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  • Question 1 - A 56-year-old woman presents to the clinic with a complaint of feeling like...

    Correct

    • A 56-year-old woman presents to the clinic with a complaint of feeling like there is a lump in her throat. She reports an itching sensation, but no pain. The symptoms are intermittent and not related to swallowing solids or liquids, and there is no persistent hoarseness. She also reports feeling anxious and tired. There is no significant family history. She was a heavy smoker between the ages of 22-32 but has since quit smoking and drinking. Her blood profile and thyroid function tests show the following results:
      - Haemoglobin: 98 g/l (normal range: 115-165 g/l)
      - Mean corpuscular value: 75 fl (normal range: 80-100 fl)
      - Thyroid stimulating hormone: 2.2 mU/L (normal range: 0.45-4.1 mU/L)

      What is the most appropriate initial investigation for this patient?

      Your Answer: Naso-endoscopy

      Explanation:

      The patient is experiencing globus sensation, but before being discharged, it is important to rule out any serious conditions. Given the patient’s history of smoking and anemia, a naso-endoscopy should be performed as an initial investigation. If the results are clear, the patient can be reassured and discharged. A CT neck is not necessary at this time unless the endoscopy results are inconclusive. A barium swallow would only be appropriate if a tumor was suspected, making it a second-line investigation. An ultrasound of the neck would only be necessary if a specific mass or thyroid issue was suspected, which is not the case here. Globus sensation can typically be diagnosed through a clinical examination and a ridged endoscopy. Overall, the initial investigation should focus on ruling out any serious conditions before considering further tests.

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  • Question 2 - A 55-year-old man with advanced cancer of the stomach presents with hoarseness. During...

    Correct

    • A 55-year-old man with advanced cancer of the stomach presents with hoarseness. During the physical examination, the physician notes enlarged deep cervical lymph nodes. What is the cause of the hoarse voice in this patient?

      Your Answer: Recurrent laryngeal branch of the vagus

      Explanation:

      The Role of Nerves in Voice Production

      The human voice is a complex system that involves the coordination of various muscles and nerves. One of the most important nerves involved in voice production is the recurrent laryngeal branch of the vagus. Damage to this nerve can cause hoarseness, as it innervates all the muscles of the larynx. The left recurrent laryngeal nerve is more commonly affected due to its longer course and proximity to mediastinal tumors.

      The internal and external branches of the superior laryngeal nerve also play a role in voice production. They innervate the cricothyroid muscle and the inferior pharyngeal constrictor, as well as provide secretomotor fibers to mucosal glands of the larynx above the vocal folds. However, damage to these nerves would not cause hoarseness.

      Lastly, the pharyngeal branch of the glossopharyngeal nerve provides sensory innervation to the pharynx, but does not directly affect voice production. Understanding the role of these nerves can help diagnose and treat voice disorders.

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  • Question 3 - A 28-year-old man presents with a swelling under the left jaw that comes...

    Incorrect

    • A 28-year-old man presents with a swelling under the left jaw that comes and goes but leaves a dull ache behind. The problem has been present for around 2 weeks and is getting worse. The pain is most noticeable at mealtimes. In the last day, the swelling has become fixed and he reports an unpleasant taste in his mouth. He smokes five cigarettes a day and drinks ten units of alcohol a week, usually on a Saturday night. On examination, there is a smooth, tender swelling in the superior part of the left anterior triangle and, on inspection of the oral cavity, there is poor dentition and pus present just behind the lower incisors.
      Which of the following is the most likely diagnosis?

      Your Answer: Dental abscess

      Correct Answer: Submandibular gland infection

      Explanation:

      Submandibular Gland Infection: Causes, Symptoms, and Management

      A submandibular gland infection is often caused by the presence of a stone in the left submandibular duct, which can lead to a secondary infection due to the stasis of gland secretions. Stones are more common in the submandibular gland due to the length and tortuosity of the duct. Symptoms include a smooth, tender swelling, pain worse at mealtimes, and pus behind the lower incisors. Management involves antibiotics to treat the infection and referral to an ENT or oral surgeon for stone removal, which can usually be done under local anesthesia. In some cases, excision of the entire submandibular gland may be necessary. It is important to note that the presence of bacterial infection indicates an ongoing issue beyond just the stone. Other conditions, such as gingivostomatitis and dental abscess, can cause similar symptoms but have different underlying causes. Mumps, on the other hand, can cause swelling of the parotid gland, not the submandibular gland.

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  • Question 4 - Sophie is a 6-year-old overweight girl brought in by anxious parents who are...

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    • Sophie is a 6-year-old overweight girl brought in by anxious parents who are worried about her loud snoring and frequent interruptions in breathing which have been getting progressively worse. Although she has difficulty getting up from sleep, she does not have any daytime somnolence. However, her parents have been receiving complaints from the school teachers about her disruptive and inattentive behaviour in class. They have done a lot of research on the Internet and are demanding that Sophie has her tonsils removed. On examination, Sophie has a short, thick neck and grade III tonsils, but no other abnormalities.
      Which of the following is the next best step in management?

      Your Answer: Order an overnight polysomnographic study

      Explanation:

      Childhood Obstructive Sleep Apnoea: Diagnosis and Treatment Options

      Childhood obstructive sleep apnoea (OSA) is a pathological condition that requires proper diagnosis and treatment. A polysomnographic study should be performed before any intervention is undertaken, even though adenotonsillectomy is the treatment of choice for childhood OSA. Childhood OSA is characterised by disordered breathing during sleep, which includes both apnoea and hypopnoea. Symptoms such as mouth breathing, abnormal breathing during sleep, poor sleep with frequent awakening or restlessness, nocturnal enuresis, nightmares, difficulty awakening, excessive daytime sleepiness or hyperactivity and behavioural problems are typically observed.

      It is important to reassure parents that snoring loudly is normal in children of this age, and their child’s behaviour pattern will improve as they mature. Elective adenotonsillectomy as a day procedure is an option, but a polysomnographic study should be performed first to confirm the diagnosis.

      While dental splints have a small role to play in OSA, they are not the ideal treatment option. Intranasal budesonide is an option for mild to moderate OSA, but it is only a temporising measure and not a proven effective long-term treatment. Therefore, it is important to consider all available treatment options and choose the most appropriate one for each individual case.

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  • Question 5 - A 38-year-old man presents with a one-month history of feeling a lump in...

    Incorrect

    • A 38-year-old man presents with a one-month history of feeling a lump in his throat. The feeling comes and goes and has not progressed. He has no difficulty swallowing food or liquids; in fact, eating and drinking help to relieve the symptoms. He has not lost weight. He is a non-smoker. He was recently diagnosed with gastro-oesophageal reflux disease (GORD) and is taking a proton pump inhibitor. He also has chronic sinusitis, for which he takes a steroid nasal spray.
      Examination is normal, without cervical lymphadenopathy.
      What is the most likely diagnosis in this case?

      Your Answer: Eosinophilic oesophagitis

      Correct Answer: Globus pharyngeus

      Explanation:

      Globus pharyngeus is a condition where patients feel a painless lump at the back of their throat. The cause of this condition is unknown, but it is often attributed to anxiety, pharyngeal spasm, reflux disease, or hiatus hernia. However, it is important to rule out more serious conditions such as thyroid disorders or cancer before diagnosing globus pharyngeus. An oesophageal ring is a benign structure at the lower end of the oesophagus that can cause swallowing difficulties. While not always symptomatic, patients may experience regurgitation and food obstruction. A diagnosis is confirmed through upper gastrointestinal endoscopy to rule out more serious causes such as oesophageal cancer. Achalasia is a disorder of the oesophagus where the lower oesophageal sphincter fails to relax, causing difficulty swallowing and regurgitation. A barium swallow and manometry can confirm the diagnosis. Eosinophilic oesophagitis is an allergic reaction that causes pain and heartburn upon swallowing, as well as vomiting and loss of appetite. Laryngeal squamous cell carcinoma is a type of head and neck cancer associated with smoking and other carcinogens. Symptoms include hoarseness, coughing, difficulty swallowing, and systemic signs of distant metastases. However, the patient in question had no warning signs or risk factors for this type of cancer.

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  • Question 6 - A 32-year-old woman comes to your General Practice clinic complaining of worsening hearing...

    Incorrect

    • A 32-year-old woman comes to your General Practice clinic complaining of worsening hearing and tinnitus. She is currently pregnant and has noticed a significant decline in her hearing, although she had hearing problems before her pregnancy. Her father and grandfather also had hearing problems, and she is concerned about her future. During the examination, both tympanic membranes appear normal without abnormalities detected.
      What is the most probable diagnosis?

      Your Answer: Wax build up

      Correct Answer: Otosclerosis

      Explanation:

      Understanding Otosclerosis: A Common Cause of Hearing Loss in Pregnancy

      Otosclerosis is a genetic condition that causes the stapes footplate to become fused to the oval window, resulting in hearing loss. While it is an autosomal dominant condition, many people develop it without a family history. Women are twice as likely to be affected, and bilateral deafness is common. The condition typically manifests during middle age and is worsened by pregnancy. Interestingly, background noise can actually improve hearing. Eustachian tube dysfunction is another common cause of hearing loss in pregnancy, but it is usually accompanied by otitis media with effusion. Wax build-up is unlikely to be the cause of hearing loss in this case, and normal age-related hearing loss is not consistent with the rapid progression of symptoms. While Meniere’s disease is a possibility, the lack of vertigo and family history make otosclerosis the most likely diagnosis.

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  • Question 7 - A 64-year-old man is undergoing evaluation for hoarseness that has persisted for 6...

    Correct

    • A 64-year-old man is undergoing evaluation for hoarseness that has persisted for 6 weeks. He smokes 25 cigarettes a day and has been experiencing a chronic cough for the past 3 months. He denies any episodes of coughing up blood. During an initial examination, an otolaryngologist observes that the right vocal fold is immobile while speaking.
      What is the most probable underlying cause?

      Your Answer: Left recurrent laryngeal nerve palsy

      Explanation:

      Differentiating Causes of Left-Sided Vocal Cord Paralysis

      Left-sided vocal cord paralysis can be caused by various factors, including nerve damage and stroke. Left recurrent laryngeal nerve palsy is a common cause, resulting in hoarseness due to the vocal cord lying in a paramedian position. This type of nerve damage is often associated with an underlying lung malignancy with mediastinal lymph node involvement. On the other hand, left glossopharyngeal nerve palsy does not affect the larynx, while left superior laryngeal nerve palsy is closely related to the recurrent laryngeal nerve and is also more common on the left side. Cerebrovascular accidents involving the left middle or anterior cerebral artery can also cause vocal cord paralysis, but the history provided does not suggest a stroke. Accurately identifying the cause of left-sided vocal cord paralysis is crucial for appropriate management and treatment.

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  • Question 8 - A 57-year-old man comes to his doctor's office with a complaint of ongoing...

    Correct

    • A 57-year-old man comes to his doctor's office with a complaint of ongoing right ear pain and associated hearing loss for several weeks. He denies any significant discharge from his ear and has not experienced any fevers. He reports feeling pain in his jaw that sometimes clicks. During the examination, the doctor observes cerumen in the right ear and no inflammation. The tympanic membrane appears normal. The patient experiences pain when moving his jaw. What is the probable diagnosis?

      Your Answer: TMJ dysfunction

      Explanation:

      Differential Diagnosis of Ear Pain and Hearing Loss

      Temporomandibular Joint Dysfunction as a Likely Cause of Hearing Loss

      When infection is ruled out and cerumen is not the culprit, temporomandibular joint (TMJ) dysfunction becomes a probable diagnosis for ear pain and hearing loss. TMJ dysfunction often involves pain that radiates to the ear through the auriculotemporal nerve and crepitus in the jaw. Treatment options for TMJ dysfunction include rest, massage, relaxation techniques, bite guards, NSAIDs, and steroid injections.

      Other Possible Causes of Ear Pain and Discharge

      Otitis externa, or inflammation of the external auditory canal, typically presents with watery discharge, pain, and itching. Cholesteatoma, a benign tumor that can erode bone and cause cranial nerve symptoms, produces a foul-smelling white discharge and an inflammatory lesion on otoscopy. Mastoiditis, an infection that spreads from the middle ear to the mastoid air cells, causes fever, swelling, and unilateral ear prominence. Acute otitis media, a common childhood infection, results in sudden ear pain and bulging of the tympanic membrane, which may rupture and release purulent discharge.

      Conclusion

      Ear pain and hearing loss can have various causes, and a thorough evaluation is necessary to determine the underlying condition. While TMJ dysfunction is a possible diagnosis that requires specific management, other conditions such as otitis externa, cholesteatoma, mastoiditis, and acute otitis media should also be considered and treated accordingly.

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  • Question 9 - A 68-year-old woman visits her GP complaining of hearing loss and ringing in...

    Correct

    • A 68-year-old woman visits her GP complaining of hearing loss and ringing in her ears for the past six months. She experienced this after being hospitalized for two weeks due to a soft tissue infection that was complicated by a bloodstream infection caused by methicillin-resistant Staphylococcus aureus. During her hospital stay, she was treated with flucloxacillin, gentamicin, and vancomycin. The tinnitus is present in both ears, and her ear and neurological examinations are normal. What is the probable underlying cause of this patient's tinnitus?

      Your Answer: Ototoxic medication

      Explanation:

      Differential diagnosis of hearing loss and tinnitus

      Gentamicin-induced ototoxicity

      A patient presenting with bilateral tinnitus and hearing loss after recent use of gentamicin is likely experiencing ototoxicity from this antibiotic. Gentamicin can damage the vestibular system and cause sensorineural hearing loss.

      Bacteraemia and viral labyrinthitis

      Bacteraemia, especially from methicillin-resistant S. aureus, would not cause tinnitus. Viral labyrinthitis may cause tinnitus, but it is usually accompanied by severe vertigo and hearing loss.

      Hyperlipidaemia and noise-induced hearing loss

      Hyperlipidaemia, particularly hypertriglyceridaemia, has been linked to an increased risk of noise-induced hearing loss and tinnitus. A low-cholesterol diet and atorvastatin may help alleviate these symptoms.

      Ménière’s disease and betahistine

      Ménière’s disease is a disorder of the inner ear characterized by excess endolymph, leading to severe vertigo, hearing loss, and tinnitus. Betahistine is a medication used to manage the symptoms of Ménière’s disease, but there is no cure for this condition.

      Otosclerosis and conductive hearing loss

      Otosclerosis is a condition that affects the bony ossicles of the ear, leading to conductive hearing loss. It results from abnormal sclerosis of the malleus, incus, and stapes, which are crucial for sound conduction from the outer to the inner ear.

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  • Question 10 - A 45-year-old man visits his GP complaining of a lump under his chin...

    Incorrect

    • A 45-year-old man visits his GP complaining of a lump under his chin that causes him pain and swelling, especially after eating a big meal. The facial nerve appears to be functioning normally. Upon examination, there is a tender swelling in the submandibular triangle.
      What is the most probable diagnosis?

      Your Answer: Adenoid cystic carcinoma

      Correct Answer: Sialolithiasis

      Explanation:

      Differential Diagnosis of Submandibular Swelling: Understanding the Causes

      Submandibular swelling can be caused by various conditions, and it is important to understand the differential diagnosis to provide appropriate treatment. One of the most common causes is sialolithiasis, which is the formation of stones within the salivary glands. This condition obstructs the salivary ducts and can lead to infection, resulting in pain and swelling after eating. Sialolithiasis is more common in men over the age of 40 and typically affects the submandibular gland.

      Sjögren syndrome is an autoimmune condition that causes dry mouth, dry eyes, and swelling of the salivary glands, usually bilaterally. However, unilateral acute pain and swelling after eating are more typical of a salivary stone, rather than Sjögren syndrome.

      Pleomorphic adenomas are benign tumors that usually present as a painless lump, slowly enlarging over time. They do not typically cause acute pain and swelling.

      Warthin’s tumor is another slow-growing lump that is commonly found in the tail of the parotid gland. Unlike sialolithiasis, it does not cause pain.

      Adenoid cystic carcinoma is a malignant tumor that presents as a slowly enlarging mass over the parotid area. It does not typically cause pain, but if left unchecked, it can invade local structures such as the facial nerve.

      In conclusion, understanding the differential diagnosis of submandibular swelling is crucial for proper diagnosis and treatment. Sialolithiasis, Sjögren syndrome, pleomorphic adenomas, Warthin’s tumor, and adenoid cystic carcinoma are all potential causes, and each requires a different approach to management.

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  • Question 11 - The patient in the picture has a slow-growing facial lump and has been...

    Correct

    • The patient in the picture has a slow-growing facial lump and has been referred to the Ear, Nose and Throat (ENT) Outpatient Clinic. He denies any other symptoms and is in good health. Radiology confirms a parotid swelling. What is the most likely pathology he has?

      Your Answer: Pleomorphic adenoma

      Explanation:

      Possible Parotid Gland Conditions and Their Characteristics

      The parotid gland is a salivary gland located in front of the ear. It can be affected by various conditions, including pleomorphic adenoma, lymphoma, parotid adenitis, parotid abscess, and adenocarcinoma.

      Pleomorphic adenoma is the most common tumour of the parotid gland. It is a slow-growing, mixed benign tumour that can potentially become malignant and has a high chance of recurrence. Surgical removal through a parotidectomy is the current treatment approach.

      Lymphoma is a possibility in the parotid gland, but it is less common than pleomorphic adenoma. Patients with lymphoma may have constitutional symptoms, such as night sweats, weight loss, and fever.

      Parotid adenitis is inflammation of the parotid gland, which can occur for various reasons. It may be unilateral or bilateral, as seen in mumps. Inflammatory conditions typically cause more tenderness than swelling.

      Parotid abscess is a collection of pus in the parotid gland. However, the unusual shape of the gland in combination with normal overlying skin is not typical of abscesses or inflammation.

      Adenocarcinoma of the parotid gland is a malignant tumour that can involve the facial nerve. However, the lack of facial nerve involvement and the relative size of the tumour make adenocarcinoma unlikely in this case.

      In summary, the characteristics of each condition can help differentiate between them, and a proper diagnosis is crucial for appropriate treatment.

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  • Question 12 - A 52-year-old woman with a history of intermittent ringing sound in her left...

    Correct

    • A 52-year-old woman with a history of intermittent ringing sound in her left ear for the last six months presents to the Ear, Nose and Throat (ENT) Outpatient Department. She describes the ringing sound to be pulsatile in nature. She has no history of fever, hearing loss, trauma or any recent ear infections. Her past medical history includes a diagnosis of multiple sclerosis under remission for the past two years. Clinical examination of the head and neck is unremarkable.
      Which is the most appropriate investigation which will help to reach a final diagnosis in this patient?

      Your Answer: Computerised tomography (CT) (contrast-enhanced) scan of the temporal bone

      Explanation:

      Investigating Pulsatile Tinnitus in a Patient with Multiple Sclerosis

      Pulsatile tinnitus, a constant ringing or humming sound perceived in the absence of actual sound, can be psychologically debilitating to the patient. In a patient with multiple sclerosis, pulsatile tinnitus may be caused by spontaneous spasm of middle ear muscles. The National Institute for Health and Care Excellence (NICE) recommends imaging for all patients with pulsatile tinnitus to identify the underlying cause. In this case, contrast-enhanced CT scanning of the temporal bone is the best investigation to identify middle ear/osseous pathology. Tympanometry and otoscopy can also be valuable initial investigations for suspected middle ear pathologies. Magnetic resonance angiography is not the best investigation in this scenario as the patient’s history suggests a muscular cause of pulsatile tinnitus. Weber’s test is not relevant in this case as the patient does not report any hearing loss.

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  • Question 13 - A 5-year-old child, who was born in Germany, is brought to the General...

    Incorrect

    • A 5-year-old child, who was born in Germany, is brought to the General Practitioner (GP) by his mother because of recurrent sinus infections and failure to thrive. She is also concerned that the child has had diarrhoea for a few months, which is not resolving.
      During the examination, you notice several shiny, pink masses occupying the nasal canals.
      What is the most suitable initial step in treating this patient?

      Your Answer: Biopsy the mass for pathology

      Correct Answer: Testing in which pilocarpine is administered

      Explanation:

      Diagnostic Testing for Nasal Polyps in Children: The Role of Pilocarpine Sweat Test

      Nasal polyps in children should raise suspicion of cystic fibrosis (CF), especially when accompanied by other symptoms. The gold standard test for CF diagnosis is the sweat test, which involves administering the direct-acting muscarinic agonist pilocarpine and measuring the chloride content of sweat. Loratadine, a second-generation antihistamine, is not the first step in managing nasal polyps. Genetic testing is more expensive and time-consuming than the sweat test and is not the initial diagnostic choice. Biopsy is not necessary for benign nasal polyps. Bacterial culture is not relevant to the pathology underlying nasal polyps in children.

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  • Question 14 - A 38-year-old man with a tumour of the left submandibular gland underwent surgery....

    Incorrect

    • A 38-year-old man with a tumour of the left submandibular gland underwent surgery. While operating on the left submandibular gland, the lingual nerve was damaged. What is the most probable postoperative complaint of the patient?

      Your Answer: Deviation of the tongue to the right

      Correct Answer: Loss of taste sensation over the anterior two-thirds of the left side of the tongue

      Explanation:

      Understanding Lingual Nerve Injury: Effects on Tongue Sensation and Movement

      The lingual nerve is a crucial component of the mandibular nerve, responsible for providing sensory innervation to the anterior two-thirds of the tongue and floor of the mouth. It also carries taste sensation fibers from the facial nerve via the chorda tympani special sensory nerves. Injuries to the lingual nerve can result in numbness, dysesthesia, paraesthesiae, and dysgeusia, affecting the anterior two-thirds of the tongue on the same side. Such injuries can occur during invasive dental and surgical procedures.

      However, it is important to note that the lingual nerve does not contain a motor component, and thus, it does not affect tongue movement. Deviation of the tongue to either side is not expected in cases of lingual nerve injury.

      It is also worth noting that the lingual nerve only supplies sensation to the anterior two-thirds of the tongue. The posterior third of the tongue, on the other hand, is supplied by the glossopharyngeal nerve. Therefore, lingual nerve injury does not affect general sensation in the posterior third of the tongue.

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  • Question 15 - A 40-year-old farmer visits the General Practitioner (GP) complaining of severe pain in...

    Incorrect

    • A 40-year-old farmer visits the General Practitioner (GP) complaining of severe pain in the left parotid area for the past week. The pain is triggered when the patient is eating or about to eat. The GP suspects a parotid duct stone.
      Regarding the parotid gland, which of the following statements is accurate?

      Your Answer: It has a duct that pierces the masseter muscle to enter the mouth opposite the upper second molar tooth

      Correct Answer: It has secretomotor action via the glossopharyngeal and auriculotemporal nerves

      Explanation:

      The parotid gland is innervated by parasympathetic nerves originating in the inferior salivary nucleus at the lower pons. These nerves travel along the glossopharyngeal and auriculotemporal nerves, and synapse in the otic ganglion before hitch-hiking with the auriculotemporal nerve to reach the gland. Injury to these nerves during parotidectomy can cause Frey syndrome. The gland consists of superficial and deep lobes separated by the neurovascular bundle, and its duct passes around the anterior border of the masseter muscle before piercing the buccinator muscle and exiting opposite the second upper molar tooth. The gland produces mainly serous secretion, which is why salivary stones are rarely found in the parotid gland.

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  • Question 16 - A 47-year-old woman presents with a lump in the upper anterior triangle of...

    Correct

    • 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 a friend pointed it out. 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. On examination, there is a small, smooth, non-tender, mobile lump. The skin overlying the lump appears normal, and it does not move on swallowing or tongue protrusion. What is the most likely diagnosis?

      Your Answer: Sebaceous cyst

      Explanation:

      Differentiating between various types of lumps and bumps on the body

      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 lumps and their characteristics to help differentiate between them.

      Sebaceous cysts are small, smooth lumps that are caused by a blocked hair follicle. They are attached to the skin and may have a central punctum with a horn on top. If infected, they can become tender and the skin over them may become red and hot. Excision may be necessary if they are unsightly or infected.

      Lipomas are deep to the skin and are typically soft, doughy, and mobile. An ultrasound or biopsy may be necessary to rule out sarcoma or liposarcoma.

      Thyroid masses may be indicative of thyroid carcinoma or goitre. A thyroid malignancy would typically be hard, firm, and non-tender, while a goitre can be smooth or multinodular. Symptoms associated with thyroid disease may also be present.

      Sternocleidomastoid tumors are congenital lumps that appear within the first few weeks of life and are located beneath the sternocleidomastoid muscle. They can restrict contralateral head movement.

      It is important to seek medical attention if any lump or bump is causing discomfort or changes in appearance.

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  • Question 17 - A 42-year-old receptionist presents to the Ear, Nose and Throat (ENT) Clinic for...

    Incorrect

    • A 42-year-old receptionist presents to the Ear, Nose and Throat (ENT) Clinic for a follow-up visit. She experiences sudden-onset bouts of vertigo and tinnitus that are debilitating and leave her confined to bed until the episode subsides. The initial episode occurred 5 years ago and since then she has noticed a slight decrease in hearing in her left ear. She has undergone a thorough evaluation, and an MRI scan revealed no abnormalities.
      What is the probable diagnosis for this patient's condition?

      Your Answer: Labyrinthitis

      Correct Answer: Ménière’s disease

      Explanation:

      Distinguishing between Ménière’s Disease and Other Causes of Vertigo

      Ménière’s disease is a condition characterized by episodic vertigo, tinnitus, and hearing loss. Patients may also experience a sense of fullness or pressure in the ear before an attack. While initially unilateral, Ménière’s can progress to become bilateral and cause a fluctuating, progressive sensorineural hearing loss and permanent tinnitus. Multiple sclerosis and acoustic neuroma can cause similar symptoms, but can be ruled out with a normal MRI scan. Benign paroxysmal positional vertigo (BPPV) can also cause vertigo and nystagmus, but is less severe and does not include tinnitus or hearing loss. Labyrinthitis may cause similar symptoms, but is typically characterized by sudden-onset, severe, constant vertigo that lasts for several weeks, whereas Ménière’s attacks are episodic. Accurately distinguishing between these conditions is important for proper diagnosis and treatment.

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  • Question 18 - A 12-year-old girl presents to the General Practitioner with severe right ear pain,...

    Incorrect

    • A 12-year-old girl presents to the General Practitioner with severe right ear pain, swelling, and itching. Her mother reports that it all started after her daughter began swimming lessons two months ago. During examination, the clinician notes tenderness when pulling the right ear upwards. Otoscopy is challenging due to the painful, swollen ear canal and white discharge. Additionally, the girl has tender cervical lymph nodes on the right side below the ear and experiences pain when moving her jaw sideways. She has a mild fever (38.3 °C), but the rest of the examination is unremarkable. What is the most appropriate management for this condition?

      Your Answer: Cleaning and irrigation of the external auditory canal

      Correct Answer: Topical acetic acid 2% spray (with wick placement) and oral antibiotics

      Explanation:

      The recommended treatment for this patient’s severe otitis externa involves a combination of topical acetic acid 2% spray with wick placement and oral antibiotics. The use of wick placement is necessary due to the swelling in the ear canal, which can hinder the effectiveness of the topical solution. Oral antibiotics are necessary in cases where the infection has spread to adjacent areas, as evidenced by the patient’s tender cervical lymphadenopathy. Flucloxacillin or clarithromycin are commonly used for severe cases. Cleaning and irrigation of the ear canal may be performed under otoscope guidance to remove debris and promote better absorption of topical medication. Oral aminoglycosides are effective but should only be used if the tympanic membrane is intact. NSAIDs can provide symptomatic relief but are not sufficient for treating severe otitis externa. While topical acetic acid 2% spray is a first-line treatment for mild cases, a combination of topical therapy and oral antibiotics is necessary for severe cases.

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  • Question 19 - A 68-year-old woman presents to her General Practitioner with her husband who has...

    Correct

    • A 68-year-old woman presents to her General Practitioner with her husband who has noticed a gradual decrease in hearing on her left side over the past six months. She also reports difficulty walking and a tendency to lean towards the left side. Upon referral to the ENT Department, the Consultant observes nystagmus and dysdiadochokinesia, as well as sensorineural loss in her left ear. What is the most suitable diagnostic test for this patient?

      Your Answer: Magnetic resonance imaging (MRI)

      Explanation:

      Diagnostic Tests for Acoustic Neuroma: An Overview

      Acoustic neuroma is a type of tumor that affects the vestibular nerve and can cause symptoms such as unilateral hearing loss and unsteady gait. To diagnose this condition, several diagnostic tests are available.

      Magnetic resonance imaging (MRI) is the most reliable 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 can provide prognostic information on post-operative hearing loss, but it cannot detect all cases of acoustic neuroma. Otoscopy is of limited or no value in cases of sensorineural deafness.

      Pure tone audiometry (PTA) is the best initial screening test for acoustic neuroma, as only 5% of patients will have a normal test. Brainstem-evoked response audiometry can be used as a further screening measure in patients with unexplained asymmetries on standard audiometric testing.

      Vestibular testing has limited utility as a screening test for acoustic neuroma, but a decreased or absent caloric response on the affected side may be seen in some cases. Overall, a combination of these tests can help diagnose acoustic neuroma and guide treatment decisions.

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  • Question 20 - A 20-year-old man presents to his doctor with an enlarging neck mass. His...

    Incorrect

    • A 20-year-old man presents to his doctor with an enlarging neck mass. His mother had a right adrenal phaeochromocytoma which was successfully removed. The patient is 1.9m tall and weighs 74 kg. During examination, the doctor notices multiple yellowish white masses on the patient's lips and tongue. Three months later, the patient undergoes a total thyroidectomy. Which structure is innervated by the nerve most at risk during this procedure, and is also part of the vagus nerve?

      Your Answer: Platysma

      Correct Answer: Aortic arch

      Explanation:

      The aortic arch has baroreceptors that send afferent fibers to the vagus nerve. A patient with an enlarging neck mass, a family history of multiple endocrine neoplasia type 2B (MEN2B), and a marfanoid habitus may have medullary carcinoma of the thyroid, which is a feature of MEN2B. Surgery is the definitive treatment, but the recurrent laryngeal nerve, a branch of the vagus nerve, is at risk during thyroidectomy. The chorda tympani innervates the taste sensation to the anterior two-thirds of the tongue, while the lingual nerve and hypoglossal nerve innervate the general somatic sensation and motor function, respectively. The platysma muscle is innervated by cranial nerve VII, and the glossopharyngeal nerve (cranial nerve IX) carries general visceral afferent information from the carotid sinus to the brainstem. The spinal accessory nerve (cranial nerve XI) innervates both the sternocleidomastoid and trapezius muscles.

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  • Question 21 - A 30-year-old man visits his GP complaining of ear pain, itch and pus-like...

    Incorrect

    • A 30-year-old man visits his GP complaining of ear pain, itch and pus-like discharge that has been present for 3 days. He reports no fever and no hearing loss. The patient has a history of psoriasis. On examination, the doctor observes a raised red lesion on the ear with thick, silvery-white adherent scales. The tympanic membrane is intact and there is no visible mucous. The external auditory canal shows mild erythema and swelling. There is no palpable lymphadenopathy. What is the most appropriate treatment for this man's acute ear condition?

      Your Answer: Oral antibiotics

      Correct Answer: Topical antibiotics

      Explanation:

      Treatment Options for Otitis Externa

      Otitis externa, commonly known as swimmer’s ear, is an infection of the outer ear canal. It can be caused by breaks in the skin, such as those seen in psoriasis. Treatment options depend on the severity of the infection and may include topical antibiotics, topical steroids, intravenous antibiotics, oral antibiotics, or topical antifungal agents.

      Topical Antibiotics
      The first line of treatment for otitis externa is topical antibacterial therapy. This may include 2% acetic acid, neomycin, or aminoglycosides. If swelling is severe, a wick may be inserted after cleaning the ear canal. Steroids may also be added to the ear drops to decrease inflammation and swelling, but their effectiveness is not always clear. Drops should be given for three days beyond the cessation of symptoms.

      Topical Steroids
      In addition to antibiotics, steroids may be added to ear drops to reduce inflammation and swelling. However, they should be used in conjunction with antibiotics.

      Intravenous Antibiotics
      If the infection is severe or unresponsive to oral antibiotics, intravenous antibiotics may be necessary. Topical cultures may be recommended to guide treatment in severe cases.

      Oral Antibiotics
      Oral antibiotics are rarely needed for otitis externa but may be used if the infection is persistent, if associated otitis media is present, or if there is local or systemic spread. Signs of systemic spread include a temperature over 38.3 °C, severe initial pain, or lymphadenopathy.

      Topical Antifungal Agents
      Fungal infections may present with white to off-white discharge or black, grey, bluish-green, or yellow discharge. Aspergillus spp. may be identified by small black or white conidiophores on white hyphae. Suspected fungal otitis externa can be treated with topical antifungal agents such as clotrimazole.

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  • Question 22 - A 30-year-old man presents with increasing pain on the left side of the...

    Correct

    • A 30-year-old man presents with increasing pain on the left side of the floor of the mouth. He has been experiencing pain on and off for about 2 weeks, particularly during meals. However, the pain has increased significantly over the last 2 days. During examination, he is found to be febrile at 38.2°C. There is a smooth swelling along the floor of the mouth. Intra-oral examination reveals poor dental hygiene and pus oozing into the floor of the mouth anteriorly.
      What is the most probable diagnosis?

      Your Answer: Left submandibular gland infection

      Explanation:

      Differential Diagnosis for Left Submandibular Gland Infection

      Left submandibular gland infection can have various causes, and it is important to differentiate between them for proper treatment. Sialolithiasis, or a submandibular gland calculus, is a common cause and presents with dull pain around the gland, worsened by mealtimes or sour foods. Dental abscess, on the other hand, causes sharp tooth pain without pus draining into the floor of the mouth. Mumps parotitis affects younger patients and presents with bilateral smooth, enlarged parotid glands and a viral-like illness. Uncomplicated sialolithiasis does not present with fever and pus oozing into the floor of the mouth. However, if left untreated, it can progress to Ludwig’s angina, a serious and potentially life-threatening infection of the soft tissues of the floor of the mouth. Ludwig’s angina typically follows a dental infection and requires early specialist intervention to secure the airway and prevent fatal consequences.

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  • Question 23 - A 5-year-old boy is presented to a paediatrician with a cystic mass on...

    Incorrect

    • A 5-year-old boy is presented to a paediatrician with a cystic mass on the right lateral aspect of his neck, just below the angle of the jaw. The mother reports intermittent discharge from a small pit located just in front of the lower anterior border of the sternocleidomastoid muscle. What is the cause of this cyst, resulting from the failure of proliferation of which mesenchyme?

      Your Answer: Third pharyngeal arch

      Correct Answer: Second pharyngeal arch

      Explanation:

      During embryonic development, the pharyngeal arches give rise to various structures in the head and neck. The second arch forms the external auditory meatus and can sometimes lead to the formation of a branchial cleft cyst. The third arch becomes the common carotid artery and gives rise to the stylopharyngeus muscle. The first arch becomes the maxillary and mandibular prominences and gives rise to the muscles of mastication. The fourth arch forms the laryngeal cartilages and is innervated by the superior laryngeal branch of the vagus nerve. The fifth arch regresses quickly. Understanding the development of these arches is important in understanding the anatomy and function of the head and neck.

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  • Question 24 - A 45-year-old woman presents with a neck swelling. The lump is smooth, non-tender...

    Correct

    • A 45-year-old woman presents with a neck swelling. The lump is smooth, non-tender and in the midline of the neck, just below the cricoid cartilage. A thyroglossal cyst is suspected.
      Which of the following features is most indicative of this condition?

      Your Answer: Rises when patient protrudes her tongue

      Explanation:

      Thyroglossal Cysts: Causes and Symptoms

      Thyroglossal cysts are a type of neck mass that can occur due to a developmental abnormality in the thyroid gland. These cysts are usually located in the midline of the neck and can cause various symptoms. Here are some important facts about thyroglossal cysts:

      Causes:
      Thyroglossal cysts occur when part of the thyroglossal duct, which connects the tongue to the thyroid gland during embryonic development, remains and transforms into a cyst. This can happen due to incomplete closure of the duct.

      Symptoms:
      One of the most distinctive symptoms of a thyroglossal cyst is that it rises upwards when the patient protrudes their tongue. This is because the cyst is still connected to the tongue. However, it remains immobile when the patient swallows. Thyroglossal cysts are usually painless, but they can become tender if infected. They are not typically associated with lymphadenopathy. Most thyroglossal cysts present in the teens or early twenties.

      Treatment:
      Surgical removal is the most common treatment for thyroglossal cysts. This involves removing the cyst and the portion of the thyroglossal duct that is still present. The surgery is usually performed under general anesthesia and has a high success rate.

      In conclusion, thyroglossal cysts are a type of neck mass that can cause distinctive symptoms. While they are usually benign, they should be evaluated by a healthcare professional to rule out other conditions and determine the best course of treatment.

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  • Question 25 - A 38-year-old male librarian presents with sudden loss of hearing in both ears....

    Correct

    • A 38-year-old male librarian presents with sudden loss of hearing in both ears. There is no ear pain, history of recent upper respiratory tract infection or history of trauma. He has no past medical history of note and does not take any regular prescribed or over-the-counter medications. Tuning fork testing suggests right side sensorineural hearing loss. Examination of the auditory canals and tympanic membranes is unremarkable, as is neurological examination. He is referred to the acute ear, nose and throat (ENT) clinic. Audiometry reveals a 40 db hearing loss in the right ear at multiple frequencies.
      Which of the following represents the most appropriate initial management plan?

      Your Answer: Arrange an urgent magnetic resonance (MR) of the brain

      Explanation:

      Management of Sudden Sensorineural Hearing Loss

      Sudden sensorineural hearing loss (SSNHL) is a medical emergency that requires urgent evaluation and management. Patients with unexplained sudden hearing loss should be referred to an ENT specialist and offered an MRI scan. A CT scan may also be indicated to rule out stroke, although it is unlikely to cause unilateral hearing loss.

      Antiviral medication such as acyclovir is not recommended unless there is evidence of viral infection. Antibiotics are also not indicated unless there is evidence of bacterial infection.

      The mainstay of treatment for SSNHL is oral prednisolone, which should be started as soon as possible and continued for 14 days. While the cause of SSNHL is often unknown, it is important to consider a wide range of differential diagnoses, including trauma, drugs, space-occupying lesions, autoimmune inner ear disease, and many other conditions. Prompt evaluation and treatment can improve the chances of recovery and prevent further hearing loss.

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  • Question 26 - A 50-year-old woman comes to her GP complaining of a sore throat, coryzal...

    Correct

    • A 50-year-old woman comes to her GP complaining of a sore throat, coryzal symptoms, cough, feeling feverish and general malaise for the past week. She reports that she is eating and drinking well. Upon examination, her temperature is 37.1°C and her chest is clear. Her tonsils are inflamed, but there is no exudate. She has no significant medical history except for carpal tunnel syndrome. Based on her Fever PAIN score, what is the most suitable course of action?

      Your Answer: Safety net and review in 1 week if no improvement

      Explanation:

      Using the FeverPAIN Score to Determine Antibiotic Use in Pharyngitis

      Pharyngitis, or sore throat, is a common reason for patients to seek medical attention. However, not all cases of pharyngitis require antibiotics. In fact, inappropriate antibiotic use can lead to antibiotic resistance and other negative outcomes. To help providers determine which patients with pharyngitis have streptococcal pharyngitis, the FeverPAIN Score was developed.

      The FeverPAIN Score assesses five factors: fever, presence of pus, how quickly symptoms attenuate, inflamed tonsils, and cough. A score of 0-1 is associated with a low likelihood of streptococcal infection, while a score of 4 or more is associated with a high likelihood. For patients with a score of 2 or 3, delayed antibiotic use may be appropriate.

      In the case of a woman with inflamed tonsils, her FeverPAIN Score indicates that antibiotics are not necessary. However, it is important to safety net patients and review their condition in one week if there is no improvement. By using the FeverPAIN Score, providers can make informed decisions about antibiotic use in pharyngitis and help reduce the risk of antibiotic resistance.

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  • Question 27 - A 49-year-old woman presents to her doctor with complaints of constipation and back...

    Correct

    • A 49-year-old woman presents to her doctor with complaints of constipation and back pain for the past 6 months. Her husband, who accompanies her, also mentions that she has been acting strangely during this time. On examination, a nodule is found in the patient's neck, just left of the midline. Further investigations reveal an elevated parathyroid hormone level and abnormal levels of various electrolytes. The patient undergoes surgery and subsequently develops hoarseness. What is the most probable cause of the patient's voice change?

      Your Answer: Damage to the recurrent laryngeal nerve

      Explanation:

      Effects of Nerve Damage on Laryngeal Function

      Hypercalcaemia and Recurrent Laryngeal Nerve Damage
      Hypercalcaemia, often caused by parathyroid adenoma, can lead to transection of the recurrent laryngeal nerve during surgical removal of the adenoma. This can result in hoarseness.

      External Laryngeal Nerve Damage
      Transection of the external laryngeal nerve can affect the cricothyroid muscle, leading to difficulty in increasing the pitch of one’s voice.

      Internal Laryngeal Nerve Damage
      Damage to the internal laryngeal nerve can impair sensation in the pharynx above the vocal cords, but it does not cause hoarseness.

      Spinal Accessory Nerve Damage
      Damage to the spinal accessory nerve can impair shoulder shrugging and head rotation.

      Vagus Nerve Damage
      Damage to the vagus nerve can cause widespread effects involving autonomic dysfunction.

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  • Question 28 - A 65-year-old man, who presented to the Emergency Department a day before for...

    Incorrect

    • A 65-year-old man, who presented to the Emergency Department a day before for uncontrollable epistaxis, has been admitted following Ear, Nose and Throat (ENT) referral. Bleeding was located and managed by posterior nasal packing. He had no complications following the procedure. However, on the next day, he developed fever, myalgia, hypotension, rashes in the oral mucocutaneous junctions, generalized oedema and several episodes of watery diarrhoea, with nausea and vomiting.
      Which of the following investigations/findings would help you make a diagnosis?

      Your Answer: Increased erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)

      Correct Answer: Culture and sensitivity of posterior nasal swab

      Explanation:

      Interpreting Clinical Findings in a Patient with Posterior Nasal Swab Procedure

      Toxic shock syndrome (TSS) is a potential complication of an infected posterior nasal swab in the management of epistaxis. Clinical signs and symptoms of multiorgan involvement, along with a positive swab from the posterior pharyngeal mucosa, would be diagnostic for TSS caused by Staphylococcus aureus. Blood cultures are not necessary for diagnosis, as they are positive in only 5% of cases. Eosinophilia is not characteristic of TSS, but rather a hallmark of drug reactions with eosinophilia and systemic symptoms (DRESS). Kawasaki’s disease, another systemic inflammatory disease, is characterised by an increase in acute phase reactants (ESR, CRP) and localised oedema. A non-blanching purpuric rash is typically seen in meningococcal infection and does not match with the clinical features and history of posterior nasal swab procedure in this patient.

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  • Question 29 - A woman in her early 50s, who is a singer, has a history...

    Incorrect

    • A woman in her early 50s, who is a singer, has a history of thyroid surgery and needs another procedure due to recurrent thyroid carcinoma. Following the surgery, she experiences a change in her voice and is unable to reach high notes while singing. During flexible laryngoscopy, it is observed that her left vocal cord does not elongate during phonation.
      Which nerve is likely to have been affected?

      Your Answer: Recurrent laryngeal nerve

      Correct Answer: External branch of the superior laryngeal nerve

      Explanation:

      Nerves Related to the Thyroid Gland and Their Risks in Surgery

      The thyroid gland is closely related to several nerves, including the external branch of the superior laryngeal nerve, recurrent laryngeal nerve, ansa cervicalis nerve, hypoglossal nerve, and lingual nerve. During neck dissection or surgery involving the thyroid or submandibular gland, these nerves may be at risk of damage.

      The external branch of the superior laryngeal nerve innervates the cricothyroid muscle, which elongates the vocal cords. Damage to this nerve can result in an inability to produce high-frequency notes. The recurrent laryngeal nerve, on the other hand, innervates all intrinsic muscles of the thyroid except the cricothyroid muscle. Its injury can cause hoarseness and difficulty in adducting the vocal cords, leading to an aspiration risk.

      The ansa cervicalis nerve is located superiorly to the thyroid and may be unavoidable to divide during surgery. The hypoglossal nerve is found even more superiorly and is at risk in submandibular gland excision and neck dissection. The lingual nerve is also located superiorly and may be at risk in submandibular gland excision, along with the hypoglossal nerve and the marginal mandibular branch of the facial nerve.

      In summary, surgeons must be aware of the location and function of these nerves to minimize the risk of damage during thyroid or submandibular gland surgery.

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  • Question 30 - A 16-year-old boy comes to the Emergency Department after being involved in a...

    Correct

    • A 16-year-old boy comes to the Emergency Department after being involved in a fight. He reports being punched on his left ear and has since lost hearing in that ear. He has a GCS score of 15 and has been coherent and lucid throughout the incident. He experiences a mild headache but has not vomited or felt drowsy. On examination, there are no focal neurological signs, and his cervical spine is not tender. Fundoscopy reveals a normal retina, but there is a ruptured left tympanic membrane with a small amount of blood. What is the most appropriate course of action?

      Your Answer: Give him a week’s course of co-amoxiclav, and advise him to keep his ear dry and to see his general practitioner in 6 weeks

      Explanation:

      Managing a Ruptured Tympanic Membrane: Treatment Options

      A ruptured tympanic membrane can occur due to otitis media or trauma. In most cases, the membrane heals on its own within six weeks. To promote healing, it is important to keep the ear dry and avoid exposing it to potentially contaminated water.

      Treatment options for a ruptured tympanic membrane depend on the severity of the condition. In most cases, a week’s course of co-amoxiclav is sufficient. However, if symptoms persist after six weeks, referral to an Ear, Nose and Throat (ENT) specialist may be necessary for a tympanoplasty.

      There is no need for neurosurgical intervention or a CT scan unless there are complications or signs of an intracranial bleed. Overall, prompt treatment and careful management can help ensure a full recovery from a ruptured tympanic membrane.

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SESSION STATS - PERFORMANCE PER SPECIALTY

ENT (16/30) 53%
Passmed