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Question 1
Correct
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A 50-year-old woman presents to the ear, nose and throat clinic with a 4-month history of left-sided hearing loss. She reports occasional ringing in her left ear and feeling unsteady. She has a medical history of well-controlled type 1 diabetes and denies any recent infections.
During the examination, Rinne's test is positive in both ears, and Weber's test lateralizes to her right ear. There is no evidence of nystagmus, and her coordination is normal. Other than an absent left-sided corneal reflex, her cranial nerve examination is unremarkable.
What is the most likely diagnosis?Your Answer: Acoustic neuroma
Explanation:If a patient presents with a loss of corneal reflex, an acoustic neuroma should be considered as a possible cause. This is a benign tumor that affects the vestibulocochlear nerve and can lead to symptoms such as vertigo, tinnitus, and unilateral sensorineural hearing loss. In some cases, the tumor can also invade the trigeminal nerve, resulting in an absent corneal reflex.
Other conditions that may cause hearing loss and vertigo include cholesteatoma, labyrinthitis, and Meniere’s disease. However, in this case, the patient’s hearing tests indicate a sensorineural hearing loss, which makes cholesteatoma less likely. Labyrinthitis typically causes acute vertigo that can persist for several days, but it would not be the cause of the loss of the corneal reflex. Meniere’s disease is characterized by a triad of symptoms, including tinnitus, vertigo, and sensorineural hearing loss, but the vertigo tends to be shorter in duration and follow a relapsing and remitting course.
Understanding Vestibular Schwannoma (Acoustic Neuroma)
Vestibular schwannoma, also known as acoustic neuroma, is a type of brain tumor that accounts for 5% of intracranial tumors and 90% of cerebellopontine angle tumors. The condition is characterized by a combination of symptoms such as vertigo, hearing loss, tinnitus, and an absent corneal reflex. The affected cranial nerves can predict the features of the condition. For instance, cranial nerve VIII can cause vertigo, unilateral sensorineural hearing loss, and unilateral tinnitus. On the other hand, cranial nerve V can lead to an absent corneal reflex, while cranial nerve VII can cause facial palsy.
Bilateral vestibular schwannomas are often seen in neurofibromatosis type 2. The diagnosis of vestibular schwannoma is made through an MRI of the cerebellopontine angle, and audiometry is also important since only 5% of patients have a normal audiogram.
The management of vestibular schwannoma involves surgery, radiotherapy, or observation. The choice of treatment depends on the size and location of the tumor, the patient’s age and overall health, and the severity of symptoms. In conclusion, understanding vestibular schwannoma is crucial in managing the condition effectively.
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This question is part of the following fields:
- ENT
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Question 2
Correct
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A 35-year-old man visits the clinic with complaints of decreased hearing and ringing in his right ear, which feels congested, and he experiences frequent bouts of vertigo lasting up to a few hours at a time. There are no abnormalities found during the neurological examination.
What is the most probable diagnosis?Your Answer: Ménière’s disease
Explanation:Differentiating Vertigo Conditions: Ménière’s Disease, Benign Paroxysmal Positional Vertigo, Central Vertigo, Labyrinthitis, and Vestibular Neuronitis
Vertigo is a common symptom that can be caused by various conditions. Ménière’s disease, for instance, is characterized by fluctuant hearing loss, vertigo, tinnitus, and aural fullness. Patients are advised to undergo vestibular rehabilitation and avoid risky activities. Prochlorperazine is recommended for acute attacks, while betahistine is used for preventive treatment. Benign paroxysmal positional vertigo, on the other hand, presents with brief episodes of vertigo triggered by movement, without tinnitus, hearing loss, or ear fullness. Central vertigo has a sudden onset, constant symptoms, and possible neurological abnormalities, requiring urgent hospital admission. Labyrinthitis causes acute vertigo and hearing loss, but the presence of ear fullness suggests Ménière’s disease. Vestibular neuronitis, caused by viral infection, results in isolated and prolonged episodes of vertigo without tinnitus or ear fullness. Accurate diagnosis and appropriate management are crucial in addressing vertigo and its underlying conditions.
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This question is part of the following fields:
- ENT
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Question 3
Correct
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A 43-year-old male accountant visits the clinic with a persistent hoarseness that has been bothering him for the past 4 weeks. He reports that this is affecting his work performance. He denies experiencing any sore throat, difficulty swallowing, or cough. He has been smoking 20 cigarettes daily for the last 25 years and drinks a glass of beer every day. Apart from this, he is in good health. What is the best course of action for managing his condition?
Your Answer: 2-week rule referral to ENT specialist
Explanation:If a patient aged over 45 years old has persistent and unexplained hoarseness, it is recommended by NICE to urgently refer them to an ENT specialist under the 2-week wait rule. This is because they may have laryngeal cancer. While a chest radiograph is important, it is more appropriate to prioritize the referral to ENT if cancer is suspected. It is not appropriate to delay the referral or provide false reassurance. While advice on smoking cessation and alcohol should be given, specialist referral is the most important aspect of management in this situation.
Understanding Hoarseness and its Causes
Hoarseness is a condition that can be caused by various factors. One of the most common causes is voice overuse, which can strain the vocal cords and lead to hoarseness. Smoking is another factor that can contribute to hoarseness, as it can irritate the throat and vocal cords. Viral illnesses, hypothyroidism, and gastro-oesophageal reflux are also known to cause hoarseness. In some cases, hoarseness can be a symptom of laryngeal or lung cancer.
When investigating patients with hoarseness, it is important to consider a chest x-ray to rule out any apical lung lesions. If laryngeal cancer is suspected, referral guidelines recommend a suspected cancer pathway referral to an ENT specialist for individuals aged 45 and over with persistent unexplained hoarseness or an unexplained lump in the neck. By understanding the causes of hoarseness and seeking appropriate medical attention, individuals can receive the necessary treatment and improve their vocal health.
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This question is part of the following fields:
- ENT
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Question 4
Incorrect
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A 45-year-old woman presents to her General Practitioner after discovering a firm lump just under her tongue on the right side. She has been experiencing discomfort and mild swelling in the same area while eating for the past few days. She is stable and not running a fever.
What is the most suitable management option for this probable diagnosis?Your Answer: Short course of oral prednisolone and referral to an ENT surgeon
Correct Answer: Short course of NSAIDs and referral to an ENT surgeon
Explanation:Management of Salivary Gland Stones: Recommended Approaches and Guidelines
Salivary gland stones, or sialolithiasis, can cause pain and swelling of the affected gland, triggered by salivary flow stimulation during eating or chewing. If left untreated, these stones can lead to secondary infections, cellulitis, and airway compromise. Here are some recommended approaches and guidelines for managing salivary gland stones:
Referral to an ENT Surgeon and NSAIDs
If a salivary stone is suspected, a referral to an ENT surgeon should be made, with the urgency guided by clinical judgement. Patients should also be advised to remain well hydrated, and NSAIDs can be used to relieve any pain.Antibiotics and Referral to an ENT Surgeon
Antibiotics should only be used if there is a suspicion of a secondary infection, typically suggested by persistent pain and swelling, sometimes with fever and systemic upset. In this case, a referral to an ENT surgeon is also recommended.Oral Antibiotics and NSAIDs
NSAIDs can be used to relieve any pain, but antibiotics should only be used if there is a suspicion of a secondary infection. This is typically suggested by persistent pain and swelling, sometimes with fever and systemic upset.Oral Steroids
Oral steroids have no role in the management of salivary gland stones.Watchful Waiting
Left untreated, salivary gland stones can cause significant stress and psychological distress to patients. Therefore, it is not recommended to adopt a watchful waiting approach. -
This question is part of the following fields:
- ENT
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Question 5
Incorrect
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A 49-year-old woman presents to the acute medical unit with a sudden onset of dizziness, describing the sensation of the room spinning around her. The dizziness persists and does not improve with rest, accompanied by severe nausea and vomiting. She reports hearing loss in her left ear and has recently experienced a cough and coryza episode. The patient has no prior medical history.
Upon examination, Rinne's test reveals air conduction greater than bone conduction in both ears, and Weber's test lateralizes to her right ear. The patient displays normal eye movements with mild horizontal nystagmus on lateral gaze and intact coordination.
What is the most likely diagnosis?Your Answer: Vestibular neuritis
Correct Answer: Labyrinthitis
Explanation:A typical scenario for viral labyrinthitis involves a person who has recently had a respiratory infection and suddenly experiences vertigo, vomiting, and hearing loss. The symptoms are usually severe and persistent, and rest may not provide relief. This is likely caused by a viral infection in the inner ear, which is known as labyrinthitis. Given the patient’s history, this is the most probable diagnosis.
Understanding Vertigo and Its Causes
Vertigo is a condition characterized by a false sensation of movement in the body or environment. It can be caused by various factors, including viral infections, vestibular neuronitis, benign paroxysmal positional vertigo, Meniere’s disease, vertebrobasilar ischaemia, and acoustic neuroma.
Viral labyrinthitis and vestibular neuronitis are often associated with recent viral infections and can cause sudden onset vertigo, nausea, and vomiting. While hearing may be affected in viral labyrinthitis, vestibular neuronitis does not cause hearing loss. Benign paroxysmal positional vertigo, on the other hand, has a gradual onset and is triggered by changes in head position. Each episode typically lasts for 10-20 seconds.
Meniere’s disease is characterized by vertigo, hearing loss, tinnitus, and a sensation of fullness or pressure in one or both ears. Vertebrobasilar ischaemia, which is more common in elderly patients, can cause dizziness when the neck is extended. Acoustic neuroma, which is associated with neurofibromatosis type 2, can cause hearing loss, vertigo, and tinnitus. An absent corneal reflex is an important sign of this condition.
Other causes of vertigo include posterior circulation stroke, trauma, multiple sclerosis, and ototoxicity from medications like gentamicin. Understanding the different causes of vertigo can help in the diagnosis and management of this condition.
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This question is part of the following fields:
- ENT
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Question 6
Correct
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During a standard cranial nerve assessment, the subsequent results are noted: Rinne's test: Air conduction > bone conduction in both ears Weber's test: Localises to the right side What is the significance of these test outcomes?
Your Answer: Left sensorineural deafness
Explanation:If there is a sensorineural issue during Weber’s test, the sound will be perceived on the healthy side (right), suggesting a problem on the opposite side (left).
Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness
Rinne’s and Weber’s tests are two diagnostic tools used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test suggests conductive deafness if BC is greater than AC.
On the other hand, Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.
To interpret the results of Rinne’s and Weber’s tests, a normal result indicates that AC is greater than BC bilaterally, and the sound is midline in Weber’s test. Conductive hearing loss is indicated by BC being greater than AC in the affected ear, while AC is greater than BC in the unaffected ear, and the sound lateralizes to the affected ear in Weber’s test. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, and the sound lateralizes to the unaffected ear in Weber’s test.
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This question is part of the following fields:
- ENT
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Question 7
Incorrect
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A 25-year-old student presents with four days of right otalgia, discharge and reduced hearing. There is no significant past medical history, and she is systemically well. She never had any similar symptoms before.
On examination, there is an inflamed auditory canal and a small amount of debris, the tympanic membrane appears to be normal.
What is the best initial management for this patient?Your Answer: Take an ear swab and start topical antibiotic
Correct Answer: Start topical antibiotic and steroid
Explanation:Management of Otitis Externa: Recommended Actions and Guidelines
Otitis externa is a common condition that affects the outer ear canal. The management of this condition depends on the severity of the inflammation and the presence of other symptoms. Here are some recommended actions and guidelines for managing otitis externa:
1. Start topical antibiotic and steroid: This is recommended for patients with acute otitis externa who present with more severe inflammation. The treatment should last for seven days.
2. Start topical acetic acid 2% spray: This is recommended for patients with mild otitis externa who do not have hearing loss or discharge.
3. Refer to ENT urgently: This is not part of initial management but should be considered for patients with chronic diffuse otitis externa when treatment is prolonged beyond two to three months.
4. Start oral amoxicillin: Oral antibiotics are rarely indicated for otitis externa. They should only be considered for patients with severe infection or at high risk of severe infection.
5. Take an ear swab and start topical antibiotic: Ear swab is not recommended as first-line management. It should only be done if there is no response to initial treatment or in recurrent infections.
In summary, the management of otitis externa depends on the severity of the inflammation and the presence of other symptoms. Following these recommended actions and guidelines can help improve patient outcomes.
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This question is part of the following fields:
- ENT
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Question 8
Incorrect
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A 38-year-old man presents to you with complaints of a persistent sensation of mucus in the back of his throat. He also reports a chronic cough for the past 6 months and frequently experiences bad breath, particularly in the mornings. He admits to smoking 10 cigarettes daily but otherwise feels fine. On examination, his ears appear normal, and his throat shows slight redness with no swelling of the tonsils. What is the most probable diagnosis?
Your Answer: Nasal polyp
Correct Answer: Postnasal drip
Explanation:Nasal tumors can cause symptoms such as nosebleeds, a persistent blocked nose, blood-stained mucus draining from the nose, and a decreased sense of smell. A chronic cough in smokers, known as a smoker’s cough, is caused by damage and destruction of the protective cilia in the respiratory tract. Nasal polyps can result in symptoms such as nasal obstruction, sneezing, rhinorrhea, and a poor sense of taste and smell. If symptoms are unilateral or accompanied by bleeding, it may be a sign of a more serious condition. Nasal foreign bodies, which are commonly found in children, can include items such as peas, beads, buttons, seeds, and sweets.
Understanding Post-Nasal Drip
Post-nasal drip is a condition that arises when the nasal mucosa produces an excessive amount of mucus. This excess mucus then accumulates in the back of the nose or throat, leading to a chronic cough and unpleasant breath. Essentially, post-nasal drip occurs when the body produces more mucus than it can handle, resulting in a buildup that can cause discomfort and irritation. This condition can be caused by a variety of factors, including allergies, sinus infections, and even certain medications. Understanding the causes and symptoms of post-nasal drip can help individuals seek appropriate treatment and alleviate their discomfort.
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This question is part of the following fields:
- ENT
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Question 9
Correct
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A 32-year-old man visits the clinic with a concern about experiencing frequent episodes of dizziness for the past four weeks, lasting about 1 hour each time. He has also noticed a ‘fullness sensation and ringing’ in his right ear.
Select the SINGLE most probable diagnosis from the options below.Your Answer: Ménière’s disease
Explanation:Understanding Common Causes of Vertigo: Ménière’s Disease, BPPV, Acoustic Neuroma, Vestibular Neuritis, and Cholesteatoma
Vertigo is a common condition that can be caused by various factors. One of the most common causes is Ménière’s disease, which is characterized by a triad of symptoms including fluctuant hearing loss, vertigo, and tinnitus. Aural fullness may also be present. On the other hand, benign paroxysmal positional vertigo (BPPV) is induced by specific movements and is accompanied by nausea, light-headedness, and imbalance. Acoustic neuroma, on the other hand, presents with progressive ipsilateral tinnitus, sensorineural hearing loss, facial numbness, and giddiness. Vestibular neuritis, which follows a febrile illness, is characterized by sudden vertigo, vomiting, and prostration, while cholesteatoma tends to be asymptomatic in the early stages and is characterized by a foul-smelling discharge and conductive hearing loss. Management of vertigo includes self-care advice, medication, and referral to an ENT specialist to confirm the condition and exclude sinister causes.
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This question is part of the following fields:
- ENT
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Question 10
Correct
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A 25-year-old male has been diagnosed with nasal polyps. Which medication sensitivity is commonly linked to this condition?
Your Answer: Aspirin
Explanation:Understanding Nasal Polyps
Nasal polyps are a relatively uncommon condition affecting around 1% of adults in the UK. They are more commonly seen in men and are not typically found in children or the elderly. There are several associations with nasal polyps, including asthma (particularly late-onset asthma), aspirin sensitivity, infective sinusitis, cystic fibrosis, Kartagener’s syndrome, and Churg-Strauss syndrome. When asthma, aspirin sensitivity, and nasal polyposis occur together, it is known as Samter’s triad.
The symptoms of nasal polyps include nasal obstruction, rhinorrhoea, sneezing, and a poor sense of taste and smell. It is important to note that any unusual symptoms, such as unilateral symptoms or bleeding, require further investigation. If nasal polyps are suspected, patients should be referred to an ear, nose, and throat (ENT) specialist for a full examination.
The management of nasal polyps typically involves the use of topical corticosteroids, which can shrink polyp size in around 80% of patients. Overall, understanding nasal polyps and their associations can help with early detection and appropriate management.
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This question is part of the following fields:
- ENT
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Question 11
Correct
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A 25-year-old woman presents to her GP with recurrent, foul-smelling discharge from her right ear and decreased hearing on that side. She has been experiencing these episodes every few months, but now notices the discharge on most days. During childhood, she frequently swam and had grommet insertion for glue ear, which fell out when she was around 10 years old. She has no significant medical history and takes only the combined oral contraceptive pill.
After conducting hearing tests, the following results were obtained:
- Rinne's test (right side): bone conduction > air conduction
- Rinne's test (left side): air conduction > bone conduction
- Weber's test: lateralisation to the right
What is the likely diagnosis?Your Answer: Cholesteatoma
Explanation:The patient is experiencing a conductive hearing loss on the right side, as evidenced by Rinne’s test showing bone conduction > air conduction in the affected ear and Weber’s test lateralizing to the right ear. The most likely diagnosis is cholesteatoma, which is associated with recurrent ear discharge and glue ear. Cholesteatoma occurs when squamous epithelium forms pockets on the tympanic membrane, leading to cyst-like growths that produce keratin and slough over time. This causes erosion in the middle ear, creating an environment for anaerobic bacterial growth.
Acoustic neuroma, on the other hand, causes sensorineural hearing loss, which is characterized by air conduction > bone conduction in both ears and Weber test lateralizing to the unaffected ear. It is associated with dizziness and typically causes unilateral hearing loss. As the tumor grows, patients may develop neurological symptoms that can be predicted by the affected cranial nerves.
Otitis externa is an acute infection of the outer ear that can cause conductive hearing loss, but as the patient has a chronic history and lacks ear pain, this diagnosis is less likely. Otosclerosis, which presents with progressive conductive hearing loss and tinnitus, is an autosomal dominant trait that typically affects individuals aged 20-40 years with a family history of early-onset hearing loss. As it does not typically present with smelly ear discharge, other diagnoses should be considered first.
Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness
Rinne’s and Weber’s tests are two diagnostic tools used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test suggests conductive deafness if BC is greater than AC.
On the other hand, Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.
To interpret the results of Rinne’s and Weber’s tests, a normal result indicates that AC is greater than BC bilaterally, and the sound is midline in Weber’s test. Conductive hearing loss is indicated by BC being greater than AC in the affected ear, while AC is greater than BC in the unaffected ear, and the sound lateralizes to the affected ear in Weber’s test. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, and the sound lateralizes to the unaffected ear in Weber’s test.
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This question is part of the following fields:
- ENT
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Question 12
Incorrect
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A 32-year-old man complains of left ear pain and hearing loss for the past week. He is an avid swimmer. During examination, you observe pre-auricular lymph nodes on the left side. The ear is inflamed, red, and tender to touch. A small amount of yellow discharge is visible in the ear canal.
What is the initial treatment of choice after obtaining swabs?Your Answer: Oral antibiotics
Correct Answer: Topical antibiotic drops
Explanation:Patients suffering from otitis media typically experience relief from symptoms within 4 days without the need for antibiotics. While antibiotics can help shorten the duration of symptoms, they come with the risk of side effects and drug resistance. Therefore, treatment is usually postponed unless symptoms persist, the patient is generally unwell, or symptoms affect both ears. In rare cases, ear syringing may be used as a secondary treatment to remove debris from the ear canal.
Understanding Otitis Externa: Causes, Features, and Management
Otitis externa is a common condition that often prompts patients to seek medical attention. It is characterized by ear pain, itch, and discharge, and is caused by various factors such as infection, seborrhoeic dermatitis, and contact dermatitis. Swimming is also a common trigger of otitis externa. Upon examination, the ear canal appears red, swollen, or eczematous.
The recommended initial management of otitis externa involves the use of topical antibiotics or a combination of topical antibiotics with a steroid. However, if the tympanic membrane is perforated, aminoglycosides are traditionally not used. In cases where there is canal debris, removal may be necessary, while an ear wick may be inserted if the canal is extensively swollen. Second-line options include oral antibiotics, taking a swab inside the ear canal, and empirical use of an antifungal agent.
It is important to note that if a patient fails to respond to topical antibiotics, referral to an ENT specialist may be necessary. Malignant otitis externa is a more serious condition that is more common in elderly diabetics. It involves the extension of infection into the bony ear canal and the soft tissues deep to the bony canal, and may require intravenous antibiotics.
Overall, understanding the causes, features, and management of otitis externa is crucial in providing appropriate care and preventing complications.
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This question is part of the following fields:
- ENT
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Question 13
Correct
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An 18-year-old woman presents to her GP with painful lumps in her neck that appeared two days ago. She also reports a sore throat and fever. Upon examination, she has tender, enlarged, smooth masses on both sides. What is the most probable diagnosis?
Your Answer: Reactive lymphadenopathy
Explanation:Differentiating Neck Lumps: Causes and Characteristics
When a patient presents with a neck lump, it is important to consider the possible causes and characteristics to determine the appropriate course of action. In this case, the patient’s sore throat and fever suggest a throat infection, which has resulted in reactive lymphadenopathy. This is a common cause of neck lump presentations in primary care.
Other possible causes of neck lumps include goitre, which is a painless mass in the midline of the throat that is not associated with fever and may be functional if accompanied by hyperthyroidism. An abscess could also present as a painful neck lump, but the history of a sore throat and bilateral swelling make this less likely.
Branchial cysts are smooth, soft masses in the lateral neck that are usually benign and congenital in origin. Lipomas, on the other hand, are lumps caused by the accumulation of soft, fatty deposits under the skin and do not typically present with systemic features.
In summary, understanding the characteristics and possible causes of neck lumps can aid in the diagnosis and management of patients presenting with this symptom.
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This question is part of the following fields:
- ENT
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Question 14
Incorrect
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A 72-year-old man who smokes visits your GP clinic and inquires about potential complications associated with surgical resection of his malignant parotid gland tumour. What is the classic complication linked to parotid gland surgery?
Your Answer: Upper motor neurone facial palsy
Correct Answer: Lower motor neurone facial palsy
Explanation:A lower motor neurone facial palsy can be caused by parotid pathology.
After exiting the stylomastoid foramen, the facial nerve passes through the parotid gland and divides into five branches: temporal, zygomatic, buccal, marginal mandibular, and cervical. If there is any pathology within the parotid gland, it can lead to a lower motor neurone facial palsy. Additionally, surgery to the parotid gland can also result in this complication.
Facial Nerve Palsy: Causes and Path
Facial nerve palsy is a condition that affects the facial nerve, which supplies the muscles of facial expression, digastric muscle, and glandular structures. It can be caused by various factors, including sarcoidosis, Guillain-Barre syndrome, Lyme disease, acoustic neuromas, and Bell’s palsy. Bilateral facial nerve palsy is less common and can be caused by the same factors as unilateral palsy, but it can also be a result of neurofibromatosis type 2.
The facial nerve has two paths: the subarachnoid path and the facial canal path. The subarachnoid path originates from the pons and passes through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve. The facial canal path passes superior to the vestibule of the inner ear and contains the geniculate ganglion at the medial aspect of the middle ear. It has three branches: the greater petrosal nerve, the nerve to stapedius, and the chorda tympani. The facial nerve then passes through the stylomastoid foramen and gives rise to the posterior auricular nerve and a branch to the posterior belly of the digastric and stylohyoid muscle.
It is important to differentiate between lower motor neuron and upper motor neuron lesions in facial nerve palsy. An upper motor neuron lesion spares the upper face, while a lower motor neuron lesion affects all facial muscles. Multiple sclerosis and diabetes mellitus can also cause an upper motor neuron palsy. Understanding the causes and path of facial nerve palsy can aid in its diagnosis and treatment.
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This question is part of the following fields:
- ENT
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Question 15
Incorrect
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A 30-year-old woman presents to surgery with a complaint of not having a regular menstrual cycle for the past year, despite a negative pregnancy test. You order initial tests to establish a baseline. Which of the following is not included in your list of possible diagnoses?
Your Answer: Thyrotoxicosis
Correct Answer: Turner's syndrome
Explanation:Primary amenorrhoea is caused by Turner’s syndrome instead of secondary amenorrhoea.
Understanding Amenorrhoea: Causes, Investigations, and Management
Amenorrhoea is a condition characterized by the absence of menstrual periods in women. It can be classified into two types: primary and secondary. Primary amenorrhoea occurs when menstruation fails to start by the age of 15 in girls with normal secondary sexual characteristics or by the age of 13 in girls with no secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.
There are various causes of amenorrhoea, including gonadal dysgenesis, testicular feminization, congenital malformations of the genital tract, functional hypothalamic amenorrhoea, congenital adrenal hyperplasia, imperforate hymen, hypothalamic amenorrhoea, polycystic ovarian syndrome, hyperprolactinemia, premature ovarian failure, Sheehan’s syndrome, Asherman’s syndrome, and thyrotoxicosis. To determine the underlying cause of amenorrhoea, initial investigations such as full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels are necessary.
The management of amenorrhoea depends on the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause in women 40 years of age or older and treat the underlying cause accordingly. It is important to note that hypothyroidism may also cause amenorrhoea.
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This question is part of the following fields:
- ENT
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Question 16
Correct
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A 75-year-old woman comes to the clinic with a painful swelling on the left side of her neck below the jaw angle that has been bothering her for the past 5 days. She also reports a bad taste in her mouth. During the physical examination, the patient has a temperature of 37.8ºC and a tender submandibular mass measuring 4x5cm. Additionally, there is tender lymphadenopathy. What is the probable diagnosis?
Your Answer: Sialadenitis
Explanation:This woman is experiencing sialadenitis, which is inflammation of the salivary gland. It is likely caused by a stone blocking the duct. The submandibular gland is located below the jawline and its duct drains into the floor of the mouth. When there is a discharge from this duct, it can cause a bad taste in the mouth. There are three main salivary glands: the parotid glands, which are located in front of and below each ear, the submandibular glands, which are located below the jawline, and the sublingual glands, which are located beneath the tongue. Disorders of these glands can be caused by infection, inflammation, obstruction, or malignancy. Swelling of the submandibular gland can be caused by a stone or a tumor, which can be either benign or malignant.
Salivary Glands and Their Pathologies
Salivary glands are responsible for producing saliva, which aids in digestion and protects the mouth from harmful bacteria. There are three pairs of salivary glands: parotid, submandibular, and sublingual. The parotid gland is the most common site for tumors, while the submandibular gland is most commonly affected by stones.
Tumors in the salivary glands are rare, but when they do occur, 80% of them are found in the parotid gland. Of these, 80% are pleomorphic adenomas, which are benign. These tumors typically grow slowly and are painless, but surgical removal carries a risk of damage to the facial nerve (CN VII). Warthin’s tumor is another benign tumor that affects the salivary glands, but it is less common than pleomorphic adenomas.
Stones in the salivary glands can cause recurrent pain and swelling, especially when eating. They are most commonly found in the submandibular gland and can lead to infection if left untreated. Other causes of salivary gland enlargement include viral or bacterial infections, as well as autoimmune disorders like Sjogren’s syndrome. Proper diagnosis and treatment are important for managing these conditions and preventing complications.
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This question is part of the following fields:
- ENT
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Question 17
Incorrect
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A 35-year-old man visits his GP complaining of nasal congestion, facial pain, a runny nose, and a decreased sense of smell that has been ongoing for three months. He has a history of seasonal allergies. Upon palpation of the maxillofacial area, tenderness is noted. No visible nasal polyps are present.
What are the primary symptoms of chronic sinusitis?Your Answer: Symptoms lasting greater than four weeks
Correct Answer: Facial pain and/or pressure
Explanation:Understanding the Symptoms of Chronic Rhinosinusitis
Chronic rhinosinusitis is a condition characterized by inflammation of the sinuses that lasts for at least 12 weeks. To diagnose this condition, doctors look for specific symptoms that are indicative of chronic sinusitis. These symptoms include nasal obstruction, nasal discharge, facial pain and pressure, and loss of smell sensation.
Facial pain and pressure are common symptoms of chronic sinusitis, and they are caused by congestion of the sinuses. Pain is typically felt over the maxillary, ethmoid, and frontal sinuses, which can be palpated by a doctor during an examination. Coughing is not a major symptom of chronic sinusitis, but it may be present in some patients and could indicate an underlying condition such as asthma or COPD.
Nasal polyps are not a major symptom of chronic sinusitis, but they can be present in some individuals with this condition. The presence of nasal polyps indicates a variant of chronic sinusitis, which may require different management strategies.
It is important to note that symptoms must last for at least 12 weeks without resolution before a diagnosis of chronic rhinosinusitis can be made. If symptoms last for less than 12 weeks, the criteria for chronic rhinosinusitis are not met. While patients may be experiencing chronic sinusitis before the 12-week mark, doctors must wait for this duration to confirm the diagnosis.
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This question is part of the following fields:
- ENT
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Question 18
Correct
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A 68-year-old male visits his primary care physician with a complaint of persistent left-sided ear pain for over a month. He reports no hearing loss or discharge and feels generally healthy. He has a history of hypertension and currently smokes 15 cigarettes a day. Otoscopy reveals no abnormalities in either ear. What is the best course of action to take?
Your Answer: Refer to ENT under 2-week wait
Explanation:If a person experiences unexplained ear pain on one side for more than 4 weeks and there are no visible abnormalities during an otoscopy, it is important to refer them for further investigation under the 2-week wait. This is particularly crucial for individuals who smoke, as they are at a higher risk for head and neck cancer. Using topical antibiotic/steroid drops or nasal steroid sprays without identifying any underlying pathology is not recommended. While amitriptyline may provide relief for symptoms, it should not be used as a substitute for proper diagnosis and treatment. Referring the patient for further evaluation is necessary to rule out the possibility of malignancy.
Understanding Head and Neck Cancer
Head and neck cancer is a broad term that encompasses various types of cancer, including oral cavity cancers, pharynx cancers, and larynx cancers. Symptoms of head and neck cancer may include a neck lump, hoarseness, persistent sore throat, and mouth ulcers.
To ensure prompt diagnosis and treatment, the National Institute for Health and Care Excellence (NICE) has established suspected cancer pathway referral criteria. For instance, individuals aged 45 and over with persistent unexplained hoarseness or an unexplained lump in the neck may be referred for an appointment within two weeks to assess for laryngeal cancer. Similarly, those with unexplained ulceration in the oral cavity lasting for more than three weeks or a persistent and unexplained lump in the neck may be referred for an appointment within two weeks to assess for oral cancer.
Dentists may also play a role in identifying potential cases of oral cancer. Individuals with a lump on the lip or in the oral cavity or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia may be urgently referred for assessment within two weeks. Finally, individuals with an unexplained thyroid lump may be referred for an appointment within two weeks to assess for thyroid cancer. By following these guidelines, healthcare providers can help ensure timely diagnosis and treatment of head and neck cancer.
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This question is part of the following fields:
- ENT
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Question 19
Incorrect
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A 35-year-old man attends morning surgery complaining of ringing in his left ear, with occasional vertigo. His coworkers have recently commented that he speaks loudly on the phone. On examination his tympanic membranes appear normal.
Which of the following is the most probable diagnosis?
Your Answer: Presbyacusis
Correct Answer: Ménière’s disease
Explanation:Understanding Ménière’s Disease: Symptoms, Diagnosis, and Management
Ménière’s disease is a progressive inner ear disorder that can cause a triad of symptoms including fluctuant hearing loss, vertigo, and tinnitus. Aural fullness may also be present. In contrast, benign paroxysmal positional vertigo (BPPV) is characterized by brief episodes of vertigo induced by specific movements, while cholesteatoma typically presents with recurrent ear discharge, conductive hearing loss, and ear discomfort. Presbyacusis, or age-related hearing loss, is not the most likely diagnosis in this case. Although impacted ear wax can cause similar symptoms, normal tympanic membranes suggest that Ménière’s disease is more likely.
Diagnosis of Ménière’s disease is based on a history of at least two spontaneous episodes of vertigo lasting 20 minutes each, along with tinnitus and/or a sense of fullness in the ear canal, and confirmed sensorineural hearing loss on audiometry. Management includes self-care advice such as vestibular rehabilitation, medication such as prochlorperazine for acute attacks and betahistine for prevention, and referral to an ENT specialist to confirm the diagnosis and exclude other causes. Patients should also consider the risks of certain activities, such as driving or operating heavy machinery, during severe symptoms. With proper management, patients with Ménière’s disease can improve their quality of life and reduce the impact of their symptoms.
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This question is part of the following fields:
- ENT
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Question 20
Incorrect
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A 58-year-old woman presents to the emergency department with a 1-day history of facial paralysis. She also complains of some mild ear pain over the last 2 days. On examination, she has a fixed half-smile on the left side of her face. She is unable to raise her left eyelid and has increased sensitivity to sound in her left ear. She denies dizziness or vertigo. The remainder of her cranial nerve examination is normal. ENT examination shows an erythematous left ear canal and vesicles over her soft palate.
What is the most appropriate treatment to initiate for the likely diagnosis?Your Answer: Oral prednisolone
Correct Answer: Oral aciclovir and prednisolone
Explanation:When a patient presents with a facial nerve palsy and a vesicular rash, Ramsay Hunt syndrome should be considered. The vesicles may not be limited to the ear canal and can also appear on the tongue or soft palate. Treatment typically involves administering oral aciclovir and corticosteroids, unless the patient is severely ill. Ganciclovir is used to treat cytomegalovirus, while amoxicillin would be a more suitable option if bacterial otitis media was the underlying cause of the patient’s symptoms.
Understanding Ramsay Hunt Syndrome
Ramsay Hunt syndrome, also known as herpes zoster oticus, is a condition that occurs when the varicella zoster virus reactivates in the geniculate ganglion of the seventh cranial nerve. The first symptom of this condition is often auricular pain, followed by facial nerve palsy and a vesicular rash around the ear. Other symptoms may include vertigo and tinnitus.
To manage Ramsay Hunt syndrome, doctors typically prescribe oral aciclovir and corticosteroids. These medications can help reduce the severity of symptoms and prevent complications.
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This question is part of the following fields:
- ENT
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Question 21
Correct
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A 42-year-old man comes to your clinic complaining of ear pain. He had visited the emergency department 3 days ago but was only given advice. He has been experiencing ear pain for 5 days now.
During the examination, his temperature is 38.5ºC and his right ear drum is red and bulging. What is the appropriate management for this patient?Your Answer: Start amoxicillin
Explanation:To improve treatment of tonsillitis and otitis media without relying on antibiotics, medical guidelines suggest waiting 2-3 days before considering treatment if symptoms do not improve. This approach is especially important when a patient has a fever, indicating systemic involvement. Therefore, recommending regular paracetamol is not appropriate in this case. While erythromycin can be a useful alternative for patients with a penicillin allergy, it should not be the first choice for those who can take penicillin. Penicillin V is the preferred antibiotic for tonsillitis, as amoxicillin can cause a rash in cases of glandular fever. However, it is not typically used for otitis media. For otitis media, amoxicillin is the recommended first-line medication at a dosage of 500mg TDS for 7 days. Co-amoxiclav is only used as a second-line option if amoxicillin is ineffective, and is not recommended as a first-line treatment according to current medical guidelines. These recommendations are based on NICE Guidelines and Clinical Knowledge Summaries.
Acute Otitis Media: Causes, Symptoms, and Management
Acute otitis media is a common condition in young children, with around 50% experiencing three or more episodes by the age of 3 years. While viral upper respiratory tract infections often precede otitis media, bacterial infections, particularly Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, are the primary cause. Viral infections disrupt the normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear through the Eustachian tube.
Symptoms of acute otitis media include ear pain, fever, hearing loss, and recent viral upper respiratory tract infection symptoms. Otoscopy may reveal a bulging tympanic membrane, opacification or erythema of the tympanic membrane, perforation with purulent otorrhoea, or decreased mobility when using a pneumatic otoscope. Diagnosis is typically based on the acute onset of symptoms, otalgia or ear tugging, the presence of a middle ear effusion, bulging of the tympanic membrane, otorrhoea, decreased mobility on pneumatic otoscopy, or inflammation of the tympanic membrane.
Acute otitis media is generally self-limiting and does not require antibiotic treatment. However, antibiotics should be prescribed if symptoms last more than four days or do not improve, if the patient is systemically unwell but not requiring admission, if the patient is immunocompromised or at high risk of complications, if the patient is younger than 2 years with bilateral otitis media, or if there is otitis media with perforation and/or discharge in the canal. Amoxicillin is the first-line antibiotic, but erythromycin or clarithromycin should be given to patients with penicillin allergy.
Common sequelae of acute otitis media include perforation of the tympanic membrane, unresolved acute otitis media with perforation leading to chronic suppurative otitis media, hearing loss, and labyrinthitis. Complications may include mastoiditis, meningitis, brain abscess, and facial nerve paralysis. Parents should seek medical help if symptoms worsen or do not improve after three days.
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This question is part of the following fields:
- ENT
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Question 22
Correct
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Which of the following viruses is linked to nasopharyngeal carcinoma?
Your Answer: Epstein-Barr virus
Explanation:EBV is linked to the development of Burkitt’s lymphoma, Hodgkin’s lymphoma, and nasopharyngeal carcinoma.
Conditions Associated with Epstein-Barr Virus
Epstein-Barr virus (EBV) is linked to several conditions, including malignancies and non-malignant conditions. The malignancies associated with EBV infection include Burkitt’s lymphoma, Hodgkin’s lymphoma, nasopharyngeal carcinoma, and HIV-associated central nervous system lymphomas. Burkitt’s lymphoma is currently believed to be associated with both African and sporadic cases.
Apart from malignancies, EBV infection is also associated with a non-malignant condition called hairy leukoplakia. This condition is characterized by white patches on the tongue and inside of the cheeks. It is often seen in people with weakened immune systems, such as those with HIV/AIDS.
In summary, EBV infection is linked to several conditions, including both malignant and non-malignant ones. Understanding the association between EBV and these conditions is crucial for developing effective prevention and treatment strategies.
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This question is part of the following fields:
- ENT
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Question 23
Correct
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A 35-year-old woman presents with hearing loss on the left and persistent tinnitus for a few weeks. On examination, an absent corneal reflex is noted.
Which of the following is the most appropriate diagnosis?Your Answer: Acoustic neuroma
Explanation:Differentiating Causes of Hearing Loss and Tinnitus: A Guide
When patients present with hearing loss and tinnitus, it is important to consider the various potential causes in order to provide appropriate treatment. One possible cause is acoustic neuroma, a rare tumor that affects the Schwann cells of the nerve sheath in the cerebellopontine angle. Patients with acoustic neuroma typically experience unilateral hearing loss and tinnitus, but vertigo is rare. Examination may reveal facial numbness, weakness, or ataxia, as well as absence of the corneal reflex.
Another potential cause is Ménière’s disease, which is characterized by sudden attacks of tinnitus, vertigo, a sensation of fullness in the ear, and fluctuating sensorineural hearing loss. However, an absent corneal reflex is not associated with this condition.
Otosclerosis is a form of conductive hearing loss that often presents in early adulthood, with symptoms including tinnitus and transient vertigo. Again, an absent corneal reflex is not typically observed.
Vestibular neuronitis, which follows a febrile illness and causes sudden vertigo, vomiting, and prostration exacerbated by head movement, is not associated with hearing loss, tinnitus, or absent corneal reflexes.
Finally, while impacted ear wax can cause tinnitus and hearing loss, it would not result in an absent corneal reflex on examination. By considering these various potential causes, healthcare providers can more accurately diagnose and treat patients with hearing loss and tinnitus.
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This question is part of the following fields:
- ENT
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Question 24
Correct
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A 45-year-old woman attends the general practice surgery with her husband who is concerned that since she has started working from home several months ago, she has had a continuous cold. She reports frequent sneezing, clear nasal discharge and a terrible taste in her mouth in the morning. Her eyes look red and feel itchy. She has noticed that the symptoms improve when she is at the office or when they have been on vacation. She has a history of migraines and is otherwise well. She has not yet tried any treatment for her symptoms.
Which of the following is the most likely diagnosis?Your Answer: Allergic rhinitis
Explanation:Understanding Allergic Rhinitis: Symptoms, Causes, and Differential Diagnosis
Allergic rhinitis is a common condition that presents with a range of symptoms, including sneezing, itchiness, rhinorrhea, and a blocked nose. Patients with allergic rhinitis often experience eye symptoms such as bilateral itchiness, redness, and swelling. While the diagnosis of allergic rhinitis is usually based on characteristic features, it is important to exclude infectious and irritant causes.
In this case, the patient’s symptoms and medical history suggest an allergic cause for his condition. It would be prudent to inquire about his new home environment, as the allergen may be animal dander from a pet or house dust mites if there are more soft furnishings and carpets than in his previous home.
Other possible diagnoses, such as acute infective rhinitis, acute sinusitis, rhinitis medicamentosa, and nasopharyngeal carcinoma, can be ruled out based on the patient’s symptoms and medical history. For example, acute infective rhinitis would present more acutely with discolored nasal discharge and other upper respiratory tract infection symptoms. Acute sinusitis would present with facial pain or pressure and discolored nasal discharge. Rhinitis medicamentosa is caused by long-term use of intranasal decongestants, which is not the case for this patient. Nasopharyngeal carcinoma is rare and typically presents with unilateral symptoms and a middle-ear effusion.
Overall, understanding the symptoms, causes, and differential diagnosis of allergic rhinitis is crucial for proper management and treatment of this common condition.
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This question is part of the following fields:
- ENT
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Question 25
Incorrect
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A 55-year-old woman with a history of diabetes complains of left-sided ear pain and discharge. During examination, her temperature is recorded at 37.9ºC and there is red discharge in the ear canal. The tympanic membrane is partially visible and appears normal. Despite visiting the out of hours clinic twice and using different ear drops for two weeks, her symptoms persist. What course of treatment should be recommended?
Your Answer: Topical antibiotic drops
Correct Answer: Referral to secondary care
Explanation:It is probable that the patient is suffering from malignant otitis externa, a condition that affects individuals with weakened immune systems like those with diabetes. This condition is characterized by osteomyelitis of the temporal bone. Despite receiving several rounds of antibiotic drops, the patient’s symptoms have not improved. It is recommended that the patient be referred to an ENT specialist for a CT scan of the temporal bones and treated with an extended course of intravenous antibiotics.
Understanding Otitis Externa: Causes, Features, and Management
Otitis externa is a common condition that often prompts patients to seek medical attention. It is characterized by ear pain, itch, and discharge, and is caused by various factors such as infection, seborrhoeic dermatitis, and contact dermatitis. Swimming is also a common trigger of otitis externa. Upon examination, the ear canal appears red, swollen, or eczematous.
The recommended initial management of otitis externa involves the use of topical antibiotics or a combination of topical antibiotics with a steroid. However, if the tympanic membrane is perforated, aminoglycosides are traditionally not used. In cases where there is canal debris, removal may be necessary, while an ear wick may be inserted if the canal is extensively swollen. Second-line options include oral antibiotics, taking a swab inside the ear canal, and empirical use of an antifungal agent.
It is important to note that if a patient fails to respond to topical antibiotics, referral to an ENT specialist may be necessary. Malignant otitis externa is a more serious condition that is more common in elderly diabetics. It involves the extension of infection into the bony ear canal and the soft tissues deep to the bony canal, and may require intravenous antibiotics.
Overall, understanding the causes, features, and management of otitis externa is crucial in providing appropriate care and preventing complications.
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This question is part of the following fields:
- ENT
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Question 26
Incorrect
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A 45-year-old woman presents to the Emergency Department with a 2-week history of dull pain under her tongue while eating. This resolves after she finishes eating and has been gradually getting worse. Over the previous three days, this was also accompanied by swelling of the floor of her mouth. She is afebrile and all of her parameters are stable.
Which of the following is the first-line investigation that needs to be done?
Your Answer: CT sialogram
Correct Answer: X-ray sialogram
Explanation:Investigating Salivary Gland Stones: Imaging and Laboratory Tests
Salivary gland stones, or sialolithiasis, can cause pain and swelling in the affected gland, especially during eating or chewing. Diagnosis is usually based on clinical examination, but imaging may be necessary in cases of diagnostic uncertainty or suspected secondary infection. X-ray sialography is the traditional first-line investigation, as it is cheap and highly sensitive. Ultrasound and more advanced techniques like magnetic resonance sialography and CT sialography may also be used, but X-ray sialography remains the preferred option. Laboratory tests like amylase levels and blood cultures are not typically used in the diagnosis of sialolithiasis, unless there is a suspicion of acute pancreatitis or secondary infection, respectively.
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This question is part of the following fields:
- ENT
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Question 27
Incorrect
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A 53-year-old male smoker presents to the emergency department with a sore throat that has been bothering him for a day. He reports feeling generally unwell and has a hoarse voice, but no cough. He has been unable to swallow for the past three hours and is spitting out saliva. During examination, he has a temperature of 38ºC and trismus. There are no obvious abnormalities in his oropharynx, and his tonsils appear normal. Additionally, he has bilateral cervical lymphadenopathy.
What is the most appropriate course of action for managing this patient?Your Answer: Discharge with oral antibiotics
Correct Answer: Immediate ENT evaluation
Explanation:If a patient presents with acute sore throat but no visible signs in the oropharynx, and experiences severe symptoms such as difficulty swallowing, sepsis, or trismus, it is crucial to seek urgent evaluation from an ENT specialist. This is because these symptoms may indicate a deeper airway infection, such as supraglottitis, which can be life-threatening. Therefore, the patient should not be discharged without a thorough examination, including flexible nasendoscopy. If supraglottitis is diagnosed, treatment should involve IV antibiotics, IV dexamethasone, and adrenaline nebulizers. The patient should be closely monitored in an airway monitored bed, such as in an ENT ward or ICU if necessary.
Sore throat is a term used to describe various conditions such as pharyngitis, tonsillitis, and laryngitis. According to Clinical Knowledge Summaries, throat swabs and rapid antigen tests should not be routinely carried out for patients with a sore throat. Pain relief can be managed with paracetamol or ibuprofen, and antibiotics are not typically necessary. However, in cases where there is marked systemic upset, unilateral peritonsillitis, a history of rheumatic fever, an increased risk from acute infection, or when three or more Centor criteria are present, antibiotics may be indicated. The Centor and FeverPAIN scoring systems can be used to determine the likelihood of isolating Streptococci. If antibiotics are necessary, phenoxymethylpenicillin or clarithromycin (for penicillin-allergic patients) can be given for a 7 or 10 day course. It is worth noting that a single dose of oral corticosteroid may reduce the severity and duration of pain, although this has not yet been incorporated into UK guidelines.
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This question is part of the following fields:
- ENT
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Question 28
Incorrect
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A 35-year-old man presented to his GP with bilateral deafness. Rinne’s test was found to be negative bilaterally. Weber's test was referred to both sides. On examination of his tympanic membrane, Schwartz's sign was visible.
Which of the following is the MOST likely cause of his symptoms?
Your Answer: Ménière's disease
Correct Answer: Otosclerosis
Explanation:Understanding the Causes of Hearing Loss: A Comparison of Otosclerosis, Cholesteatoma, Ménière’s Disease, Otitis Externa, and Otitis Media
Hearing loss can be caused by a variety of factors, including otosclerosis, cholesteatoma, Ménière’s disease, otitis externa, and otitis media. When conducting a differential diagnosis, it is important to consider the patient’s age, symptoms, and medical history.
Otosclerosis is a common cause of hearing loss in young adults, typically presenting as unilateral conductive hearing loss that progresses bilaterally. A negative Rinne’s test is indicative of conductive deafness, and a pink tinge on the tympanic membrane (Schwartz’s sign) is a diagnostic indicator for otosclerosis.
Cholesteatoma, on the other hand, typically presents with unilateral conductive hearing loss and/or ear discharge. Given the patient’s bilateral symptoms and young age, cholesteatoma is less likely to be the cause of her hearing loss.
Ménière’s disease is characterized by sudden attacks of tinnitus, vertigo, a sensation of fullness in the ear, and fluctuating sensorineural hearing loss. This is not the likely cause of the patient’s conductive hearing loss.
Otitis externa is inflammation of the external ear canal, which can cause hearing loss in rare cases due to occlusion of the ear canal from inflammation. Otitis media, on the other hand, is inflammation of the middle ear and is more commonly seen in children. It may present with unilateral conductive deafness, but is unlikely to be the cause of the patient’s bilateral symptoms.
In conclusion, when considering the causes of hearing loss, it is important to take into account the patient’s age, symptoms, and medical history. Otosclerosis is the most likely cause of conductive hearing loss in young adults, while cholesteatoma, Ménière’s disease, otitis externa, and otitis media may also be potential causes depending on the individual case.
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This question is part of the following fields:
- ENT
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Question 29
Incorrect
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A 35-year-old woman presents to your clinic with a history of recurrent episodes of dizziness characterized by a sensation of the entire room spinning around her. She reports feeling nauseous during these episodes but denies any hearing disturbance or tinnitus. The dizziness is not exacerbated by head movement and lasts for approximately 4-5 hours, with complete resolution in between episodes. She recalls having a viral illness the week prior to the onset of her symptoms. What is the most probable diagnosis?
Your Answer: Benign paroxysmal positional vertigo
Correct Answer: Vestibular neuronitis
Explanation:Patients with vestibular neuronitis experience recurrent episodes of vertigo lasting for hours to days, often accompanied by nausea. Unlike other causes of vertigo, there is no hearing loss, tinnitus, or neurological symptoms. Meniere’s disease, on the other hand, presents with vertigo, hearing loss, and tinnitus. Benign paroxysmal positional vertigo is characterized by brief episodes of vertigo triggered by head movement, while acoustic neuromas typically present with hearing loss, tinnitus, and facial nerve palsy. Vertebrobasilar insufficiency, which occurs in elderly patients, is associated with neck pain and symptoms triggered by head movement.
Understanding Vestibular Neuronitis
Vestibular neuronitis is a type of vertigo that typically occurs after a viral infection. It is characterized by recurrent episodes of vertigo that can last for hours or days, accompanied by nausea and vomiting. Horizontal nystagmus, or involuntary eye movements, is a common symptom, but there is usually no hearing loss or tinnitus.
It is important to distinguish vestibular neuronitis from other conditions that can cause similar symptoms, such as viral labyrinthitis or posterior circulation stroke. The HiNTs exam can be used to differentiate between vestibular neuronitis and stroke.
Treatment for vestibular neuronitis may involve medications such as prochlorperazine or antihistamines to alleviate symptoms. However, vestibular rehabilitation exercises are often the preferred treatment for patients with chronic symptoms. These exercises can help to retrain the brain and improve balance and coordination. With proper management, most people with vestibular neuronitis can recover fully and resume their normal activities.
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This question is part of the following fields:
- ENT
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Question 30
Correct
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A 58-year-old man contacts his General Practitioner to request a repeat prescription of xylometazoline hydrochloride nasal spray. He has been using this for the past four weeks to 'clear up his sinuses.'
What is the most likely side effect this patient will develop based on his current management?Your Answer: Rebound nasal congestion
Explanation:Understanding the Side Effects of Long-Term Nasal Decongestant Use
Nasal decongestants are a common treatment for nasal congestion, but long-term use can lead to adverse effects. One of the most significant risks is rebound nasal congestion, which can encourage further use and hypertrophy of the nasal mucosa. It is recommended to use nasal decongestants for a maximum of seven days to avoid this risk. Other adverse effects of long-term use include nasal burning, irritation, and dryness, but chronic rhinitis is not a recognized side effect. While cardiovascular effects like tachycardia and hypertension are possible, they are more common with oral decongestants. Septal perforation is a rare side effect of intranasal corticosteroids, not nasal decongestants. It is essential to understand the potential risks of long-term nasal decongestant use and to use them only as directed.
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This question is part of the following fields:
- ENT
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Question 31
Correct
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A 43-year-old male patient presents with a chief complaint of hearing difficulty. During the examination, you perform Weber's test and find that he hears the sound most loudly in his right ear. On conducting Rinne test, the sound is loudest when the tuning fork is placed in front of the ear canal on the left and loudest when placed on the mastoid process on the right. What type of hearing loss is evident in this case?
Your Answer: Conductive hearing loss on the right
Explanation:The presence of conductive hearing loss can be identified by conducting Rinne and Weber tests. During the Rinne test, bone conduction will be more audible than air conduction, while the Weber test will indicate the affected ear.
If the hearing loss is conductive and affects the right ear, bone conduction will be louder than air conduction. This is because the ear canal, middle ear, or tympanic membrane is unable to conduct sound waves effectively. The Weber test will also indicate that the affected ear is where the sound is loudest.
The other options provided are incorrect as they do not align with the results of the examination. In sensorineural hearing loss, air conduction is louder than bone conduction.
Conductive hearing loss can be caused by various factors, including impacted earwax, inner ear effusion, debris or foreign objects in the ear canal, a perforated eardrum, or otosclerosis.
Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness
Rinne’s and Weber’s tests are two diagnostic tools used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test suggests conductive deafness if BC is greater than AC.
On the other hand, Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.
To interpret the results of Rinne’s and Weber’s tests, a normal result indicates that AC is greater than BC bilaterally, and the sound is midline in Weber’s test. Conductive hearing loss is indicated by BC being greater than AC in the affected ear, while AC is greater than BC in the unaffected ear, and the sound lateralizes to the affected ear in Weber’s test. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, and the sound lateralizes to the unaffected ear in Weber’s test.
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This question is part of the following fields:
- ENT
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Question 32
Correct
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A 10-year-old girl presents to the general practice clinic with a sore throat and fever that have been present for 3 days. What clinical sign would indicate that the patient may have a bacterial throat infection and could benefit from antibiotics? Choose ONE positive indicator from the options provided.
Your Answer: Tender cervical lymphadenopathy
Explanation:Assessing the Need for Antibiotics in Acute Sore Throat: Understanding the Centor Criteria and Other Indicators
When a patient presents with a sore throat, it is important to determine whether antibiotics are necessary for treatment. The Centor criteria and FeverPAIN score are two approved scoring systems used to predict the likelihood of a bacterial cause for the sore throat.
Tender cervical lymphadenopathy is one of the parameters in the Centor criteria and scores 1 point. Other parameters include age, exudate on tonsils, absence of cough, and fever. A score of 3 or more suggests a high probability of bacterial infection and the need for antibiotic treatment.
Cough present is not an indicator for antibiotic therapy, but its absence is one of the factors in the Centor criteria. Sore throat alone is also not an indicator for antibiotics, but a score of 4-5 on the FeverPAIN score or a Centor criteria score above 3 may indicate the need for antibiotics.
Vomiting and nasal congestion are not included in either scoring system for determining the need for antibiotics. However, vomiting may be a sign of severe illness and dehydration, and any patient presenting with vomiting and a sore throat should be assessed for signs of sepsis and dehydration. Nasal congestion may suggest a viral cause for the sore throat, but alternative causes should still be assessed.
In summary, understanding the Centor criteria and other indicators can help healthcare providers determine whether antibiotics are necessary for treating acute sore throat.
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This question is part of the following fields:
- ENT
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Question 33
Correct
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You assess a 75-year-old woman who is taking several medications. She reports experiencing hearing loss and bilateral tinnitus over the past few months. Which of the following medications could potentially be causing these symptoms?
Your Answer: Furosemide
Explanation:Loop diuretics have the potential to cause ototoxicity.
Loop Diuretics: Mechanism of Action and Indications
Loop diuretics, such as furosemide and bumetanide, are medications that inhibit the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle. This reduces the absorption of NaCl and increases the excretion of water and electrolytes, making them effective in treating conditions such as heart failure and resistant hypertension. Loop diuretics act on NKCC2, which is more prevalent in the kidneys.
As loop diuretics work on the apical membrane, they must first be filtered into the tubules by the glomerulus before they can have an effect. This means that patients with poor renal function may require higher doses to achieve a sufficient concentration within the tubules.
Loop diuretics are commonly used in the treatment of heart failure, both acutely (usually intravenously) and chronically (usually orally). They are also effective in treating resistant hypertension, particularly in patients with renal impairment.
However, loop diuretics can have adverse effects, including hypotension, hyponatremia, hypokalemia, hypomagnesemia, hypochloremic alkalosis, ototoxicity, hypocalcemia, renal impairment (from dehydration and direct toxic effect), hyperglycemia (less common than with thiazides), and gout.
In summary, loop diuretics are effective medications for treating heart failure and resistant hypertension, but their use should be carefully monitored due to potential adverse effects. Patients with poor renal function may require higher doses to achieve therapeutic effects.
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This question is part of the following fields:
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Question 34
Correct
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A 38-year-old factory worker undergoes a routine hearing assessment as part of his annual work-based medical. He is noted to have a positive Rinne’s test (normal) and Weber’s test localising to the left ear.
What is the most likely defect in this patient?Your Answer: Right sensorineural hearing loss
Explanation:For a man with a positive Rinne’s test and sound localization to the left ear on Weber’s testing, the diagnosis is likely to be right-sided sensorineural hearing loss. If the Rinne’s test had been negative, it would have indicated left-sided conductive hearing loss. Similarly, if the sound had been localized to the right ear, it would have suggested left-sided sensorineural hearing loss. In the case of bilateral hearing loss, the Rinne’s test would be negative on both sides, and the Weber test would not localize to either ear. Finally, if the man had right-sided conductive hearing loss, the Rinne’s test would be negative on the right side, and the Weber test would localize to the right side.
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Question 35
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A 44-year-old man visits his GP with complaints of vertigo. He had a cough and sore throat last week and has been experiencing a spinning sensation since then. The vertigo can last for hours and causes significant nausea, making it difficult for him to leave the house and go to work as a teacher. During an ENT examination, the GP observes horizontal nystagmus and intact tympanic membranes with no hearing loss. What is the best course of treatment?
Your Answer: Short course of oral prochlorperazine
Explanation:In cases of vestibular neuronitis, prochlorperazine can be effective during the acute phase, but it should not be continued for an extended period as it can hinder the central compensatory mechanisms that aid in recovery. This patient’s symptoms, including recurrent vertigo attacks, nausea, and horizontal nystagmus, are consistent with vestibular neuronitis, likely triggered by a recent viral upper respiratory tract infection. A brief course of oral prochlorperazine is recommended, with the option of using buccal or intramuscular administration for more severe cases. However, it is important to discontinue prochlorperazine after a few days to avoid impeding the recovery process. Long-term use of prochlorperazine would not be appropriate in this situation.
Understanding Vestibular Neuronitis
Vestibular neuronitis is a type of vertigo that typically occurs after a viral infection. It is characterized by recurrent episodes of vertigo that can last for hours or days, accompanied by nausea and vomiting. Horizontal nystagmus, or involuntary eye movements, is a common symptom, but there is usually no hearing loss or tinnitus.
It is important to distinguish vestibular neuronitis from other conditions that can cause similar symptoms, such as viral labyrinthitis or posterior circulation stroke. The HiNTs exam can be used to differentiate between vestibular neuronitis and stroke.
Treatment for vestibular neuronitis may involve medications such as prochlorperazine or antihistamines to alleviate symptoms. However, vestibular rehabilitation exercises are often the preferred treatment for patients with chronic symptoms. These exercises can help to retrain the brain and improve balance and coordination. With proper management, most people with vestibular neuronitis can recover fully and resume their normal activities.
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Question 36
Incorrect
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A 47-year-old woman presents with a lump in the upper anterior triangle of her neck. She reports that it has been present for a few weeks and only started to bother her after her friend pointed it out and asked what it was. She denies any other symptoms such as weight loss or fevers. She recalls her mother having a similar swelling removed, but does not remember the diagnosis.
Upon examination, there is a small, smooth, nontender, mobile lump. The skin overlying the lump appears normal in color and temperature. The lump does not move on swallowing or tongue protrusion, and the skin cannot be moved over the top of the lump. What is the most likely diagnosis?Your Answer: Lipoma
Correct Answer: Sebaceous cyst
Explanation:Differentiating between lumps and bumps: A guide to common masses
When it comes to lumps and bumps on the body, it can be difficult to determine what they are and whether they require medical attention. Here are some common types of masses and their characteristics to help differentiate between them:
Sebaceous cysts: These small, smooth lumps are caused by a blocked hair follicle and have a central punctum. They are attached to the skin and may develop a horn. If infected, they can become tender and erythematous.
Lipomas: These deep masses are typically soft, doughy, and mobile. An ultrasound or biopsy may be needed to rule out sarcoma or liposarcoma.
Sternocleidomastoid tumors: This congenital lump appears within the first few weeks of life and is located beneath the sternocleidomastoid muscle. It restricts contralateral head movement.
Thyroid carcinoma: A hard, firm, non-tender mass close to the midline that moves up with swallowing may indicate thyroid cancer.
Thyroid goitre: A smooth or multi-nodular enlargement close to the midline that moves up with swallowing may indicate a thyroid goitre. Symptoms associated with thyroid diseases may also be present.
Knowing the characteristics of these common masses can help individuals determine when to seek medical attention.
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This question is part of the following fields:
- ENT
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Question 37
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A 79-year-old man presents to the emergency department with persistent left-sided epistaxis following a fall and hitting his nose on a door. He has a medical history of hypertension managed with amlodipine, atrial fibrillation managed with apixaban, stroke, and type 2 diabetes managed with metformin. On examination, he has active bleeding from the left anterior nasal septum and is spitting blood. Despite attempting to control the bleeding by squeezing his nose for 30 minutes and inserting a Rapid Rhino, the bleeding persists. What is an indication for surgical intervention in this case?
Your Answer: Failure of nasal packing
Explanation:If all emergency measures fail to stop epistaxis, sphenopalatine ligation in a surgical setting may be necessary.
To manage epistaxis in an emergency, it is important to provide adequate first aid for at least 20 minutes by firmly squeezing both nasal ala and sitting forward. Ice in the mouth can also be helpful. Topical adrenaline and local anaesthetic, as well as topical tranexamic acid, can be applied. If these measures are unsuccessful, nasal packing with devices such as Rapid Rhino may be necessary. If the bleeding persists, a posterior pack or Foley catheter may be used. In cases where all of these measures fail, surgical intervention such as sphenopalatine artery ligation may be required.
Understanding Epistaxis: Causes and Management
Epistaxis, commonly known as nosebleeds, can be categorized into anterior and posterior bleeds. Anterior bleeds usually have a visible source of bleeding and occur due to an injury to the network of capillaries that form Kiesselbach’s plexus. On the other hand, posterior haemorrhages tend to be more severe and originate from deeper structures. They are more common in older patients and pose a higher risk of aspiration and airway obstruction.
Most cases of epistaxis are benign and self-limiting. However, certain factors can exacerbate the condition, such as nose picking, nose blowing, trauma to the nose, insertion of foreign bodies, bleeding disorders, and immune thrombocytopenia. Other causes include the use of cocaine, hereditary haemorrhagic telangiectasia, and granulomatosis with polyangiitis.
If the patient is haemodynamically stable, bleeding can be controlled with first aid measures. This involves asking the patient to sit with their torso forward and their mouth open, pinching the cartilaginous area of the nose firmly for at least 20 minutes, and using a topical antiseptic to reduce crusting and the risk of vestibulitis. If bleeding persists, cautery or packing may be necessary. Patients should be advised to avoid activities that increase the risk of re-bleeding.
In cases where emergency management fails, sphenopalatine ligation in theatre may be required. Patients with unknown or posterior sources of bleeding should be admitted to the hospital for observation and review. Overall, understanding the causes and management of epistaxis is crucial in providing effective care for patients experiencing this condition.
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This question is part of the following fields:
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Question 38
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A 65-year-old man is brought to his General Practitioner by his daughter, who has noticed that his hearing on the right side has been progressively diminishing for the past six months. Additionally, he also complains of feeling unbalanced and of not being able to walk properly and leaning more towards the right side. On referral to the Ear, Nose and Throat (ENT) Department, the Consultant conducts a detailed clinical examination and finds nystagmus and dysdiadochokinesia, in addition to a sensorineural loss in his right ear.
Which of the following is the most appropriate diagnostic investigation for this patient?Your Answer: Magnetic resonance imaging (MRI)
Explanation:Diagnostic Tests for Acoustic Neuroma
Acoustic neuroma is a condition characterized by unilateral hearing loss and unsteady gait. The following diagnostic tests can aid in the diagnosis of this condition:
Magnetic Resonance Imaging (MRI): This is the preferred test for detecting acoustic neuroma as it can detect tumors as small as 1-1.3 mm. MRI with gadolinium contrast is recommended in cases where brainstem testing is abnormal or there is a high suspicion of vestibular schwannoma.
Plain Computerized Tomography (CT) Scan: CT scan with contrast can provide prognostic information on post-operative hearing loss by assessing the widening of the internal auditory canal and the extent of tumor growth. However, plain CT cannot detect some cases of acoustic neuroma.
Otoscopy: This test is useful in diagnosing conditions of bone conduction deafness but is of limited or no value in cases of sensorineural deafness.
Pure Tone Audiometry (PTA): This is the best initial screening laboratory test for the diagnosis of acoustic neuroma. Test results typically show an asymmetric sensorineural hearing loss, usually more prominent at higher frequencies.
Vestibular Colorimetric Test: This test has limited utility as a screening test for the diagnosis of acoustic neuroma. A decreased or absent caloric response on the affected side may be seen, but with small-sized tumors, a normal response is often seen.
In conclusion, a combination of these diagnostic tests can aid in the accurate diagnosis of acoustic neuroma.
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This question is part of the following fields:
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Question 39
Incorrect
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A 4-year-old girl is brought to the clinic. Her mother reports that she has been complaining of a painful right ear for the past 2-3 days. This morning she noticed some 'yellow pus' coming out of her ear. On examination her temperature is 38.2ºC. Otoscopy of the left ear is normal. On the right side, the tympanic membrane cannot be visualised as the ear canal is filled with a yellow discharge. What should be done in this situation?
Your Answer: Admit to paediatrics
Correct Answer: Amoxicillin + review in 2 weeks
Explanation:Perforated Tympanic Membrane: Causes and Management
A perforated tympanic membrane, also known as a ruptured eardrum, is a condition where there is a tear or hole in the thin tissue that separates the ear canal from the middle ear. The most common cause of this condition is an infection, but it can also be caused by barotrauma or direct trauma. When left untreated, a perforated tympanic membrane can lead to hearing loss and increase the risk of otitis media.
In most cases, no treatment is needed as the tympanic membrane will usually heal on its own within 6-8 weeks. During this time, it is important to avoid getting water in the ear. However, if the perforation occurs following an episode of acute otitis media, antibiotics may be prescribed. This approach is supported by the 2008 Respiratory tract infection guidelines from the National Institute for Health and Care Excellence (NICE).
If the tympanic membrane does not heal by itself, myringoplasty may be performed. This is a surgical procedure where a graft is used to repair the hole in the eardrum.
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This question is part of the following fields:
- ENT
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Question 40
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A 45-year-old woman visits her primary care physician (PCP) complaining of bilateral tinnitus. She denies any changes in her hearing or other ear-related symptoms. The PCP conducts ear and cranial nerve examinations, which reveal no abnormalities. The patient's medication list is reviewed.
Which ONE medication from the following list is most likely responsible for the patient's tinnitus?Your Answer: Quinine
Explanation:Medication and Tinnitus: Understanding the Association
Tinnitus, the perception of sounds in the ears or head without an external source, can be distressing and may indicate an underlying condition. While it is often considered a minor symptom, certain medications have been associated with tinnitus. Quinine, commonly used to treat malaria, is one such medication. Other medications that may cause tinnitus include aspirin, aminoglycosides, loop diuretics, and non-steroidal anti-inflammatory drugs. However, medications like spironolactone, salbutamol, metformin, and nifedipine are not associated with tinnitus. It is important to understand the potential side effects of medications and to consult with a healthcare provider if experiencing tinnitus or any other concerning symptoms.
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- ENT
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