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Question 1
Incorrect
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A 12-year-old boy comes to his General Practitioner with his dad, reporting that he has been unable to breathe through either nostril since he caught a cold three days ago. During examination, the doctor observes smooth pink swellings in the lower part of the lateral side of each nostril. The swellings are tender, but there is no evidence of ulceration. The boy is otherwise healthy, with no fever or facial pain, and he has never had a nosebleed before.
What is the most suitable course of action in this scenario?Your Answer: Prescribe nasal steroids
Correct Answer: Reassure
Explanation:Management of Inferior Turbinate Bones in Children
Description: The inferior turbinate bones are often visible in children and do not require any treatment. If a child has recent unexplained symptoms on one side of the nose, such as a blockage or bloody discharge, urgent referral to ENT is necessary to exclude nasopharyngeal carcinoma. Nasal steroids are indicated for allergic rhinitis and swelling associated with nasal polyps, but not for normal appearances of the nasal mucosa. Oral steroids are not indicated in this case. Nasal polyps are unusual in children and their presence suggests the possibility of underlying disease, such as cystic fibrosis. Referral for nasal polypectomy is only necessary if the polyps are persistent and causing obstruction that has not responded to steroid treatment.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 2
Incorrect
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You have a follow-up appointment with a 4-year-old boy. He was seen two weeks ago for left-sided ear pain and discharge, for which you prescribed amoxicillin. Today, his mother reports that he has improved and she has been able to keep his ear dry. However, upon examination of the left ear, a tympanic membrane perforation is observed. What should be done next?
Your Answer: Refer to ENT
Correct Answer: Advise to keep ear dry and see in a further 4 weeks time
Explanation:Perforated Tympanic Membrane: Causes and Management
A perforated tympanic membrane, also known as a ruptured eardrum, is often caused by an infection but can also result from barotrauma or direct trauma. This condition can lead to hearing loss and increase the risk of otitis media.
In most cases, no treatment is necessary as the tympanic membrane will typically heal on its own within 6-8 weeks. However, it is important to avoid getting water in the ear during this time. Antibiotics may be prescribed if the perforation occurs after an episode of acute otitis media. This approach is supported by the 2008 Respiratory Tract Infection Guidelines from NICE.
If the tympanic membrane doesn’t heal by itself, myringoplasty may be performed. This surgical procedure involves repairing the perforation with a graft of tissue taken from another part of the body. With proper management, a perforated tympanic membrane can be successfully treated and hearing can be restored.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 3
Incorrect
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A 30-year-old football player comes in for evaluation the day after a game. He has noticeable swelling and redness in his left ear. Upon examination, it appears to be an auricular hematoma. What is the best course of action for treatment?
Your Answer: Apply an ice-pack six times a day for the next three days
Correct Answer: Refer to secondary care
Explanation:The RCGP curriculum includes a specific mention of auricular haematomas.
Auricular haematomas are frequently observed in individuals who participate in rugby or wrestling. It is crucial to seek immediate medical attention to prevent the development of ‘cauliflower ear’. The management of auricular haematomas necessitates an evaluation by an ENT specialist on the same day. Incision and drainage have been demonstrated to be more effective than needle aspiration.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 4
Incorrect
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Choose from the options below the one that is an appropriate reason for ROUTINE referral to the nearby ENT department for a patient in their 60s.
Your Answer: Hoarseness for 2 months
Correct Answer: An intermittent feeling of ‘something stuck in the throat’
Explanation:Urgent Referral Criteria for Suspicious Symptoms
When it comes to identifying potentially serious health issues, it’s important to know which symptoms require urgent referral. In the case of the last three presentations, all of them are recognized as needing immediate attention under the 2-week-wait criteria. However, it’s worth noting that acute otitis externa can typically be managed in primary care.
In terms of the throat symptom, it’s important to conduct a flexible laryngoscopy examination of the pharynx, which means that a non-urgent referral is necessary. The intermittent nature of the symptom suggests that it may be a benign problem, such as a globus sensation.
If you’re concerned about cancer, it’s worth checking out the external links for more information on upper gastrointestinal tract cancers and head and neck cancers. By staying informed and knowing when to seek medical attention, you can help ensure that you receive the care you need when you need it most.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 5
Incorrect
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You see a 28-year-old man who complains of painful mouth ulcers. He is in good health otherwise.
During the examination, you notice around 5 small and shallow aphthous ulcers on the inner lining of his mouth.
What is the accurate statement about aphthous mouth ulcers?Your Answer: A positive family history can be found in only 10% of people
Correct Answer: Stopping smoking is a risk factor for aphthous mouth ulcers
Explanation:There are various factors that can contribute to the development of oral ulcers. These include smoking, deficiencies in iron, folic acid, or vitamin B12, and local trauma to the oral mucosa. Additionally, anxiety and exposure to certain foods such as chocolate, coffee, peanuts, and gluten products may also play a role. However, hormonal factors are not typically associated with the development of oral ulcers.
Aphthous mouth ulcers are painful sores that are circular or oval in shape and are found only in the mouth. They are not associated with any systemic disease and often occur repeatedly, usually starting in childhood. These ulcers can be caused by damage to the mouth, such as biting the cheek or brushing too hard, or may be due to a genetic predisposition. Other factors that can trigger these ulcers include stress, certain foods, stopping smoking, and hormonal changes related to the menstrual cycle.
Aphthous ulcers are characterized by their round or oval shape, a clearly defined margin, a yellowish-grey slough on the floor, and a red periphery. They usually appear on non-keratinized mucosal surfaces, such as the inside of the lips, cheeks, floor of the mouth, or undersurface of the tongue. In most cases, investigations are not necessary, but they may be considered if an underlying systemic disease is suspected.
Treatment for aphthous ulcers involves avoiding any factors that may trigger them and providing symptomatic relief for pain, discomfort, and swelling. This may include using a low potency topical corticosteroid, an antimicrobial mouthwash, or a topical analgesic. Most ulcers will heal within two weeks without leaving any scars. However, if a mouth ulcer persists for more than three weeks, it is important to seek urgent referral to a specialist.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 6
Correct
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An 80-year-old man presents to the emergency department with worsening pain and fever following a dental extraction 5 days ago. He is usually in good health. On examination, he has a tender swelling in the left submandibular region and mild trismus. His tongue is slightly displaced upwards and he is unable to protrude it. There is no respiratory distress or stridor. What is the best course of action for management?
Your Answer: Arrange a 999 ambulance for immediate transfer to hospital
Explanation:Ludwig’s Angina is a medical emergency that falls under the domain of ENT. The patient in question is displaying symptoms and indications that suggest the presence of this rare infection, which affects the soft tissues of the neck and the floor of the mouth. While it is typically caused by dental issues, it can also arise from other types of soft tissue infections in the neck. Due to the effectiveness of modern antibiotics and dental hygiene, Ludwig’s Angina is now quite uncommon, and many physicians may not be familiar with its presentation. However, it can lead to rapid deterioration and airway obstruction within a matter of minutes, necessitating immediate airway management and aggressive surgical intervention. If there is any suspicion of Ludwig’s Angina, it is crucial to transfer the patient to the emergency department without delay.
Understanding Ludwig’s Angina
Ludwig’s angina is a serious form of cellulitis that affects the soft tissues of the neck and the floor of the mouth. It is usually caused by an infection that originates from the teeth and spreads to the submandibular space. The condition is characterized by symptoms such as neck swelling, fever, and difficulty swallowing.
Ludwig’s angina is a medical emergency that requires immediate attention as it can lead to airway obstruction, which can be life-threatening. The management of this condition involves airway management and the administration of intravenous antibiotics.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 7
Incorrect
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A 60-year-old male presents to his GP with complaints of severe ear pain. He reports experiencing pain and white discharge from his left ear for the past two weeks, along with a feeling of dulled hearing. The patient has a medical history of glaucoma, hypertension, and type two diabetes, with a recent HbA1c of 59 mmol/mol.
During the examination, the patient appears to be in discomfort. The right ear appears normal, but the left external auditory canal is swollen and painful to examine, with copious amounts of white discharge. There is no swelling or erythema affecting the pinna nor mastoid. Cranial nerve exam detects a conductive hearing loss in the left ear and a subtle inability to wrinkle the forehead on the left. The patient is afebrile with a blood pressure of 142/96 mmHg.
What is the most appropriate course of action for managing this patient's symptoms?Your Answer: Arrange urgent ENT review for microsuction and popewick
Correct Answer: Arrange urgent admission for intravenous antibiotics, imaging
Explanation:If a patient has unilateral ear discharge and a facial nerve palsy on the left side, it is more likely to be a case of malignant otitis externa. This is a serious condition where the infection has spread to the temporal bone and can affect the facial nerve. The pain associated with this condition is severe and persistent, often waking the patient at night. Malignant otitis externa can be life-threatening in severe cases, and immediate referral to an ENT specialist for intravenous antibiotics and imaging is necessary.
Malignant Otitis Externa: A Rare but Serious Infection
Malignant otitis externa is a type of ear infection that is uncommon but can be serious. It is typically found in individuals who are immunocompromised, with 90% of cases occurring in diabetics. The infection starts in the soft tissues of the external auditory meatus and can progress to involve the soft tissues and bony ear canal, eventually leading to temporal bone osteomyelitis.
Key features in the patient’s history include diabetes or immunosuppression, severe and persistent ear pain, temporal headaches, and purulent otorrhea. In some cases, patients may also experience dysphagia, hoarseness, and facial nerve dysfunction.
Diagnosis is typically done through a CT scan, and non-resolving otitis externa with worsening pain should be referred urgently to an ENT specialist. Treatment involves intravenous antibiotics that cover pseudomonal infections.
In summary, malignant otitis externa is a rare but serious infection that requires prompt diagnosis and treatment. Patients with diabetes or immunosuppression should be particularly vigilant for symptoms and seek medical attention if they experience persistent ear pain or other related symptoms.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 8
Incorrect
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A 50-year-old woman comes to her General Practitioner with concerns about a lump in her throat that she has been feeling for the past six months. She reports feeling the lump even when she is not swallowing. Upon examination, her oropharynx, ears, nose, and neck appear normal. She is also a non-smoker.
What would be a significant cause for worry in a patient with these symptoms who is 50 years old?Your Answer: It persists for six months
Correct Answer: Left-sided ear pain
Explanation:Understanding Unilateral Ear Pain and Globus Sensation
Unilateral ear pain in adults with normal otoscopy findings may indicate cancer of the base of the tongue, especially if accompanied by persistent hoarseness, dysphagia, weight loss, or a swelling in the neck. Risk factors for head and neck cancers include smoking and alcohol consumption. However, if the pain is worse between meals and eating or drinking alleviates the symptoms, it is more likely to be globus sensation, which is the feeling of a lump in the throat that doesn’t affect swallowing function. If the symptom persists for six months without affecting swallowing, it is less likely to be a worrying cause such as laryngeal or esophageal cancer. Intermittent symptoms are also less likely to indicate a malignant cause, as they are typical for globus and often exacerbated by stress.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 9
Incorrect
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A 25-year-old man comes to his General Practitioner complaining of a painful discharging right ear and a mild unilateral right-sided hearing loss that has been going on for 3 days. During examination, the doctor observes an intact tympanic membrane and copious purulent liquid discharge. The patient has a normal heart rate of 70 bpm and is not running a fever.
What is the most suitable course of action for this patient?Your Answer: Prescribe analgesia only
Correct Answer: Prescribe topical antibiotics
Explanation:Management Options for Otitis Externa
Otitis externa is a common condition characterized by pain, itching, and discharge in the ear canal. Here are some management options for this condition:
Prescribe Topical Antibiotics: Topical antibiotics are the first-line treatment for otitis externa. Neomycin or clioquinol are recommended, and they may be combined with a topical corticosteroid if there is inflammation and eczema. Aminoglycosides should be used cautiously as second line if there is perforation of the eardrum.
Prescribe Oral Antibiotics: Oral antibiotics may be necessary if the patient is systemically unwell or there is preauricular lymphadenitis or cellulitis. Flucloxacillin or erythromycin is the drug of choice.
Refer to Ear, Nose and Throat (ENT) for Ear Wick Insertion: If there is extensive swelling of the auditory canal, an ear wick may be used. This is impregnated with antibiotic-steroid combination and is inserted into the auditory canal. However, if the tympanic membrane is visible, topical antibiotics would be the first-line treatment.
Prescribe Analgesia Only: Paracetamol or ibuprofen is usually sufficient for analgesia in cases of otitis externa. However, analgesia should be used in combination with antibiotics to aid in curing and preventing the worsening of symptoms.
Do Not Prescribe Topical Antifungals: Topical antifungals are not indicated in simple cases of otitis externa. They may be necessary if there is a secondary fungal infection, but this is not described in this case.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 10
Correct
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A 72-year-old man presents to the General Practitioner with complaints of hearing loss in his left ear. He reports feeling a blockage in the ear and has previously had his ears syringed. Upon examination, the ear is found to be occluded by wax. What is the most appropriate initial management option?
Your Answer: Ear drops
Explanation:Treatment Options for earwax: Ear Drops, Microsuction, and Manual Removal
earwax, also known as cerumen, can cause discomfort and hearing problems if it builds up in the ear canal. The first-line treatment for earwax is ear drops, which can soften the wax and make it easier to remove. Microsuction is a safer alternative to irrigation, but it is not widely available. Manual removal using a probe is also an option. However, there is little evidence on the effectiveness of these treatments.
Various types of ear drops can be used, including sodium bicarbonate, sodium chloride, olive oil, and almond oil. Cerumol® is a commonly used proprietary agent. However, the British National Formulary warns against using docusate sodium (Waxsol®, Molcer®) or urea hydrogen peroxide (Exterol®, Otex®) as they may irritate the external meatus.
Regardless of the type of ear drop used, the patient should lie with the affected ear uppermost for 5-10 minutes after applying the drops. While using any type of ear drop appears to be better than no treatment, it is uncertain if one type of drop is more effective than another. Therefore, it is important to seek advice from a healthcare professional before attempting to remove earwax at home.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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