acute otitis media. myringoplasty may b may be
performed if the tympanic membrane does not heal by itself.
Reference
Dr Khalid/Rabia
Q:
Clincher(s)
A
34
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B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q: 1545
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
A 19yo man with known hx of OM presents with headache, lethargy,
sweating and shivering. What is the single most likely dx?
a. Furuncle
b. Meningitis
c. Myringitis
d. Nasopharyngeal tumor
e. OM
Painful staphylococcal abscess arising in a hair follicle
Myringitis is a form of acute otitis media in which vesicles develop on
the tympanic membrane. Myringitis can develop with viral, bacterial
(particularly Streptococcus pneumoniae), or mycoplasmal otitis media.
• A lump or growth anywhere in the neck area that does not go
away after 3 weeks (this may be the only sign you have)
• Hearing loss – usually on one side only
• Tinnitus
• Fluid collection in the ear
• Blocked or stuffy nose – particularly if only blocked on one side
• Blood stained discharge from the nose
• Headache
• Double vision
• Numbness of the lower part of your face
• Difficulty with swallowing
• Changes in voice – such as hoarseness
b
Intracranial and extracranial complications of acute and chronic otitis
media are possible. A discussion of the diagnosis and management of
these complications is the focus of this article. (See the image below.)[2]
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Healthy tympanic
membrane.
Spread of infection from the ear and temporal bone causes intracranial
complications of otitis media. Spread of infection occurs through 3
routes, namely, direct extension, thrombophlebitis, and hematogenous
dissemination. Extracranial complications are usually direct sequelae of
localized acute or chronic inflammation.The complications of otitis media
include the following:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Reference
Dr Khalid/Rabia
Chronic suppurative otitis media [3, 4]
Postauricular abscess
Facial nerve paresis
Labyrinthitis
Labyrinthine fistula
Mastoiditis
Temporal abscess
Petrositis
Intracranial abscess
Meningitis
Otitic hydrocephalus
Sigmoid sinus thrombosis
Encephalocele
Cerebrospinal fluid (CSF) leak
Ohcs, wikepedia, cancer research.org
A very rare and serious complication of OM is meningitis. This can occur
if the infection spreads to the protective outer layer of the brain and
spinal chord (the meninges).
Symptoms of meningitis can include:
severe headache
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being sick
a high temperature (fever)
stiff neck
sensitivity to light
rapid breathing
AOM is seen frequently in children but is less common in adults.
Smoking is a risk factor. Om occurs more commonly in winters.
Complications of AOM:
Infra-temporal infections can include:
Tympanic membrane perforation.
Mastoiditis.
Facial nerve palsy.
Acute labyrinthitis.
Petrositis.
Acute necrotic otitis.
Chronic otitis media.
Intracranial infections can include:
Meningitis.
Encephalitis.
Brain abscess.
Otitic hydrocephalus (hydrocephalus associated with AOM, usually
accompanied by lateral sinus thrombosis but the exact pathophysiology
is unclear).
Subarachnoid abscess.
Subdural abscess.
Sigmoid sinus thrombosis.
Rarely, systemic complications can occur, including bacteraemia, septic
arthritis and bacterial endocarditis.
Q: 1555
A 40yo woman on chemotherapy for metastatic breast carcinoma now
presents with painful swallowing. Exam: she has white plaques on top of
friable mucosa in her mouth and more seen on esophagoscopy. What is
the most effective tx for this pt?
a. Antispasmodic
b. H2 blocker
c. Antibiotics
d. Antifungals
e. I&D
Clincher(s)
A
On chemotherapy, painful swallowing, white plaques in mouth
Not required
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B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
----Anti fungal for oral and esophageal candidiasis
--d
Q: 1581
. A 35yo woman presents with a swelling in the neck. The swelling has
increased in size gradually over the last two years and the patient feels
she has difficulty with breathing. Exam: mass measures 8cm by 10 cm,
soft and not warm to touch. It moves with deglutition. Which is the most
appropriate management of this mass?
a. Partial thyroidectomy
b. Oral thyroxine
c. Oral propylthiouracil
d. Excision biopsy
Clincher(s)
Soft swelling in neck, difficulty breathing, moves with deglutition – thyroid
swelling.
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Ohcm 533
The immunocompromised state, location of infection, gross picture all
point to Esophageal Candidiasis which is treated with antifungals. The
treatment of choice is Fluconazole 400mg STAT, then 200mg per day
PO.
Discussion:
* Candidal infection is the most common cause of invasive fungal
infections in hospital patients.
* Dysphagia, retrosternal discomfort.
* Fluconazole 50-100mg PO x 24hourly for 7-14 days.
* If invasive, fluconazole 400mg/day. Side effects nausea, raised LFTs,
thrombocytopenia.
* Severe systemic infection, amphotericin B.
Given in hypothyroidism
Anti thyroid
Soft swelling, unlikely tom be CA
A
The mass is large and obviously arising from the thyroid. The fact that it
is causing difficulty breathing would indicate a thyroidectomy. Thyroxine
would be given in hypothyroidism, PTU is given as an antithyroid drug
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and excision biopsy is undertaken if CA is suspected which isn’t the
case here as the swelling is not hot. The mass is also soft which doesn’t
go towards CA.
Discussion: Surgery is indicated in simple goitre if:
* There is clinical or radiological evidence of compression of surrounding
structures, especially the trachea.
* There are substernal goitres, which are best removed surgically, as
biopsy is difficult and clinical observation without frequent CT or MRI
scans is impossible.
* The goitre continues to grow.
* There are cosmetic reasons - for example, large or unsightly.
Types of thyroid operations:
* Thyroid lobectomy to remove a nodule (solitary hot or cold nodules)
and goitres that occur in one lobe.
* Partial thyroid lobectomy to remove a solitary nodule in one specific
part of the thyroid.
* Thyroid lobectomy with isthmectomy for benign Hürthle cell tumours
and for non-aggressive thyroid cancers.
* Subtotal thyroidectomy (leaving enough of the gland to produce some
hormones) is now little used and has been replaced by total
thyroidectomy or thyroid lobectomy alone.
* Total thyroidectomy for thyroid cancers, Hürthle cell tumours and also
increasingly for multinodular goitres and patients with Graves' disease.
Robotic surgery: advantages include three-dimensional imaging and
tremor elimination. Robotic thyroid surgeries include thyroid lobectomy,
total thyroidectomy, central compartment neck dissection, and radical
neck dissection for benign and malignant thyroid diseases.
Thyroid surgery is safe in the elderly, assuming careful preoperative
evaluation and risk stratification.
Complications:
Possible complications following thyroid surgery include:
* Minor complications such as collections of serous fluid (they resolve
spontaneously if small and asymptomatic but may require single or
repeated aspiration if large) and poor scar formation.
* Bleeding, which may cause tracheal compression.
* Recurrent laryngeal nerve injury:
o Innervates all of the intrinsic muscles of the larynx, except the
cricothyroid muscle.
o Patients with unilateral vocal fold paralysis present with postoperative
hoarseness.
o Presentation is often subacute and voice changes may not present for
days or weeks.
o Unilateral paralysis may resolve spontaneously.
o Bilateral vocal fold paralysis may occur following a total thyroidectomy
and usually presents immediately after extubation.
o Both vocal folds remain in the paramedian position, causing partial
airway obstruction. * Hypoparathyroidism: the resulting hypocalcaemia
may be permanent but is usually transient. The cause of transient
hypocalcaemia postoperatively is not clearly understood. * Thyrotoxic
storm: is an unusual complication of surgery but is potentially lethal.
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* Superior laryngeal nerve injury:
o The external branch provides motor function to the cricothyroid
muscle.
o Trauma to the nerve results in an inability to lengthen a vocal fold and
thus to create a higher-pitched sound.
o The external branch is probably the most commonly injured nerve in
thyroid surgery.
o Most patients do not notice any change but the problem may be
career-ending for a professional singer.
* Infection: occurs in 1-2% of all cases. Peri-operative antibiotics are not
recommended for thyroid surgery. * Hypothyroidism.
* Damage to the sympathetic trunk may occur but is rare.
Q: 1617
A 38yo man has just returned from a holiday where he went swimming
everyday. For the last few days he has had irritation in both ears. Now
his right ear is hot, red, swollen and acutely
painful. What is the single most likely dx?
a. Foreign body
b. Impacted earwax
c. OE
d. OM
e. Perforation of eardrum
Clincher(s)
A
B
C
D
E
KEY
Holiday, swimming history, irritation acutely painful inflamed ear
Additional
Information
Reference
Dr Khalid/Rabia
Otitis Externa (C)
The swimming history, irritation in both ears and ear being hot, red,
swollen and painful indicates inflammation of the external acoustic
meatus called Otitis Externa. It isn’t otitis media because of the lack of
Tympanic membrane signs, perforated eardrum would present with just
pain and deafness, impacted earwax would also present with pain and
conductive deafness. Foreign body would have history of something
being used near or inside the ear and would be seen on examination of
the ear canal.
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Q: 1653
A pt has loss of sensation on the tip of her tongue and the inner aspect
of the lip. Which nerve is
most likely to be involved?
a. Vagus nerve
b. Glossopharyngeal nerve
c. Lingual nerve
d. Buccal nerve
e. Facial nerve
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Nerve supply for the tip of tongue and inner lip
C: Lingual Nerve
a. Vagus nerve: It leaves the skull through the jugular foramen,
passes within the carotid sheath in the neck, through the thorax
supplying the lungs, and continues on via the oesophageal
opening to supply the abdominal organs.
b. Glossopharyngeal nerve: Passes across the posterior fossa,
through the jugular foramen and into the neck, supplying tonsil,
palate and posterior third of tongue.
c. Lingual nerve: lingual nerve is a branch of the mandibular
division of the trigeminal nerve (CN V3), which supplies sensory
innervation to thetongue. It also carries fibers from the facial nerve,
which return taste information from the anterior two thirds of the
tongue, via thechorda tympani
d. Buccal nerve:brach of mandibular division of trigeminal nerve,
supplies the skin and mucous membrane of the cheek
e. Facial nerve: Mainly motor (some sensory fibres from external
acoustic meatus, fibres controlling salivation and taste fibres from
the anterior tongue).
Q:
Clincher(s)
A
B
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ENT-System Wise 1700-by Sush and Team. 2016
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C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:
Clincher(s)
A
B
C
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D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:
Clincher(s)
A
B
C
D
503
A 26yo woman has become aware of increasing right sided hearing deficiency
since her recent pregnancy. Her eardrums are normal. Her hearing tests show:
BC-normal. Weber test lateralizes to the right ear. What is the single most
likely dx?
a. Encephalopathy
b. Functional hearing loss
c. Tympano-sclerosis
d. Otosclerosis
e. Sensorineural deafness
Hearing def after her pregnancy and BC normal with Webber test lateralise
to right ear
occurs when the functioning of the ears is normal, but the person is showing a
reduced response or not responding at all to sounds. Because there are no
functional hearing problems in individuals with functional hearing loss, it is the
most difficult type of hearing loss to detect and the most often misdiagnosed.
Functional hearing loss is caused by mental health problems, such as ADHD
and depression.
Ear drums are normal so that's why it's not tympani sclerosis
Most common in females in pregnancy, during me trial cycles and
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E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
menopause.
BC will not be normal and Webber will lateralise to the normal ear.
D
In otosclerosis the hearing gets better in background noises whereas in
presbycusis which is gradual deterioration of hearing with age due to noise
toxicity the hearing gets worse in background noises.
Otosclerosis is a conductive deafness whereas presbycusis is a SNHL
There are no features of encephalopathy.
As Weber test is lateralized it is unlikely to be functional hearing loss
. In tympanosclerosis ear drum becomes chalky white. So as the ear drum is
normal it is not tympanosclerosis.
Weber test is lateralized to right and deafness is also on the right. So it not
sensorineural deafness but conductive deafness which makes otosclerosis as
the most likely diagnosis.
Rinne's test
· air conduction (AC) is normally better than bone conduction (BC)
· if BC > AC then conductive deafness
Weber's test
· in unilateral sensorineural deafness, sound is localised to the unaffected side
· in unilateral conductive deafness, sound is localised to the affected side
Q:544
A 52yo man whose voice became hoarse following thyroid surgery 1 wk ago
shows no improvement. Which anatomical site is most likely affected?
a. Bilateral recurrent laryngeal nerve
b. Unilateral recurrent laryngeal nerve
c. Unilateral external laryngeal nerve
d. Bilateral external laryngeal nerve
e. Vocal cords
Clincher(s)
A
Hoarseness of voice after thyroid surgery and no improvement
In bilateral paralysis, both cords generally fixed midway and presents with
aphonia. The airway, however, is inadequate, resulting in stridor and dyspnea
with moderate exertion as each cord is drawn to the midline glottis by an
inspiratory Bernoulli effect. Aspiration is also a danger.
In unilateral paralysis, the voice may be hoarse and breathy, but the airway is
usually not obstructed because the normal cord abducts sufficiently and fixed
in the midline.
The ability to produce pitched sounds is then impaired along with easy voice
fatigability, (usually mono-toned voice). Inability to make explosive sounds due
to paralysis of crick thyroid muscle.
Bilateral palsy presents as a tiring and hoarse voice.
B
C
D
E
KEY
B
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Additional
Information
In unilateral vocal cord paralysis, hoarseness or breathlessness may not
manifest for days to weeks; other potential sequelae are dysphagia and
aspiration
Bilateral vocal-fold paralysis usually manifests immediately after extubation;
patients may present with biphasic stridor, respiratory distress, or both
Reference
Dr Khalid/Rabia
bilateral injury of the RLN leads to aphonia.
In unilateral damage, the patient voice is still preserved but it's harsh ( hoarse )
due to unilateral paralysis of the vocal cords.
Direct injury to the vocal cords is unlikely in thyroid procedures since the
larynx isn't opened.
The external laryngeal nerves are more frequently damaged than the RLN , but
they cause only minor changes in voice quality ( pitch changes).
Bilateral rln palsy will cause emergency airway obstruction and stridor
Vocal cord inj should be transient and improving
External laryngeal inj doesnt cause hoarseness
B due to close relation of the inferior thyroid artery to the recurrent laryngeal
nerve the clamping of artery during surgery might accidentally injured the
nerve causing hoarseness of voice if bilaterally affected the nerve it will most
likely causing acute respiratory distress
Q:559
A 10yo girl has been referred for assessment of hearing as she is finding
difficulty
in hearing her teacher in the class. Her hearing tests show: BC normal,
symmetrical AC threshold reduced bilaterally, weber test shows no
lateralization. What is the single most likely dx?
a. Chronic perforation of tympanic membrane
b. Chronic secretory OM with effusion
c. Congenital sensorineural deficit
d. Otosclerosis
e. Presbycusis
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Hearing difficulty bilaterally and conductive deafness.
Mainly unilateral
Common cause of hearing problems in children
Webber is normal so it's not possible.
Common in females during pregnancy, mensturation and menopause.
Hearing loss with increasing age. Weber test is normal
B
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Reference
Dr Khalid/Rabia
B/L conductive deafness
glue ear/ OM e effusion
Bc normal means no sn deafness .. there is conductive deafness .. otosclerosis
has cd but it usually appears in 3rd decade of life n associated with tinnitus ..
perforation on both sides is uncommon .. so we're left with
csom with effusion which is most common cause of cd in school going age
Glue Ear/ otitis media with effusion: recurrent ear infections, poor speech
development, and failing
performances at school, typically in children between the ages of 2 and
decreasing with advancement of
age.. .Causes conductive hearing loss.
The clincher also is 'child finding difficulty in hearing in classroom/turning up
the volume of Tv'
Chronic suppurative otitis media (CSOM) is a chronic inflammation of the
middle ear and mastoid cavity.
Clinical features are recurrent otorrhoea through a tympanic perforation, with
conductive hearing loss of varying severity.
· CSOM presents with a chronically draining ear (>2 weeks), with a possible
history of recurrent AOM, traumatic perforation, or insertion of grommets.
· The otorrhea should occur without otalgia or fever.
· Fever, vertigo and otalgia should prompt urgent referral to exclude
intratemporal or intracranial complications.
· Hearing loss is common in the affected ear
Treatment options include:
· grommet insertion - to allow air to pass through into the middle ear and
hence do the job normally done by the Eustachian tube. The majority stop
functioning after about 10 months
· adenoidectomy
Q:560
A thin 18yo girl has bilateral parotid swelling with thickened calluses on the
dorsum of her hand. What is the single most likely dx?
a. Bulimia nervosa
b. C1 esterase deficiency
c. Crohn’s disease
d. Mumps
e. Sarcoidosis
Clincher(s)
Thin girl with bilateral parotid swelling and thick calluses on the dorsal of her
hand.
A
B
Hereditary angioedema (HAE) is a rare, autosomal dominantly inherited blood
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C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
disorder that causes episodic attacks of swelling that may affect the face,
extremities, genitals, gastrointestinal tract and upper airways.
Swellings of the intestinal mucosa may lead to vomiting and painful, colic-like
intestinal spasms that may mimic intestinal obstruction.
Acquired angioedema present in the fourth decade.
Irrelevant here
No signs of infection.
Not the case.
A
Bulimia nervosa Presentation :
· The history often dates back to adolescence.
o Regular binge eating.
o Attempts to counteract the binges - eg, vomiting, using laxatives, diuretics,
dietary restriction and excessive exercise.
o Preoccupation with weight, body shape, and body image.
o low self-esteem, and self-harm.
o Periods may be irregular.
· Physical examination is usually normal and is mainly aimed at excluding
medical complications such as dehydration or dysrhythmias (induced by
hypokalaemia).
o Examination must include height and weight (and calculation of the BMI)
and blood pressure.
o Salivary glands (especially the parotid) may be swollen.
o There may be oedema if there has been laxative or diuretic abuse.
o Russell's sign may be present (calluses form on the back of the hand,
caused by repeated abrasion against teeth during inducement of
vomiting).
Q:568
A 4yo has earache and fever. Has taken paracetamol several times. Now it’s
noticed that he increases the TV volume. His preschool hearing test shows
symmetric loss of 40db. What is the most likely dx?
a. OM with effusion
b. Otitis externa
c. Cholesteatoma
d. CSOM
e. Tonsillitis
Clincher(s)
Young boy with ear ache and fever with hearing loss testing and increases
the volume of tv.
Typical picture
Infection of external ear. Pain and watery discharge.
A
B
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C
D
Offensive discharge due to active squamous chronic otitis media
Chronic suppurative otitis media (CSOM) is a chronic inflammation of the
middle ear and mastoid cavity. Clinical features are recurrent otorrhoea
through a tympanic perforation, with conductive hearing loss of varying
severity.
CSOM presents with a chronically draining ear (>2 weeks), with a possible
history of recurrent AOM, traumatic perforation, or insertion of grommets.
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
It's not going to cause hearing problems.
A
Q:574
A 15m child is due for his MMR vaccine. There is a fam hx of egg allergy. He is
febrile with acute OM. What is the single most appropriate action?
a. Defer immunization for 2wks
b. Don’t give vaccine
c. Give half dose of vaccine
d. Give paracetamol with future doses of the same vaccine
e. Proceed with standard immunization schedule
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Otitis media infection and MMR vaccine
A
egg allergy is not contraindication for MMR ...therefore if pt is febrile then wait
for the next two weeks until he is afebrile and give the normal dose of
immunization.
Children in the UK receive two doses of the Measles, Mumps and Rubella
(MMR) vaccine before entry to primary school. This currently occurs at 12-15
months and 3-4 years as part of the routine immunisation schedule
Contraindications to MMR
· severe immunosuppression
· Acute illness
· allergy to neomycin
· children who have received another live vaccine by injection within 4 weeks
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· pregnancy should be avoided for at least 1 month following vaccination
· immunoglobulin therapy within the past 3 months (there may be no immune
response to the measles vaccine if antibodies are present)
Adverse effects
· malaise, fever and rash may occur after the first dose of MMR. This typically
occurs after 5-10 days and lasts around 2-3 days
Note that the following are NOT contra-indications:
· Family history of any adverse reactions following immunisation.
· Previous history of infection with pertussis, measles, rubella or mumps.
· Contact with an infectious disease.
· Asthma, eczema, hay fever or rhinitis.
· Treatment with antibiotics or locally acting (eg, topical or inhaled) steroids.
· The child's mother being pregnant.
· The child being breast-fed.
· History of jaundice after birth.
· Being over the age recommended in the immunisation schedule.
· 'Replacement' corticosteroids.
· Allergy to eggs
· Neurological conditions are not a contra-indication although, if the condition
is poorly controlled (eg, epilepsy), immunisation should be deferred.
· MMR should ideally be given at the same time as other live vaccines, such as
BCG. However, if live vaccines cannot be administered simultaneously, a fourweek interval is recommended.
Q:
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:
Clincher(s)
A
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B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q: 586
A 4yo boy who prv had normal hearing, has a mild earache relieved by
paracetamol. He has been noticed to turn up the vol on the TV. He has
bilateral dull tympanic membranes. His preschool hearing test shows
symmetrical loss of 40dB. What is the single most likely dx?
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ENT-System Wise 1700-by Sush and Team. 2016
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a. Acute otitis externa
b. Acute OM
c. Ear wax
d. Foreign body
e. OM with effusion
Clincher(s)
A
B
C
D
E
KEY: E
Additional
Information
Reference
Dr Khalid/Rabia
turning up the volume of Tv, symmetrical loss of 40dB
Minimal discharge, itch, pain and tragal tenderness due to an acute
inflammation of the skin of the meatus, eg caused by moisture (swimming)
(h/o of holiday), trauma eg fingernails (a consequence from conditions causing
itch, eg eczema/psoriasis), high humidity, an absence of wax, a narrow ear
canal, and hearing aids.
middle ear inflammation; it presents with rapid onset of pain, fever ±
irritability, anorexia, or vomiting often after a viral upper respiratory
infection.
Foreign bodies are common if <5yrs old and in adults with learning difficulty
OM with effusion
Hearing impairment noticed by parents is the mode of presentation in
80%. The fundamental problem lies with dysfunction of the Eustachian tubes.
OME is commoner in boys, Down’s syndrome, winter season, atopy, children
of smokers and primary ciliary dyskinesia.
OME is the chief cause of hearing loss in young children, and can cause
disastrous learning problems (rare). OME may cause no pain, so its presence
may not be suspected.
History: Focus on poor listening, poor speech, language delay, inattention,
poor behaviour, hearing fluctuation, ear infections/URTI, balance and, school
work.
Tests: Audiograms: Look for conductive defects. Impedance audiometry: Look
for flat tympanogram (helps distinguish OME from Eustachian
malfunction and otosclerosis).
Tx:
• reassurance + 3-monthly review
• Hearing aids: Reserve for persistent bilateral OME and hearing loss if
surgery is not accepted.
• Surgery: If persistent bilateral OME + hearing level in better ear of <25–
30dBHL(=decibel hearing loss) confirmed over 3 months then
myringotomy + suction of fluid, and insertion of air-conducting
grommets ± adenoidectomy (if hearing loss).
• NICE also says surgery is an option if hearing loss is less severe but
learning difficulties are to the fore.
OHCS pg: 546
Glue Ear/ otitis media with effusion: recurrent ear infections, poor speech
development, and failing performances at school, typically in children between
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the ages of 2 and decreasing with advancement of age.
Causes conductive hearing loss.
The clincher also is 'child finding difficulty in hearing in classroom/turning up
the volume of Tv'
Chronic suppurative otitis media (CSOM) is a chronic inflammation of the
middle ear and mastoid cavity. Clinical features are recurrent otorrhoea
through a tympanic perforation, with conductive hearing loss of varying
severity.
· CSOM presents with a chronically draining ear (>2 weeks), with a possible
history of recurrent AOM, traumatic perforation, or insertion of grommets.
· The otorrhea should occur without otalgia or fever.
· Fever, vertigo and otalgia should prompt urgent referral to exclude
intratemporal or intracranial complications.
· Hearing loss is common in the affected ear
Treatment options include:
· grommet insertion - to allow air to pass through into the middle ear and
hence do the job normally done by the Eustachian tube. The majority stop
functioning after about 10 months
· adenoidectomy
Q: 644
A 25yo woman complains of dizziness, nausea, vomiting, visual disturbances
and anxiety which keep coming from time to time. Most of the attacks are a/w
sudden change in posture. What is the most likely dx?
a. Panic disorder
b. Carotid sinus syncope
c. BPPV (Benign paroxysmal positional vertigo)
d. Vertebrobasilar insufficiency
e. Postural hypotension
Clincher(s)
A
B
attacks are a/w sudden change in posture
C
D
E
KEY: C
The diagnosis is frequently made in:
• men over 50
• patients with atherosclerosis and hypertension
Most commonly due to atherosclerosis will have Brain stem symptoms such as
diplopia, dysarthria and facial nuumbness
A drop in systolic blood pressure upon standing of greater than 20 mmHg
BPPV (Benign paroxysmal positional vertigo)
Ask about duration of vertigo:
• seconds to minutes ≈ BPPV;
• 30mins to 30h ≈ Ménière’s or migraine;
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•
Additional
Information
Reference
Dr Khalid/Rabia
30h to a week ≈ acute vestibular failure.
· vertigo triggered by change in head position (e.g. rolling over in bed or gazing
upwards)
· may be associated with nausea
· each episode typically lasts 10-20 seconds
· positive Dix-Hallpike manoeuvre
BPPV has a good prognosis and usually resolves spontaneously after a few
weeks to months. Symptomatic relief may be gained by:
· Epley manoeuvre (successful in around 80% of cases)
· teaching the patient exercises they can do themselves at home, for example
Brandt-Daroff exercises
Medication is often prescribed (e.g. Betahistine) but it tends to be of limited
value.
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Q: 656
Clincher(s)
A
B
C
D
E
KEY: A
Additional
Information
Reference
Dr Khalid/Rabia
A 56yo male pt presents with intermittent vertigo, tinnitus and hearing loss.
What is the best drug tx for this pt?
a. Buccal prochlorperazine
b. Oral flupenphenazine
c. TCA (tricyclic antidepressant)
d. Gentamicin patch on the round window
e. No med tx available
Probable case of Menieres disease. Treated with prochlorperazine
OHCM pg: 554
a. Buccal prochlorperazine
meiners disease-t/t oral percholperazine
Features
· recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural).
Vertigo is usually the prominent symptom
· a sensation of aural fullness or pressure is now recognised as being common
· other features include nystagmus and a positive Romberg test
· episodes last minutes to hours
· typically symptoms are unilateral but bilateral symptoms may develop after a
number of years
Natural history
· symptoms resolve in the majority of patients after 5-10 years
· the majority of patients will be left with a degree of hearing loss
· psychological distress is common
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Management
· ENT assessment is required to confirm the diagnosis
· patients should inform the DVLA. The current advice is to cease driving until
satisfactory control of symptoms is achieved
· acute attacks: buccal or intramuscular prochlorperazine. Admission is
sometimes required
· prevention: betahistine may be of benefit
Q: 663
Clincher(s)
A
B
C
D
E
KEY: A??
Additional
Information
Reference
Dr Khalid/Rabia
Pt had a fight following which he developed bleeding, ringing and hearing loss
from one ear. What is the inv of choice?
a. CT
b. XR skull
c. Otoscopy
d. MRI vestibule
e. Coagulation study
CT
CT scan to rule out basilar skull fracture esp when there is history of fight,
bleeding from ear (hemotympanum) If bleeding and tinnitus is present it is
almost certain that the patient has a traumatic perforation... So now our main
aim is to rule out fracture base of skull which can be best done by a CT scan.
Selection of adults for CT scan
CT scan of the brain within one hour (with a written radiology report within
one hour of the scan being undertaken):
· Glasgow Coma Scale (GCS) <13 when first assessed or GCS <15 two hours
after injury
· Suspected open or depressed skull fracture
· Signs of base of skull fracture*
· Post-traumatic seizure
· Focal neurological deficit
· >1 episode of vomiting
All patients with a coagulopathy or on oral anticoagulants should have a CT
brain scan within eight hours of the injury, provided there are no other
identified risk factors, as listed above. Again, a written radiology report should
be available within one hour of the scan being undertaken.
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ENT-System Wise 1700-by Sush and Team. 2016
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Q: 690
Clincher(s)
A
B
C
D
E
KEY: A
A 28yo man complains of vertigo, nausea and vomiting for more than 30 mins
and tinnitus, hearing loss in the left ear. What is the tx for this pt?
a. Buccal prochlorperazine
b. Metachlorpromide
c. Cyclazine
d. Cotrimazole
e. Ondansetron
Buccal prochlorperazine
1st line-if vomiting or betahistine or chlorthalidone (OHCS)
Additional
Information
Reference
Dr Khalid/Rabia
Q: 1052
A 45yo woman has dull pain in her right ear which has been present for several
weeks. There is no discharge. Chewing is uncomfortable and her husband has
noticed that she grinds her teeth during sleep. The eardrum appears normal.
What is the single most likely dx?
a. Dental caries
b. Mumps
c. OM
d. Temporomandibular joint pain
e. Trigeminal neuralgia
Clincher(s)
dull pain in her right ear for weeks, no discharge, chewing is uncomfortable,
teeth grinding
Tooth ache, localised swelling
A prodrome of non-specific symptoms like fever, malaise myalgias, and
anorexia may be followed by enlargement of one or both parotid glands,
developing over a period of 1 to 3 days.
Severe and progressive otalgia, discharge
A
B
C
D
E
KEY: D
a unilateral disorder characterised by brief electric shock-like pains, abrupt in
onset and termination, limited to the distribution of one or more divisions of
the trigeminal nerve
Temporomandibular joint pain
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Additional
Information
Reference
Dr Khalid/Rabia
Q:727
Clincher(s)
A
B
C
D
E
KEY
OHCS pg: 542
Temporomandibular joint pain may cause pain in ear and teeth grinding as in
oromandibular dyskinesia is a recognized cause of this symptom
Earache, facial pain, and joint clicking/popping related to malocclusion, teethgrinding (bruxism)
or joint derangement.
Stress making this a biopsychosocial disorder which may become a chronic
pain syndrome
Signs:
Joint tenderness exacerbated by lateral movement of the open jaw, or trigger
points in the pterygoids.
Imaging: MRI.
Associations: Depression; Ehlers Danlos
Rx: NSAIDs (PO or topical, eg Diclofenac); Stabilizing orthodontic occlusal
prostheses; cognitive therapy; physiotherapy; biofeedback; Reconstructive
Surgery; acupuncture.
A 25yo man presents with hoarseness of voice. He has swollen vocal cords. His
BMI=32 and he smokes 20-25 cigarettes/day. What would you advise him?
a.
Stop smoking
b. Lose weight
a- Stop smoking
There are several reasons for hoarsness of voice on of which is CA larynx.
Smoking is a big risk factor for it.
Additional
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Information
Reference
Dr Khalid/Rabia
Q:752
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:769
A 17yo lady presents with a worm in her ear. She is very agitated and anxious.
What is the next step?
a. Remove under GA
b. Suction
c.
Alcohol drops
d. Forceps
Alcohol next step
Removed eventually with help of forcep
c-Alcohol drops
. A 45yo woman presents with rotational vertigo, nausea and vomiting,
especially on moving her head. She also had a similar episode 2yrs back. These
episodes typically follow an event of runny nose, cold, cough and fever. What is
the most probable dx?
a. Acoustic neuroma
b. Meniere’s disease
c.
Labyrinthitis
d. BPPV
e. vestibular neuronitis
Clincher(s)
A
B
C
D
E
KEY
Acoustic neuroma will ve other nerve ivolvement also
Meniers characterized by vertigo , SN hearing loss , aural fullness , tinnitus
Labyrinthitis resembles vestibular neuronitis but with hearing loss
BPPV characterized by vertigo and dizziness related to head movement
Rotational vertigo , nausea , vomiting , f/b viral illness
e.
Vestibular neuronitis
above scenario is that of vestibular neuronitis.
Symptoms of rotational vertigo nausea and vomiting followed an event of viral
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illness.
Presentation: nausea, vomiting and vertigo .moving head aggravates
symptoms.
Nystagmus
Investigations: clinical diagnosis.
MRI ct to rule out other causes
Differntials: BPPV, labyrinthitis, Meniers
Management: reassurance. Bed rest.If severe, antiemetics.Prochlorperazine
Additional
Information
Reference
Dr Khalid/Rabia
Q:783
. A 2yo girl prv well presents with ahx of vomiting and diarrhea for 4hrs. What
is the most suitable indication for IV fluid administration?
a.
Capillary refill time >4s
b. HR >90bpm
c.
Increased RR
d. Stool >10x/d
e.
Weight of child = 10kgs
Clincher(s)
A
B
C
D
E
KEY
2 yr old , vomiting diarrhea for 4hrs
Checked in diarrhea
In diarrhea – patient might be hypotensive
Sign of pneumonia
Investigation
Not sensible
A- CAPILLARY REFILL
In diarrhea – you examine the patient and look for signs of dehydration
Depressed ant fontanelle , capillary refill time ,
Additional
Information
Reference
Dr Khalid/Rabia
Q:786
A 74yo lady called an ambulance for an acute chest pain. She has ahx of DM
and HTN, and is a heavy smoker. Paramedics mentioned that she was
overweight and recently immobile because of a hip pain. She collapsed and died
in the ambulance. What is the most likely cause of death?
a.
Pulmonary embolism
b. MI
c.
Stroke
d. Cardiac arrhythmia
e.
Cardiac failure
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ENT-System Wise 1700-by Sush and Team. 2016
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Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
74, DM , HTN , acute chest pain , smoker , over weight , immobile due to hip
pain---died
Chest pain +/- , tachycardia , sudden ,
Chest pain Loss of consciousness or focal deficit
Palpitations shud ve been there
dyspnnea shud be there
A- Pulmonary embolism
acute onset of chest pain and hx of immobility point towards pul embolism.
Causes: DVT
After long bone fracture
Amniotic fluid
Air embolism
Immobility
Risk factors for venous thromboembolism[3]
Major risk factors: relative risk of
5-20
Minor risk factors: relative risk of 24
Cardiovascular:
Surgery:
·
Major abdominal/pelvic
surgery
or hip/knee replacement
(risk lower if prophylaxis used).
·
Postoperative intensive
care.
60
·
Congenital heart disease.
·
Congestive cardiac failure.
·
Hypertension.
·
Paralytic stroke.
Oestrogens:
·
Pregnancy (but see major
risk factors for late pregnancy and
ENT-System Wise 1700-by Sush and Team. 2016
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Obstetrics:
puerperium).
·
Late pregnancy.
·
·
Puerperium.
contraceptive.
·
Caesarean section.
·
Lower limb problems:
Combined oral
Hormone replacement
therapy.
Haematological:
·
Fracture.
·
Varicose veins - previous
·
Thrombotic disorders (a
varicose vein surgery;
detailed list is available)
superficial thrombophlebitis;
Consider this in cases of PE aged
varicose veins per se are not a
<40 years, recurrent VTE or a
risk factor.
positive family history.
Malignancy:
·
·
Abdominal/pelvic.
·
Advanced/metastatic.
Reduced mobility:
Myeloproliferative disorders.
Renal:
·
Nephrotic syndrome.
·
Chronic dialysis.
Paroxysmal nocturnal
·
Hospitalisation.
·
·
Institutional care.
haemoglobinuria.
Miscellaneous:
Previous proven VTE:
·
Intravenous (IV) drug use
·
Chronic obstructive
(could be major or
pulmonary disease (COPD).
minor risk factor:
·
Neurological disability.
no data on relative risk).
·
Occult malignancy.
·
Long-distance sedentary
Other:
·
travel.
Major trauma.
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·
Spinal cord injury.
·
Obesity.
·
Central venous lines.
·
Other chronic diseases:
inflammatory bowel disease,
Behçet's disease.
Symptoms -· Dyspnoea.
·
Pleuritic chest pain, retrosternal chest pain.
·
Cough and haemoptysis.
·
Any chest symptoms in a patient with symptoms suggesting a
deep vein thrombosis (DVT).
·
In severe cases, right heart failure causes dizziness or
syncope.
Signs include: Tachypnoea, tachycardia.
Hypoxia, which may cause anxiety, restlessness, agitation and impaired
consciousness.
·
Pyrexia.
·
Elevated jugular venous pressure.
·
Gallop heart rhythm, a widely split second heart sound,
tricuspidregurgitant murmur.
•
·
Pleural rub.
·
Systemic hypotension and cardiac arrest
Offer patients in whom PE is suspected and with a likely twolevel PE Wells' score either an immediate computed
tomography pulmonary angiogram (CTPA) or immediate
interim parenteral anticoagulant therapy followed by a CTPA, if
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a CTPA cannot be carried out immediately. Consider a proximal
leg vein ultrasound scan if the CTPA is negative and DVT is
suspected.
•
Offer patients in whom PE is suspected and with an unlikely twolevel PE Wells' score a D-dimer test and, if the result is positive,
offer either an immediate CTPA or immediate interim parenteral
anticoagulant therapy followed by a CTPA, if a CTPA cannot be
carried out immediately.
•
For patients who have an allergy to contrast media, or who
have renal impairment, or whose risk from irradiation is high:
o
Assess the suitability of a ventilation/perfusion singlephoton emission computed tomography (V/Q SPECT)
scan or, if a V/Q SPECT scan is not available, a V/Q
planar scan, as an alternative to CTPA.
o
If offering a V/Q SPECT or planar scan that will not be
available immediately, offer immediate interim parenteral
anticoagulant therapy.
•
Diagnose PE and treat patients with a positive CTPA or in whom
PE is identified with a V/Q SPECT or planar scan.
•
Consider alternative diagnoses in the following two groups
of patients:
•
Patients with an unlikely two-level PE Wells' score and either
a negative D-dimer test, or a positive D-dimer test and a
negative CTPA.
•
Patients with a likely two-level PE Wells' score and both a
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negative CTPA and no suspected DVT.
initial resuscitation
·
Oxygen 100%.
Obtain IV access, monitor closely, start baseline
·
investigations.
·
Give analgesia if necessary (eg, morphine).
·
Assess circulation: suspect massive PE if systolic BP is <90
mm Hg or there is a fall of 40 mm Hg, for 15 minutes, not due to
other causes.
Anticoagulation therapy[4]
·
Offer a choice of low molecular weight heparin (LMWH) or
fondaparinux to patients with confirmed PE, with the following
exceptions:
For patients with severe renal impairment or established
·
chronic kidney disease (estimated glomerular filtration rate
(eGFR) <30 ml/min/1.73 m2) offer unfractionated heparin (UFH)
with dose adjustments based on the activated partial
thromboplastin time (aPTT) or LMWH with dose adjustments
based on an anti-Xa assay.
For patients with an increased risk of bleeding, consider
·
UFH.
·
For patients with PE and haemodynamic instability, offer
UFH and consider thrombolytic therapy.
·
Start the LMWH, fondaparinux or UFH as soon as possible
and continue it for at least five days or until the international
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normalised ratio (INR) is 2 or above for at least 24 hours, whichever
is longer.
Offer LMWH to patients with active cancer and confirmed PE,
·
and continue the LMWH for six months. At six months, assess the
risks and benefits of continuing anticoagulation.
Offer a vitamin K antagonist (VKA) to patients with
·
confirmed PE within 24 hours of diagnosis and continue the VKA
for three months. At three months, assess the risks and benefits of
continuing VKA treatment.
Offer a VKA beyond three months to patients with an
·
unprovoked PE, taking into account the patient's risk of VTE
recurrence and whether they are at increased risk of bleeding.
Rivaroxaban:[7]
·
·
Rivaroxaban is recommended by NICE as an option
for treating PE and preventing recurrent DVT and PE in
adults.
·
The duration of treatment recommended depends on
bleeding risk and other clinical criteria.
·
Short-term treatment (at least three months) is
recommended for people with transient risk factors such
as recent surgery and trauma. Longer treatment is
recommended for people with permanent risk factors, or
idiopathic (unprovoked) DVT or PE.
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Q:799
Clincher(s)
A
B
C
D
E
KEY
A 2yo child is brought by his mother. The mother had hearing impairment in
her early childhood and is now concerned about the child. What inv would you
do?
a.
Audiometry
b. Distraction testing
c.
Scratch test
d. Tuning fork
Answer: A. Audiometry. Family history of deafness so audiometry should be
done.
Additional
Information
Reference
Q: 378
Clincher(s)
A
B
C
D
E
KEY
A 32yo woman had progressive decrease in vision over 3yrs. She is no dx as
almost blind. What would be the mechanism?
a. Cataract
b. Glaucoma
c. Retinopathy
d. Uveitis
e. Keratitis
Cataract is unlikely at this age.
Open angle glaucoma.
Nothing in the history suggests retinopathy.
Uveitis and iritis doesn’t have such degree of vision loss and iritis and anterior
uveitis have pain, redness and photophobia.
B. Glaucoma. C>? skype
Additional
Information
Reference
66
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Dr Khalid/Rabia
Q: 395
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q: 405
Clincher(s)
A
B
C
D
E
KEY
A 32yo man presents with hearing loss. AC>BC in the right ear after Rhine test.
He also complains of tinnitus, vertigo and numbness on same half of his face.
What is the most appropriate inv for his condition?
a. Audiometry
b. CT
c. MRI
d. Tympanometry
e. Weber’s test
features are suggestive of acaustic neuroma, so MRI is the preferred option. it
involves basically 8th nerve but 6 7 9 and 10th nerves are also involved with it
The key is C. MRI.
A 31yo man has epistaxis 10 days following polypectomy. What is the most
likely dx?
a. Nasal infection
b. Coagulation disorder
c. Carcinoma
HEMORRHAGE AFTER 5 TO 7 DAYS IS SECONDARY HEMORRHAGE [Infection is
one of the most important cause of secondary hemorrhage].
The key is A. Nasal infection.
Additional
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Information
Reference
Dr Khalid/Rabia
Q: 422
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q: 503
A 5yo child complains of sore throat and earache. He is pyrexial. Exam: tonsils
enlarged and hyperemic, exudes pus when pressed upon. What is the single
most relevant dx?
a. IM
b. Acute follicular tonsillitis
c. Scarlet fever
d. Agranulocytosis
e. Acute OM
Acute follicular tonsillitis. [Tonsillitis is usually caused by a viral infection or,
less commonly, a bacterial infection. The given case is a bacterial tonsillitis
(probably caused by group A streptococcus). There are four main signs that
tonsillitis is caused by a bacterial infection rather than a viral infection. They
are:
•
a high temperature
•
white pus-filled spots on the tonsils
•
no cough
•
swollen and tender lymph nodes (glands).
Ans. The key is B.
A 26yo woman has become aware of increasing right sided hearing deficiency
since her recent pregnancy. Her eardrums are normal. Her hearing tests show:
BC-normal. Weber test lateralizes to the right ear. What is the single most
likely dx?
a. Encephalopathy
b. Functional hearing loss
c. Tympano-sclerosis
d. Otosclerosis
e. Sensorineural deafness
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Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
There are no features of encephalopathy.
As Weber test is lateralized it is unlikely to be functional hearing loss.
In tympanosclerosis ear drum becomes chalky white. So as the ear drum is
normal it is not tympanosclerosis.
It is conductive deafness which makes otosclerosis as the most likely diagnosis.
Rinne's test
•
air conduction (AC) is normally better than bone conduction (BC)
•
if BC > AC then conductive deafness
Weber's test
•
in unilateral sensorineural deafness, sound is localised to the
unaffected side
•
in unilateral conductive deafness, sound is localised to the affected side
Weber test is lateralized to right and deafness is also on the right. So it not
sensorineural deafness
key is D. Otosclerosis.
Q:
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:
Clincher(s)
A
B
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ENT-System Wise 1700-by Sush and Team. 2016
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C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
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ENT-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal
Q: 1383
A pt, a small child presented with URTI and later developed fever, earache and
tympanic membrane is dull. What is the likely dx?
a. OM
b. OE
c. Glue ear
d. Perforation of the tympanic membrane
e. Referred ear ache
Clincher(s)
A
Age, Upper respiratory tract infection, earache and dull tympanci membrane.
Correct diagnosis is otitis media.
B
Oitis externa is associated with swimming and there should be some discharge
from ear and hearing impairement.
All the signs are present in glue ear except fever. 80% presents with hearing loss.
Irrelevant here.
Herpes zoster which have signs of blister and pustules around the preauriclar
area.
A- Otitis media.
C
D
E
KEY
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Additional
Information
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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal
Reference
Dr Khalid/Rabia
Q: 1384
A 72yo male who is a regular smoker has come to the ED with complaints of
loss of weight and loss of appetite. He also complains of odynophagia. Exam:
actively bleeding ulcer on right tonsil. What is the most appropriate dx?
a. Tonsillar ca
b. Vincent angina.
c. Irritant ingestion
d. Paracoccidiodmycosis
e. Herpes simplex infection
Clincher(s)
A
B
C
D
E
KEY
Smoker and odynophagia. Actively bleeding.
Correct diagnosis is tonsillar carcinoma.
Vinvent angina is tooth abscess
Irritant ingestion is associated with corrosive intake.
Fungal inflammatory infection.
Cause of primary oral infection, signs are herpes labialis, gingivostomatis,
pharyngitis.
Key A
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Additional
Information
Reference
Dr Khalid/Rabia
Q: 1385
A pt with regular episodes of SNHL, vertigo and tinnitus lasting >30min.
Neurological exam=normal. What is the likely dx?
a. Meniere’s disease
b. Acoustic neuroma
c. Otosclerosis
d. Benign positional vertigo
e. Labrynthitis
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Episodes of SNHL vertigo and tinnitus, neurological examination is normal.
Correct diagnosis.
There should be unilateral progressive unilateral sensorineural loss.
Otosclerosis is an autosominal dominant with incomplete penetrance in which
vascular spongy bone is replaced with lamellar bone of otic capsule origin
particularly around the oval window which fixes the stapes footplate.
Disorder of semilunar canal of ear,
A- Meniere’s disease.
Reference
Dr Khalid/Rabia
Q: 1410
A 35yo man has been given a dx of allergic rhinitis and asthma. Exam:
peripheral neuropathy with tingling and numbness in a glove and stocking’s
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distribution. Skin elsions are present in the form of tender subcutaneous
nodules. The pt is responding well to corticosteroids. What is the single most
appropriate dx?
a. AS
b. Churg-strauss syndrome
c. Crytogenic organizing
d. Extrinsic allergic alveolitis
e. Tropical pulmonary eosinophilia
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Allergic rhinitis, asthma, peripheral neuropathy with tingling and numbness
in glove and stocking’s distribution.
B- Churg-strauss syndrome.
churg- strauss syndrome. allergic rhinitis with asthma points towards the
diagnosis of churg strauss syndrome. mnemonic : BEAN SAP
BE: Blood Eosinophilia A : Asthma N : Neuropathy (mononeuritis
multiplex) - usually common peroneal nerve S : Sinus abnormality A :
Allergies P : Perivascular eosinophils / vasculitis
Churg Strauss Syndrome
A triad of adult-onset asthma, eosinophilia, and vasculitis (± vasospasm
± MI ± DVT), affecting lungs, nerves, heart, and skin. A septic-shock
picture/systemic inflammatory response syndrome may occur (with
glomerulo nephritis/ renal failure, esp. if ANCA +ve). Presentation:
The physical findings are specific to organ system involvement. There
are three phases:
Allergic rhinitis and asthma.
Eosinophilic infiltrative disease, such as eosinophilic
pneumonia or gastroenteritis.
Systemic medium and small vessel vasculitis with
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ENT-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal
granulomatous inflammation.
Investigations: Antineutrophil cytoplasmic antibodies (ANCA): 70% of
patients are
perinuclear staining (p-ANCA) positive (anti myeloperoxidase
antibodies).Other likely
findings include eosinophilia and anaemia on the FBC; elevated ESR
and CRP; elevated
serum creatinine; increased serum IgE levels
Treatment= Steroids; biological agents if refractory disease, eg
rituximab.
Reference
Dr Khalid/Rabia
Q: 1447
A 29yo woman has developed and itchy scaly rash particularly over her wrist
with fine white streaks overlying the lesion. Her nails have ridges and her
buccal mucosa is lined with a lacy white pattern. What is the single most likely
dx?
a. Psoriasis
b. Scabies
c. Urtericaria
d. Dermatitis herpetiformis
e. Hyperthyroidism
f. Lichen planus
Clincher(s)
Scaly itchy rash over wrist and nails and buccal mucosa is lined with a lacy
white pattern.
A
B
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ENT-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal
C
D
E
KEY
Additional
Information
F- Lichen Planus.
Reference
Dr Khalid/Rabia
Q: 1504
A 10yo boy develops nasal bleeding. What is the best way to stop the bleeding
from the nose?
a. Pressure over base of the nose
b. Ice packs
c. Pressure over the soft tissues
d. Nasal packing
e. Surgery
Clincher(s)
A
B
C
D
E
KEY
Additional
Information
C- Pressure over the soft tissues.
The classification of nosebleeds is as anterior or posterior, depending
upon the source of bleeding. The blood supply to the nose is derived
from branches of the internal (anterior and posterior ethmoid arteries)
and external carotid arteries (sphenopalatine and branches of the
internal maxillary arteries). Bleeding usually occurs when the mucosa is
eroded
and
vessels
become
exposed
and
subsequently
break. Epistaxis is usually benign, self-limiting and spontaneous. The
majority are caused by simple trauma. Although most incidents are not
life-threatening, they can cause significant parental concern when they
occur in children. Management of epistaxis: Resuscitate the patient (if
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ENT-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal
necessary) - remember the ABCD(E) of resuscitation. Ask the patient to
sit upright, leaning slightly forward, and to squeeze the bottom part of
the nose (NOT the bridge of the nose) for 10-20 minutes to try to stop
the bleeding. The patient should breathe through the mouth and spit out
any blood/saliva into a bowl. An ice pack on the bridge of the nose may
help. Monitor the patient's pulse and blood pressure. If bleeding has
stopped after this time (as it does in most cases) proceed to inspect the
nose, using a nasal speculum; consider cautery. If the history is of
severe and prolonged bleeding, get expert help - and watch carefully for
signs of hypovolemia.
Reference
Dr Khalid/Rabia
78