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Question 1
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A 35-year-old female patient complains of recurring episodes of vertigo accompanied by a sensation of 'fullness' and 'pressure' in her ears. She believes her hearing is impaired during these episodes. Physical examination reveals no abnormalities. What is the probable diagnosis?
Your Answer: Meniere's disease
Explanation:Understanding Meniere’s Disease
Meniere’s disease is a condition that affects the inner ear and its cause is still unknown. It is more commonly seen in middle-aged adults but can occur at any age and affects both men and women equally. The condition is characterized by excessive pressure and progressive dilation of the endolymphatic system. The most prominent symptoms of Meniere’s disease are recurrent episodes of vertigo, tinnitus, and sensorineural hearing loss. Other symptoms include a sensation of aural fullness or pressure, nystagmus, and a positive Romberg test. These episodes can last from minutes to hours and are typically unilateral, but bilateral symptoms may develop over time.
The natural history of Meniere’s disease shows that symptoms usually resolve in the majority of patients after 5-10 years. However, most patients are left with some degree of hearing loss, and psychological distress is common. To manage the condition, an ENT assessment is required to confirm the diagnosis. Patients should inform the DVLA, and the current advice is to cease driving until satisfactory control of symptoms is achieved. During acute attacks, buccal or intramuscular prochlorperazine may be administered, and admission to the hospital may be required. To prevent future attacks, betahistine and vestibular rehabilitation exercises may be of benefit.
In summary, Meniere’s disease is a condition that affects the inner ear and can cause recurrent episodes of vertigo, tinnitus, and hearing loss. While the cause is unknown, there are management strategies available to help control symptoms and prevent future attacks. It is important for patients to seek medical attention and inform the DVLA to ensure their safety and well-being.
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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 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 3
Correct
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As the GPST1 in the emergency department, you are requested to assess a 34-year-old woman who fell and struck her head while drinking three hours ago. Your consultant instructs you to confirm the absence of any clinical indications of a base of skull fracture. Which of the following is not linked to a base of skull injury?
Your Answer: Stellwag's sign
Explanation:The base of the skull is made up of three bony fossae: the anterior, middle, and posterior. These structures provide support for various internal structures within the cranium. If these bones are fractured, it can result in damage to associated neurovascular structures, which can have external manifestations in areas such as the nasal cavity or auditory canal. Bleeding from ruptured vessels can lead to haemotympanum or Battle’s sign in the mastoid area, while ruptured CSF spaces can cause CSF rhinorrhoea and otorrhoea. Stellwag’s sign, on the other hand, is not related to base of skull trauma and refers to reduced blinking.
Patients with head injuries should be managed according to ATLS principles and extracranial injuries should be managed alongside cranial trauma. There are different types of traumatic brain injuries, including extradural hematoma, subdural hematoma, and subarachnoid hemorrhage. Primary brain injury may be focal or diffuse, and secondary brain injury can occur due to cerebral edema, ischemia, infection, or herniation. Management may include IV mannitol/frusemide, decompressive craniotomy, and ICP monitoring. Pupillary findings can provide information on the location and severity of the injury.
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This question is part of the following fields:
- ENT
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Question 4
Correct
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A previously well 62-year-old bank clerk was seen by her general practitioner (GP), complaining of recurrent attacks of dizziness. She complains of recurring attacks of the room spinning around her in a horizontal plane, which is happening on multiple occasions every day. Each attack lasts about 10 seconds and seems to occur whenever she turns in bed, lies down or sits up from the supine position. There are no other associated symptoms. She is taking no medication. Standard neurological examination is normal.
Which of the following diagnoses is most likely?Your Answer: Benign positional paroxysmal vertigo (BPPV)
Explanation:Differential diagnosis of recurrent positional vertigo
Recurrent positional vertigo is a common complaint that can have various underlying causes. One of the most frequent diagnoses is benign positional paroxysmal vertigo (BPPV), which typically affects middle-aged and older women and is triggered by specific head movements. BPPV is diagnosed based on the patient’s history and confirmed with the Hallpike manoeuvre, which elicits characteristic nystagmus. Treatment options include canalith repositioning manoeuvres and vestibular rehabilitation exercises.
However, other conditions may mimic BPPV or coexist with it, and therefore a thorough differential diagnosis is necessary. Migraine-associated vertigo is a type of vestibular migraine that can cause brief episodes of vertigo without headache, but usually has a longer duration and is not triggered by positional changes. Posterior circulation ischaemia, which affects the brainstem and cerebellum, can also cause vertigo, but typically presents with other neurological symptoms and has a more acute onset. Postural hypotension, which results from a drop in blood pressure upon standing, can cause dizziness and syncope, but is not usually related to head movements. Labyrinthitis, an inflammation of the inner ear, can cause vertigo and hearing loss, but is not typically triggered by positional changes.
Therefore, a careful history and physical examination, including a neurological assessment, are essential to differentiate between these conditions and guide appropriate management. In some cases, further testing such as imaging or vestibular function tests may be necessary to confirm the diagnosis.
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This question is part of the following fields:
- ENT
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Question 5
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A 75-year-old man visits his doctor with worries about a tiny spot on his inner, lower lip. The spot has been there for about a month and has not shown any changes during this time. He reports no pain. He used to smoke but quit a decade ago. During the examination, his oral hygiene appears to be good, and there is a small, white patch less than 1 cm in size on the inner surface of his lower lip.
What is the best course of action for this patient?Your Answer: Refer oral surgery under 2-week wait
Explanation:If a patient has had persistent oral ulceration for more than three weeks, it is recommended that they be referred to oral surgery under the two week wait. This is especially important for smokers, as it raises suspicion for malignancy. Referring the patient to oral surgery under the two week wait is more appropriate than routine referral, as it allows for a quicker diagnosis. Following up with a community dentist is not recommended, as it may cause delays in diagnosis if the patient does not attend. While chlorhexidine may provide symptom relief, it does not address the underlying diagnosis, and reassurance alone is also not sufficient. Medical practitioners should refer patients with this presentation to oral surgery.
When to Refer Patients with Mouth Lesions for Oral Surgery
Mouth lesions can be a cause for concern, especially if they persist for an extended period of time. In cases where there is unexplained oral ulceration or mass that lasts for more than three weeks, or red and white patches that are painful, swollen, or bleeding, a referral to oral surgery should be made within two weeks. Additionally, if a patient experiences one-sided pain in the head and neck area for more than four weeks, which is associated with earache but does not result in any abnormal findings on otoscopy, or has an unexplained recent neck lump or a previously undiagnosed lump that has changed over a period of three to six weeks, a referral should be made.
Patients who have persistent sore or painful throats or signs and symptoms in the oral cavity that last for more than six weeks and cannot be definitively diagnosed as a benign lesion should also be referred. It is important to note that the level of suspicion should be higher in patients who are over 40, smokers, heavy drinkers, and those who chew tobacco or betel nut (areca nut). By following these guidelines, healthcare professionals can ensure that patients with mouth lesions receive timely and appropriate care. For more information on this topic, please refer to the link provided.
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This question is part of the following fields:
- ENT
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Question 6
Correct
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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: 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 7
Correct
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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: 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 8
Incorrect
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A 45-year-old man presents to surgery with several weeks of intermittent vertigo, tinnitus, and decreased hearing on the right side. You suspect Ménière’s disease.
Which of the following is the most appropriate management option for this patient?Your Answer: Vestibular rehabilitation
Correct Answer: Referral to ENT
Explanation:Management of Meniere’s Disease
Meniere’s disease is a condition characterized by intermittent bouts of vertigo, tinnitus, and/or deafness in one or both ears, as well as a feeling of fullness or pressure in the affected ear. If a patient presents with these symptoms, a referral to an ear, nose, and throat (ENT) consultant is advisable to confirm the diagnosis and exclude other potential causes.
If the patient is experiencing an acute attack, self-care advice and medication may be warranted. Prochlorperazine is recommended for acute attacks, while betahistine is used for preventive treatment. Severe symptoms may require hospital admission for supportive treatment.
Long-term use of oral or buccal prochlorperazine is not recommended, and vestibular rehabilitation is not the most appropriate management for this condition. Instead, patients should be referred to a specialist for further evaluation and management.
Carbamazepine is not indicated for the management of Meniere’s disease. Patients should also be advised to inform the Driver and Vehicle Licensing Authority (DVLA) of their condition.
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This question is part of the following fields:
- ENT
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Question 9
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 10
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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