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  • Question 1 - Liam is a 26-year-old man who complained of hearing loss and was diagnosed...

    Correct

    • Liam is a 26-year-old man who complained of hearing loss and was diagnosed with bilateral impacted wax. Despite using olive oil drops for a week, there was no improvement.

      What other options can be considered at this point?

      Your Answer: Sodium bicarbonate drops

      Explanation:

      When attempting to remove impacted earwax, it is recommended to try olive oil drops first. If this method is unsuccessful, other options such as almond oil drops, sodium bicarbonate drops, and sodium chloride drops can be considered. Otomize and betamethasone ear drops are commonly used for treating otitis externa. It is important to avoid attempting to remove earwax through ear candling or the use of cotton buds.

      Understanding earwax and Its Impacts

      earwax is a natural substance produced by the body to protect the ear canal. However, it is not uncommon for earwax to become impacted, leading to a range of symptoms such as pain, hearing loss, tinnitus, and vertigo. In such cases, treatment is necessary to alleviate the discomfort caused by the impacted earwax. Primary care options for treatment include ear drops or irrigation, also known as ‘ear syringing’. It is important to note that treatment should not be administered if there is a suspected perforation or if the patient has grommets. Ear drops such as olive oil, sodium bicarbonate 5%, and almond oil can be used to help alleviate the symptoms of impacted earwax.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 2 - A 35-year-old male patient complains of constant sneezing, nasal congestion, and a persistent...

    Incorrect

    • A 35-year-old male patient complains of constant sneezing, nasal congestion, and a persistent runny nose. What is not considered a part of the treatment plan for allergic rhinitis?

      Your Answer: Oral corticosteroids

      Correct Answer: Oral decongestants

      Explanation:

      Understanding Allergic Rhinitis

      Allergic rhinitis is a condition that causes inflammation in the nose due to sensitivity to allergens such as dust mites, grass, tree, and weed pollens. It can be classified into seasonal, perennial, or occupational, depending on the timing and cause of symptoms. Seasonal rhinitis, which occurs due to pollens, is commonly known as hay fever. Symptoms of allergic rhinitis include sneezing, bilateral nasal obstruction, clear nasal discharge, post-nasal drip, and nasal pruritus.

      The management of allergic rhinitis involves allergen avoidance and medication. For mild-to-moderate intermittent or mild persistent symptoms, oral or intranasal antihistamines may be prescribed. For moderate-to-severe persistent symptoms or if initial drug treatment is ineffective, intranasal corticosteroids may be recommended. In some cases, a short course of oral corticosteroids may be necessary to cover important life events. Topical nasal decongestants, such as oxymetazoline, may also be used for short periods, but prolonged use can lead to tachyphylaxis and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) upon withdrawal.

      In summary, allergic rhinitis is a common condition that can cause discomfort and affect daily life. Understanding the different types of allergic rhinitis and its symptoms can help in managing the condition effectively. It is important to consult a healthcare professional for proper diagnosis and treatment.

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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 3 - A 2-year-old girl is presented to the GP by her mother who has...

    Incorrect

    • A 2-year-old girl is presented to the GP by her mother who has noticed a peculiar lump on her neck. The mother is uncertain about the duration of the lump. The lump is situated in the anterior triangle, just in front of the sternocleidomastoid muscle, and has a soft texture. The lump is mobile but doesn't transilluminate.

      After a biopsy, cholesterol crystals are discovered in the extracted fluid. What is the probable underlying diagnosis?

      Your Answer: Lipoma

      Correct Answer: Branchial cyst

      Explanation:

      Branchial cysts are a type of neck lump that are present from birth and typically appear in the front of the neck, near the sternocleidomastoid muscle. These cysts are lined with either squamous or columnar cells and may contain fluid that includes cholesterol crystals. They develop when the second and third branchial arches fail to fuse properly during fetal development. Cystic hygromas, lipomas, and thyroglossal cysts are different types of neck lumps that are located in different areas and do not typically contain cholesterol crystals.

      Understanding Branchial Cysts: A Developmental Defect of the Neck

      A branchial cyst is a non-cancerous growth that develops due to a defect in the branchial arches. It is filled with fluid and encapsulated by stratified squamous epithelium. These cysts may have a fistula and are prone to infection, which can cause them to enlarge following a respiratory tract infection. They typically present in late childhood or early adulthood as asymptomatic lateral neck lumps, usually located anterior to the sternocleidomastoid muscle. Although there is a slight male predisposition, they account for around 20% of paediatric neck masses.

      When examining a neck lump in children, it is important to consider and exclude other potential causes such as congenital, inflammatory, or neoplastic conditions. A branchial cyst can be diagnosed through ultrasound and fine-needle aspiration, and referral to an Ear Nose and Throat (ENT) specialist is necessary for treatment. Branchial cysts can be treated conservatively or surgically excised, and antibiotics are required for acute infections.

      In summary, understanding branchial cysts is important for proper diagnosis and treatment. These developmental defects of the neck can present as asymptomatic lateral neck lumps and are prone to infection. With proper evaluation and management, branchial cysts can be effectively treated by ENT specialists.

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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 4 - Which one of the following statements regarding cholesteatomas is accurate? ...

    Incorrect

    • Which one of the following statements regarding cholesteatomas is accurate?

      Your Answer: Cholesteatoma is 3 times more common in diabetics

      Correct Answer: The peak incidence is 10-20 years

      Explanation:

      Understanding Cholesteatoma

      Cholesteatoma is a benign growth of squamous epithelium that can cause damage to the skull base. It is most commonly found in individuals between the ages of 10 and 20 years old. Those born with a cleft palate are at a higher risk of developing cholesteatoma, with a 100-fold increase in risk.

      The main symptoms of cholesteatoma include a persistent discharge with a foul odor and hearing loss. Other symptoms may occur depending on the extent of the growth, such as vertigo, facial nerve palsy, and cerebellopontine angle syndrome.

      During otoscopy, a characteristic attic crust may be seen in the uppermost part of the eardrum.

      Management of cholesteatoma involves referral to an ear, nose, and throat specialist for surgical removal. Early detection and treatment are important to prevent further damage to the skull base and surrounding structures.

      In summary, cholesteatoma is a non-cancerous growth that can cause significant damage if left untreated. It is important to be aware of the symptoms and seek medical attention promptly if they occur.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 5 - You have a telephone consultation with a 39-year old male patient who has...

    Incorrect

    • You have a telephone consultation with a 39-year old male patient who has paralysis on the left-hand side of his face. It started 2 days ago with left sided facial and ear pain. The pain is now very severe and causing him considerable discomfort. He is unable to move his left forehead, close the left eye or move the left-hand side of his mouth. He is normally fit and well.

      You suspect that he has a Bell's palsy and arrange to see him in your clinic that afternoon to examine him.

      Which statement below regarding Bell's palsy is correct?

      Your Answer: It is normal for the paralysis to continue for up to six months

      Correct Answer: In a patient with a Bell's palsy, severe pain might indicate Ramsay Hunt syndrome

      Explanation:

      Severe pain in a patient with Bell’s palsy may be a sign of Ramsay Hunt syndrome, which is caused by herpes zoster and is accompanied by a painful rash and herpetic vesicles. Urgent referral to ENT is necessary if the facial paralysis has not improved after one month. Loss of taste in the anterior two-thirds of the tongue on the same side as the facial weakness may occur but doesn’t require urgent referral. Referral to a plastic surgeon with expertise in facial reconstructive surgery should be considered if there is residual paralysis after 6-9 months. Corticosteroid treatment is recommended as it has been shown to improve prognosis based on evidence from meta-analyses, while antiviral treatments are not recommended alone or in combination with prednisolone.

      Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It typically affects individuals between the ages of 20 and 40, and is more common in pregnant women. The condition is characterized by a lower motor neuron facial nerve palsy that affects the forehead, while sparing the upper face. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.

      The management of Bell’s palsy has been a topic of debate, with various treatment options proposed in the past. However, there is now consensus that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, with some experts recommending it for severe cases. Eye care is also crucial to prevent exposure keratopathy, and patients may need to use artificial tears and eye lubricants. If they are unable to close their eye at bedtime, they should tape it closed using microporous tape.

      Follow-up is essential for patients who show no improvement after three weeks, as they may require urgent referral to ENT. Those with more long-standing weakness may benefit from a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within three to four months. However, untreated cases can result in permanent moderate to severe weakness in around 15% of patients.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 6 - A 43-year-old man presents to you with complaints of tinnitus and hearing loss...

    Correct

    • A 43-year-old man presents to you with complaints of tinnitus and hearing loss for the past few weeks. He has a history of chronic obstructive pulmonary disease and is currently on medications including salbutamol inhaler, azithromycin, beclomethasone-formoterol (Fostair) inhaler, tiotropium inhaler, and glycopyrronium bromide.

      Upon examination, you note a positive Rinne test bilaterally with reduced hearing on both sides, worse on the left. The Weber test lateralizes to the right, and otoscopy is normal. You suspect a sensorineural hearing loss and urgently refer the patient to an ENT specialist.

      Which medication from his current regimen may be contributing to his symptoms and should be discontinued?

      Your Answer: Azithromycin

      Explanation:

      Azithromycin has been found to have a negative impact on hearing, causing tinnitus and sensorineural hearing loss. Patients should discontinue use of the medication immediately if these symptoms occur to prevent irreversible hearing damage. While most cases of hearing loss will improve, caution should be exercised when taking this medication.

      Salbutamol and beclomethasone-formoterol are associated with common side effects such as arrhythmias, headaches, dizziness, nausea, palpitations, tremor, and hypokalaemia (with high doses). Tiotropium and glycopyrronium are also associated with side effects such as arrhythmias, cough, headaches, dry mouth, and nausea.

      Macrolides are a class of antibiotics that include erythromycin, clarithromycin, and azithromycin. They work by blocking translocation during bacterial protein synthesis, ultimately inhibiting bacterial growth. While they are generally considered bacteriostatic, their effectiveness can vary depending on the dose and type of organism being treated. Resistance to macrolides can occur through post-transcriptional methylation of the 23S bacterial ribosomal RNA.

      However, macrolides can also have adverse effects. They may cause prolongation of the QT interval and gastrointestinal side-effects, such as nausea. Cholestatic jaundice is a potential risk, but using erythromycin stearate may reduce this risk. Additionally, macrolides are known to inhibit the cytochrome P450 isoenzyme CYP3A4, which metabolizes statins. Therefore, it is important to stop taking statins while on a course of macrolides to avoid the risk of myopathy and rhabdomyolysis. Azithromycin is also associated with hearing loss and tinnitus.

      Overall, while macrolides can be effective antibiotics, they do come with potential risks and side-effects. It is important to weigh the benefits and risks before starting a course of treatment with these antibiotics.

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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 7 - A 36-year-old woman has been receiving treatment for the past three weeks for...

    Incorrect

    • A 36-year-old woman has been receiving treatment for the past three weeks for otitis externa with flumetasone/clioquinol 0.02%/1%, followed by gentamicin 0.3% w/v and hydrocortisone acetate 1% ear drops. She acquired the condition while on vacation in Spain. She is now experiencing increasing itchiness in her ears. During examination, her ears have abundant discharge with black spots on a white background. What is the most appropriate next step in managing this patient?

      Your Answer: Refer to Ear, Nose and Throat (ENT) for urgent review

      Correct Answer: Clotrimazole solution

      Explanation:

      Treatment Options for Fungal Otitis Externa

      Fungal otitis externa is a common ear infection that can be difficult to diagnose and treat. Patients who have had prolonged courses of steroid and antibiotic drops are particularly susceptible to this type of infection. Symptoms include pruritus and discharge, which may not respond to antibiotics. The most common fungal agents are Aspergillus and Candida, which can be treated with topical clotrimazole. Topical ciprofloxacin is not effective against fungal infections, and co-amoxiclav tablets should not be used. Sofradex® ear drops, which contain steroids, may exacerbate symptoms. If initial treatment with antifungal medication is unsuccessful, referral to an Ear, Nose and Throat specialist may be necessary for further evaluation and treatment.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 8 - A 3-year-old boy has been unwell and crying during the night and this...

    Correct

    • A 3-year-old boy has been unwell and crying during the night and this has continued during the day with some benefit from paracetamol and ibuprofen. He has a cold. His temperature is 38C and both tympanic membranes are inflamed but not bulging.
      Select from the list the single most appropriate management option.

      Your Answer: Amoxicillin

      Explanation:

      Antibiotics for Acute Otitis Media in Children: When to Prescribe and Which Antibiotic to Use

      Acute otitis media (AOM) is a common childhood infection, and antibiotics are often prescribed to treat it. However, a Cochrane review found that antibiotics only provide a small benefit, with an increase in resolution at 1 week of only 13%. Two trials found that the numbers needed to treat (NNT) to prevent one treatment failure ranged from 8 to 17.

      Despite these findings, there are certain indications for prescribing antibiotics. Children under 2 years of age with bilateral disease or any child with significant systemic symptoms (fever above 38.5oC, vomiting) or bulging drums or otorrhoea should receive antibiotics. For most other children with mild disease, a wait-and-see policy is justified. Antibacterial treatment may be started after 4 days if there has been no improvement, and a delayed prescription is an option.

      When antibiotics are used, a broad-spectrum antibiotic is prescribed for 5 days. The most common pathogens are Streptococcus pneumoniae, Haemophilus influenza, and Moraxella catarrhalis. Amoxicillin is still the antibiotic of choice, with clarithromycin for penicillin-allergic patients. If there is no improvement within 48 hours or symptoms reoccur within 14 days, treatment failure may have occurred, and co-amoxiclav should be considered.

      It is important to note that ciprofloxacin doesn’t have a license in young children for this indication. Overall, the decision to prescribe antibiotics for AOM should be based on individual patient factors and the potential risks and benefits of treatment.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 9 - You are a primary care physician seeing a 2-year-old girl with her mother....

    Incorrect

    • You are a primary care physician seeing a 2-year-old girl with her mother. The mother reports that over the past 48 hours, her daughter has had intermittent fevers (up to 37.5ºC) and has been fussy. However, she has been eating and drinking normally.

      The mother has also noticed that her daughter has been tugging at her right ear.

      Upon examination, the child appears comfortable, and the following vital signs are noted:
      Temperature 37.2ºC
      Heart rate 105 beats/min
      Respiratory rate 22 breaths/min

      Upon otoscopy, you observe a small perforation in the right tympanic membrane with a small amount of discharge present in the external ear canal. The left tympanic membrane appears normal.

      What is the most appropriate course of action based on the information provided?

      Your Answer: Discuss with the on call ENT team

      Correct Answer: Prescribe a 7 day course of amoxicillin

      Explanation:

      In cases of acute otitis media with perforation, oral antibiotics should be prescribed. The recommended course of treatment is a 7-day course of amoxicillin. While most cases of otitis media resolve on their own with simple analgesia, antibiotics may be necessary in certain situations, such as bilateral infection in children under 2, otorrhoea, perforated tympanic membrane, and symptoms that do not improve after 3 days. In this case, the patient has ongoing and bilateral infection with on and off fevers for 3 days, making a 7-day course of amoxicillin the most appropriate option. Tympanic membrane perforations usually heal within 4-8 weeks, and it is good practice to re-examine them after a few weeks to ensure healing. However, this should be done earlier than 12-16 weeks. Tympanic membrane perforation is a common complication of otitis media and can usually be managed in the community without the need for discussion with ENT. Otomize, which contains aminoglycosides that are ototoxic, should not be used in cases of otitis media with perforation.

      Acute otitis media is a common condition in young children, often caused by bacterial infections following viral upper respiratory tract infections. Symptoms include ear pain, fever, and hearing loss, and diagnosis is based on criteria such as the presence of a middle ear effusion and inflammation of the tympanic membrane. Antibiotics may be prescribed in certain cases, and complications can include perforation of the tympanic membrane, hearing loss, and more serious conditions such as meningitis and brain abscess.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 10 - A five-year-old boy presents with a three-day history of right ear pain. He...

    Correct

    • A five-year-old boy presents with a three-day history of right ear pain. He is feeling well otherwise, with no fever and normal fluid intake. His mother has been giving him paracetamol for pain relief. During examination, his left tympanic membrane appears normal, but his right tympanic membrane is inflamed, erythematous, and bulging. He has a temperature of 36.5ºC. There is no significant medical history, but he has a penicillin allergy. What is the most appropriate treatment option for the likely diagnosis?

      Your Answer: Supportive treatment with paracetamol/ibuprofen

      Explanation:

      To diagnose otitis media, the presence of a middle ear effusion is necessary.

      In this case, the child has unilateral otitis media with a middle ear effusion, but is otherwise healthy.

      According to NICE guidelines, decongestants and antihistamines are not recommended for treating acute otitis media.

      The first-line antibiotic treatment for otitis media is amoxicillin or clarithromycin/erythromycin for patients with a penicillin allergy. However, NICE recommends prescribing antibiotics only if the child is under 2 years old and has bilateral otitis media or otorrhoea. Therefore, antibiotics are not necessary in this case.

      The appropriate course of action is to provide supportive treatment for the child’s symptoms, which can last up to a week.

      Acute otitis media is a common condition in young children, often caused by bacterial infections following viral upper respiratory tract infections. Symptoms include ear pain, fever, and hearing loss, and diagnosis is based on criteria such as the presence of a middle ear effusion and inflammation of the tympanic membrane. Antibiotics may be prescribed in certain cases, and complications can include perforation of the tympanic membrane, hearing loss, and more serious conditions such as meningitis and brain abscess.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      73.5
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