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  • Question 1 - A parent is concerned about her 9-month-old child’s prominent ears. ...

    Correct

    • A parent is concerned about her 9-month-old child’s prominent ears.

      Your Answer: Delay operation until the age of 8

      Explanation:

      Prominent Ears: Causes, Diagnosis, and Treatment Options

      Prominent ears affect a small percentage of the population and are usually inherited. This condition arises due to the lack or malformation of cartilage during ear development in the womb, resulting in abnormal helical folds or lateral growth. While some babies are born with normal-looking ears, the problem may arise within the first three months of life.

      Before six months of age, the ear cartilage is soft and can be molded and splinted. However, after this age, surgical correction is the only option. Pinnaplasty or otoplasty can be performed on children from the age of five, but the ideal age for the procedure is around eight years old. This allows enough time to see if the child perceives the condition as a problem, while also avoiding potential teasing or bullying at school.

      While some prominent ears may become less visible over time, it is best not to delay corrective procedures. Younger ears tend to produce better results after surgery, and waiting too long may increase the risk of bullying at school. Overall, understanding the causes, diagnosis, and treatment options for prominent ears can help individuals make informed decisions about their care.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      28.5
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  • Question 2 - A 25-year-old male patient complains of mouth pain and halitosis. During examination, it...

    Incorrect

    • A 25-year-old male patient complains of mouth pain and halitosis. During examination, it is observed that he has poor dental hygiene, bleeding gums, and extensive gingival ulceration. He also has a fever of 38.0ºC. You suggest that he should visit a dentist. What other treatment alternatives should be provided?

      Your Answer: Paracetamol + chlorhexidine mouthwash

      Correct Answer: Paracetamol + oral metronidazole + chlorhexidine mouthwash

      Explanation:

      Understanding Gingivitis and its Management

      Gingivitis is a dental condition that is commonly caused by poor oral hygiene. It is characterized by red and swollen gums that bleed easily. In severe cases, it can lead to acute necrotizing ulcerative gingivitis, which is accompanied by painful bleeding gums, bad breath, and ulcers on the gums.

      For patients with simple gingivitis, regular dental check-ups are recommended, and antibiotics are usually not necessary. However, for those with acute necrotizing ulcerative gingivitis, it is important to seek immediate dental attention. In the meantime, oral metronidazole or amoxicillin may be prescribed for three days, along with chlorhexidine or hydrogen peroxide mouthwash and simple pain relief medication.

      It is crucial to maintain good oral hygiene to prevent gingivitis from developing or worsening. This includes brushing teeth twice a day, flossing daily, and using mouthwash regularly. By understanding the causes and management of gingivitis, individuals can take steps to protect their oral health and prevent complications.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      54.9
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  • Question 3 - A 6-year-old girl presents to the surgical department with complaints of a sore...

    Correct

    • A 6-year-old girl presents to the surgical department with complaints of a sore throat. She is running a temperature of 39.2ºC and is experiencing difficulty in eating due to the pain, although she is able to tolerate fluids. There are no other associated symptoms such as cough or rash. On examination, her heart rate is 120/min and chest auscultation is normal. Bilateral tonsils are covered in exudate, while ear examination is unremarkable. Apart from supportive care, what is the most appropriate course of action?

      Your Answer: Phenoxymethylpenicillin for 10 days

      Explanation:

      The patient is exhibiting signs of systemic disturbance and requires antibiotic treatment. A 7 to 10-day antibiotic regimen is recommended to effectively eliminate any potential Streptococcus infection. The BNF recommends Phenoxymethylpenicillin as the primary antibiotic option.

      Management of Sore Throat

      Sore throat is a common condition that includes pharyngitis, tonsillitis, and laryngitis. Routine throat swabs and rapid antigen tests are not recommended for patients with a sore throat. Pain relief can be achieved with paracetamol or ibuprofen, and antibiotics are not usually necessary. However, antibiotics may be indicated for patients with marked systemic upset, unilateral peritonsillitis, a history of rheumatic fever, an increased risk from acute infection, or when 3 or more Centor criteria are present. The Centor criteria and FeverPAIN criteria can be used to determine the likelihood of isolating Streptococci. If antibiotics are necessary, phenoxymethylpenicillin or clarithromycin can be given for a 7 or 10 day course. There is some evidence that a single dose of oral corticosteroid may reduce the severity and duration of pain, but this has not yet been incorporated into UK guidelines.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      112.7
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  • Question 4 - A 9-year-old patient had a tonsillectomy 4 days ago. His father has brought...

    Incorrect

    • A 9-year-old patient had a tonsillectomy 4 days ago. His father has brought him to the clinic as earlier today he noticed a small amount of bright red bleeding from his mouth. He is otherwise recovering well and has been eating and drinking normally.

      What is the best course of action for managing this patient's bleeding?

      Your Answer: Suggest simple analgesia and cool drinks

      Correct Answer: Refer immediately to ENT for assessment

      Explanation:

      If a patient experiences bleeding after a tonsillectomy, it is important to seek urgent assessment from the operating team. While simple analgesia may be appropriate for those experiencing only pain, the presence of bleeding requires immediate attention. Prescribing oral antibiotics in the community would not be appropriate in this context, and techniques such as silver nitrate cautery should only be performed by a specialist after a thorough assessment.

      Complications after Tonsillectomy

      Tonsillectomy is a common surgical procedure that involves the removal of the tonsils. However, like any surgery, it carries some risks and potential complications. One of the most common complications is pain, which can last for up to six days after the procedure.

      Another complication that can occur after tonsillectomy is haemorrhage, or bleeding. There are two types of haemorrhage that can occur: primary and secondary. Primary haemorrhage is the most common and occurs within the first 6-8 hours after surgery. It requires immediate medical attention and may require a return to the operating room.

      Secondary haemorrhage, on the other hand, occurs between 5 and 10 days after surgery and is often associated with a wound infection. It is less common than primary haemorrhage, occurring in only 1-2% of all tonsillectomies. Treatment for secondary haemorrhage usually involves admission to the hospital and antibiotics, but severe bleeding may require surgery.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      50.4
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  • Question 5 - Ramsey Hunt syndrome ...

    Incorrect

    • Ramsey Hunt syndrome

      Your Answer: Refer routinely to ENT for eustachian tube decompression and grommet insertion

      Correct Answer: Refer under 2-week wait to ENT for suspected cancer

      Explanation:

      If an adult presents with unilateral middle ear effusion, it could be a sign of nasopharyngeal cancer. In such cases, the appropriate action would be to refer the patient for an urgent 2-week wait ENT appointment to investigate the possibility of cancer. This is especially important if the patient is of East Asian origin and the effusion is not related to an upper respiratory tract infection. Other options, such as arranging a CT scan of the paranasal sinuses, do not address the urgent need to rule out cancer and should not be done in primary care. Further investigations, such as nasal endoscopy or MRI, may be arranged by the specialist to confirm or rule out the possibility of nasopharyngeal cancer.

      Understanding Nasopharyngeal Carcinoma

      Nasopharyngeal carcinoma is a type of squamous cell carcinoma that affects the nasopharynx. It is a rare form of cancer that is more common in individuals from Southern China and is associated with Epstein Barr virus infection. The presenting features of nasopharyngeal carcinoma include cervical lymphadenopathy, otalgia, unilateral serous otitis media, nasal obstruction, discharge, and/or epistaxis, and cranial nerve palsies such as III-VI.

      To diagnose nasopharyngeal carcinoma, a combined CT and MRI scan is typically used. The first line of treatment for this type of cancer is radiotherapy. It is important to catch nasopharyngeal carcinoma early to increase the chances of successful treatment.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      25.4
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  • Question 6 - A 30-year-old female patient complains of recurrent episodes of 'dizziness'. These episodes usually...

    Incorrect

    • A 30-year-old female patient complains of recurrent episodes of 'dizziness'. These episodes usually last for 30-60 minutes and happen every few days. The patient experiences a sensation of the room spinning and often feels nauseous during these attacks. Additionally, there is a 'roaring' sensation in the left ear. Otoscopy shows no abnormalities, but Weber's test indicates localization to the right ear. What is the probable diagnosis?

      Your Answer: Vestibular neuritis

      Correct Answer: Meniere's disease

      Explanation:

      The Weber’s test in sensorineural hearing loss indicates that the sound is perceived more strongly in the ear opposite to the affected ear.

      Meniere’s disease is a condition that affects the inner ear and its cause is 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 the excessive pressure and progressive dilation of the endolymphatic system. The main symptoms of Meniere’s disease are recurrent episodes of vertigo, tinnitus, and sensorineural hearing loss. Vertigo is usually the most prominent symptom, but patients may also experience 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 is that symptoms usually resolve in the majority of patients after 5-10 years. However, most patients will be left with some degree of hearing loss, and psychological distress is common. ENT assessment is required to confirm the diagnosis, and patients should inform the DVLA as the current advice is to cease driving until satisfactory control of symptoms is achieved. Acute attacks can be managed with buccal or intramuscular prochlorperazine, and admission to the hospital may be required. Prevention strategies include the use of betahistine and vestibular rehabilitation exercises, which may be beneficial.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      63.9
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  • Question 7 - A 55-year-old man with a history of asthma complains of worsening hay fever...

    Correct

    • A 55-year-old man with a history of asthma complains of worsening hay fever symptoms. He reports a persistent sensation of nasal congestion, particularly in his right nostril, and a decreased ability to smell.

      During the examination, you observe a nasal polyp on the right side.

      What is the most suitable course of action to take next?

      Your Answer: Specialist referral (urgent)

      Explanation:

      Understanding Chronic Rhinosinusitis

      Chronic rhinosinusitis is a common condition that affects approximately 10% of the population. It is characterized by inflammation of the nasal passages and paranasal sinuses that lasts for 12 weeks or more. There are several factors that can predispose individuals to this condition, including atopy, nasal obstruction, recent infections, swimming/diving, and smoking.

      Symptoms of chronic rhinosinusitis include facial pain, nasal discharge, nasal obstruction, and post-nasal drip. Treatment options include avoiding allergens, using intranasal corticosteroids, and nasal irrigation with saline solution. However, it is important to be aware of red flag symptoms such as unilateral symptoms, persistent symptoms despite treatment, and epistaxis, which may require further evaluation and management.

      In summary, chronic rhinosinusitis is a common inflammatory disorder that can cause significant discomfort and impact quality of life. Understanding the predisposing factors and symptoms, as well as appropriate management strategies, can help individuals effectively manage this condition.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      34.5
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  • Question 8 - A 27-year-old female comes to the clinic with a nodule in her neck...

    Incorrect

    • A 27-year-old female comes to the clinic with a nodule in her neck that she has noticed for the past month.
      Upon examination, a non-tender, 3.5 cm nodule is found on the right side of her neck, deep to the lower half of the right sternocleidomastoid. The nodule moves upwards on swallowing, and no other masses are palpable in the neck.
      What is the nature of this mass?

      Your Answer: Thyroid nodule

      Correct Answer: Lymph node

      Explanation:

      Thyroid Nodule: Causes and Investigation

      A thyroid nodule is suspected in this patient due to the movement observed during swallowing. The possible causes of a thyroid nodule include colloid cyst, adenoma, and carcinoma. To investigate this lesion, the most appropriate method would be fine needle aspiration. This procedure involves using a thin needle to extract a small sample of cells from the nodule for examination under a microscope. It is a safe and effective way to determine if the nodule is benign or malignant. Early detection and treatment of thyroid nodules can prevent complications and improve outcomes.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      44.2
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  • Question 9 - What is a true statement about mumps infection? ...

    Incorrect

    • What is a true statement about mumps infection?

      Your Answer:

      Correct Answer: Sterility commonly follows orchitis

      Explanation:

      Mumps: Symptoms and Complications

      Mumps is a viral infection that has an incubation period of 14-21 days. It can affect any of the salivary glands, but sometimes only one gland is affected. In rare cases, mumps can cause meningoencephalitis, which is inflammation of the brain and its surrounding tissues.

      One of the common complications of mumps is orchitis, which is inflammation of the testicles. This occurs in around 25% of cases and can cause pain, swelling, and fever. However, sterility is a relatively uncommon complication following orchitis.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 10 - An 80-year-old man presents with tinnitus.
    Which of the following statements about tinnitus is...

    Incorrect

    • An 80-year-old man presents with tinnitus.
      Which of the following statements about tinnitus is correct?

      Your Answer:

      Correct Answer: Tinnitus may be a sign of a brain tumour

      Explanation:

      Myths and Facts About Tinnitus

      Tinnitus, the perception of sound in the absence of external sound, is a common condition that affects around 10% of adults in the UK. However, there are many myths and misconceptions surrounding this condition.

      One myth is that tinnitus may be a sign of a brain tumour. While unilateral tinnitus may be a sign of an acoustic neuroma, this is rare.

      Another myth is that tinnitus is usually caused by drugs. While over 200 drugs are reported to cause tinnitus, drugs are not the commonest cause.

      A third myth is that there is no treatment for tinnitus. However, a hearing aid can often help, and relaxation techniques or background music may also be beneficial.

      Finally, some people believe that tinnitus is rare in the absence of ear disease and that it is usually constant in severity. In fact, tinnitus can have a wide variety of causes and symptoms, and many cases have no identifiable cause. Symptoms may come and go, and most cases of tinnitus are mild and improve over time.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 11 - A 3-year-old boy has been unwell and crying during the night and this...

    Incorrect

    • 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:

      Correct 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 12 - A 70-year-old man has unilateral hearing loss of gradual onset, but most noticeably...

    Incorrect

    • A 70-year-old man has unilateral hearing loss of gradual onset, but most noticeably for the last six months. His hearing test shows 60-dB unilateral high-frequency sensorineural hearing loss.
      What is the single most appropriate intervention?

      Your Answer:

      Correct Answer: Refer for magnetic resonance imaging (MRI) scan of the head

      Explanation:

      Management of Unilateral Sensorineural Hearing Loss

      Unilateral sensorineural hearing loss can be a sign of an acoustic neuroma, a tumour of the vestibulocochlear nerve. Therefore, any patient presenting with this symptom should undergo an MRI scan of the head to investigate the cause. Betahistine is not appropriate for this condition, but may be used in patients with Ménière’s disease. Hearing aid provision may be considered if the MRI is normal and the diagnosis is presbyacusis. High-dose oral steroids are not indicated for gradual-onset hearing loss. Grommet insertion is not a suitable treatment for sensorineural hearing loss.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 13 - A 55-year-old smoker requests more antibiotics for a left-sided earache. He had seen...

    Incorrect

    • A 55-year-old smoker requests more antibiotics for a left-sided earache. He had seen a locum for tonsillitis three weeks ago, which was mainly on the left side, and was prescribed penicillin V. On examination, his ears appear normal.
      What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Examine the pharynx

      Explanation:

      Treatment Options for Different Ear Conditions

      Examination of the Pharynx for Unilateral Ear Pain

      If a patient presents with unilateral ear pain and a normal appearance of the ear, it is important to examine the pharynx and tonsils. Tonsillar carcinoma may cause referred pain and present with unilateral tonsillar enlargement. Prognosis is poor, but surgery and radiotherapy may be helpful.

      No Antibiotics Needed for Unresolved Symptoms

      If a patient’s symptoms have not improved despite initial treatment, a delayed prescription for antibiotics will not help and may delay diagnosis. Further investigation should be considered.

      Exercises for Eustachian Tube Dysfunction

      Eustachian tube dysfunction may cause muffled sounds or a popping/clicking sensation. Treatment may include exercises such as swallowing, yawning, or chewing gum to help open the Eustachian tube.

      Topical Antibiotics for Otitis Externa

      Otitis externa may cause a swollen and erythematous ear canal with discharge or debris. Topical antibiotics such as neomycin or ciprofloxacin may be prescribed to treat this condition. However, the appearance of a normal ear canal and tympanic membrane doesn’t indicate a need for topical antibiotics.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 14 - A 70-year-old man visits his doctor after his family complains about his hearing...

    Incorrect

    • A 70-year-old man visits his doctor after his family complains about his hearing loss. He claims that they speak too softly, but admits that he struggles to hear in noisy settings. The patient reports feeling generally healthy, but has a history of hypertension and chronic obstructive pulmonary disease.

      During the examination, the doctor discovers bilateral sensorineural hearing loss. Presbycusis is suspected as the cause and the patient is referred for audiometric testing.

      What is the expected audiogram pattern for this individual?

      Your Answer:

      Correct Answer: Bilateral high-frequency hearing loss. Air conduction better than bone

      Explanation:

      Presbycusis is characterized by a bilateral loss of high-frequency hearing. This type of age-related hearing loss affects the inner ear and is often accompanied by difficulty hearing in noisy environments. In sensorineural hearing loss, air conduction is more effective than bone conduction, which is the opposite of conductive hearing loss. Therefore, the correct answer is ‘Bilateral high-frequency hearing loss. Air conduction is more effective than bone conduction.’

      Understanding Presbycusis: Age-Related Hearing Loss

      Presbycusis is a type of hearing loss that affects older individuals. It is a sensorineural hearing loss that typically affects high-frequency hearing bilaterally, leading to difficulties in understanding conversations, especially in noisy environments. The condition progresses slowly as the sensory hair cells and neurons in the cochlea atrophy over time. Although certain factors are associated with presbycusis, it is distinct from noise-related hearing loss.

      The prevalence of presbycusis increases with age, with an estimated 25-30% of 65-74 year-olds and 40-50% of those over 75 years experiencing impaired hearing in the USA. The exact cause of presbycusis is unknown, but it is likely multifactorial. Arteriosclerosis, diabetes, accumulated exposure to noise, drug exposure, stress, and genetics are some of the factors that may contribute to the development of presbycusis.

      Patients with presbycusis typically present with a chronic, slowly progressing history of difficulty understanding speech, increased volume needed for television or radio, difficulty using the telephone, loss of directionality of sound, and worsening of symptoms in noisy environments. Hyperacusis, a heightened sensitivity to certain frequencies of sound, and tinnitus, a ringing or buzzing in the ears, may also occur but are less common.

      To diagnose presbycusis, otoscopy is performed to rule out other causes of hearing loss, such as otosclerosis or conductive hearing loss. Tympanometry is used to assess middle ear function, and audiometry is used to confirm bilateral sensorineural hearing loss. Blood tests may also be performed to rule out other underlying conditions.

      In summary, presbycusis is an age-related hearing loss that affects a significant portion of the elderly population. Although the exact cause is unknown, it is likely due to a combination of factors. Patients with presbycusis may experience difficulty understanding speech, increased volume needed for audio devices, and other symptoms. Diagnosis is made through a combination of physical examination and hearing tests.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 15 - A 48-year-old man presents to the clinic for follow-up. He is worried about...

    Incorrect

    • A 48-year-old man presents to the clinic for follow-up. He is worried about some discoloration of the oral mucosa that he has noticed while brushing his teeth. These have been present for three weeks and have not been associated with any bleeding.

      He has a history of hypertension for which he takes medication, but is otherwise healthy. He smokes six cigarettes per day and drinks a glass of wine each evening.

      On examination, there are several patches within the oral mucosa that have either increased reddening or pallor. The diagnosis of erythroplakia is made. There is no lymphadenopathy, but the examination is otherwise unremarkable.

      Investigations reveal:
      - Hb 140 g/L (135-180)
      - WCC 8.9 ×109/L (4.5-10)
      - PLT 310 ×109/L (150-450)
      - Na 140 mmol/L (135-145)
      - K 4.2 mmol/L (3.5-5.5)
      - Cr 90 µmol/L (70-110)

      What is the most appropriate next step?

      Your Answer:

      Correct Answer: Urgent referral (under 2 week wait)

      Explanation:

      NICE Guidance on Management of Oral Lesions

      Consider an urgent referral for assessment for possible oral cancer by a dentist in people who have a lump on the lip or in the oral cavity or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. Patients who have other symptoms, such as contact bleeding or unexplained tooth mobility with symptoms persisting for longer than three weeks, should also be referred urgently.

      Whilst oral candida is a possibility, the clinical picture as described doesn’t fit with this as an underlying diagnosis. Fluconazole is unlikely to have any impact on the appearance of the oral mucosa, and neither is regular mouth rinsing. However, it is good practice to rinse the mouth after using an inhaler.

      Minor lymph node enlargement is a common occurrence, and urgent referral to a haematologist is unwarranted given the normal blood picture. Although urgent intervention is not required, reassurance is inappropriate because of the need to confirm the diagnosis underlying the lesions within the oral cavity.

      In summary, it is important to promptly refer patients with suspicious oral lesions for assessment by a dentist to rule out oral cancer. Other symptoms such as contact bleeding or unexplained tooth mobility should also be referred urgently. Regular mouth rinsing is good practice, but it is unlikely to have an impact on the appearance of the oral mucosa. Finally, minor lymph node enlargement is common and doesn’t warrant urgent referral to a haematologist.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 16 - A 30 year old man comes to the clinic complaining of anorexia, feverishness,...

    Incorrect

    • A 30 year old man comes to the clinic complaining of anorexia, feverishness, and vertigo that have been going on for four days. He reports having difficulty balancing and staying upright when walking, as well as experiencing mild vertigo episodes lasting 10-20 minutes at a time. His hearing is unaffected. During the examination, some cervical lymphadenopathy is observed, but otherwise, there are no notable findings. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Vestibular neuronitis

      Explanation:

      A typical case of vestibular neuritis involves a patient who has recently recovered from an upper respiratory tract infection and experiences recurrent episodes of vertigo accompanied by nausea and vomiting. There is usually no hearing loss or tinnitus present. Prior to the onset of symptoms, the patient may have experienced viral symptoms. Unlike labyrinthitis, vestibular neuritis doesn’t cause hearing loss or tinnitus. If a patient experiences any neurological symptoms or signs, acute deafness, new types of headaches, or vertical nystagmus, urgent referral should be considered.

      Vertigo is a condition characterized by a false sensation of movement in the body or environment. There are various causes of vertigo, each with its own unique characteristics. Viral labyrinthitis, for example, is typically associated with a recent viral infection, sudden onset, nausea and vomiting, and possible hearing loss. Vestibular neuronitis, on the other hand, is characterized by recurrent vertigo attacks lasting hours or days, but with no hearing loss. Benign paroxysmal positional vertigo is triggered by changes in head position and lasts for only a few seconds. Meniere’s disease, meanwhile, is associated with hearing loss, tinnitus, and a feeling of fullness or pressure in the ears. Elderly patients with vertigo may be experiencing vertebrobasilar ischaemia, which is accompanied by dizziness upon neck extension. Acoustic neuroma, which is associated with hearing loss, vertigo, and tinnitus, is also a possible cause of vertigo. Other causes include posterior circulation stroke, trauma, multiple sclerosis, and ototoxicity from medications like gentamicin.

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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 17 - A 25-year-old woman comes in with complaints of hearing loss. She appears to...

    Incorrect

    • A 25-year-old woman comes in with complaints of hearing loss. She appears to be in good health and there are no noticeable abnormalities during otoscopy. Tuning fork tests are conducted, revealing a negative Rinne test on the right side (bone conduction is better than air conduction) and a positive Rinne test on the left side. The Weber test shows lateralisation to the right ear. How should these tuning fork test results be interpreted?

      Your Answer:

      Correct Answer: Right-sided conductive hearing loss

      Explanation:

      Tuning Fork Tests for Hearing Loss

      Tuning fork tests are commonly used to differentiate between conductive and sensorineural hearing loss. Two tests are usually performed: the Rinne test and the Weber test. The Rinne test compares air conduction to bone conduction by placing the tuning fork against the mastoid and adjacent to the ear canal on both sides. Normally, sound is heard better by air conduction than bone conduction, resulting in a Rinne-positive outcome. However, conductive hearing loss can reverse this result, causing a Rinne-negative pattern where bone conduction is better than air conduction. On the other hand, sensorineural hearing loss and normal hearing both result in a Rinne-positive outcome, requiring the Weber test for further information.

      The Weber test involves placing the tuning fork on the forehead and checking if sound waves are transmitted equally to both ears. If the sound is heard equally in both ears, the result is normal. However, conductive hearing loss in one ear causes the sound to be heard on the same side as the conductive loss. In contrast, sensorineural hearing loss causes sound to be heard on the opposite side.

      In this particular case, the Rinne test resulted in a negative outcome on the right side, indicating right-sided conductive hearing loss. The Weber test confirmed this by lateralizing to the affected side. Tuning fork tests are a quick and non-invasive way to determine the type and location of hearing loss, allowing for appropriate treatment to be initiated.

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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 18 - A 65-year-old woman presents with a painful face that started gradually over the...

    Incorrect

    • A 65-year-old woman presents with a painful face that started gradually over the past day and has now become severe. The pain is localized around one of her lower molars, which is tender to touch and sensitive to temperature. Upon examination, an abscess is visible around the affected tooth and the surrounding tissues are inflamed. The patient has a temperature of 37.1 ºC and is otherwise healthy with no medication use or allergies.

      What is the initial treatment approach for this patient?

      Your Answer:

      Correct Answer: Advise the patient to see her dentist today

      Explanation:

      Brant Daroff exercises

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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 19 - A 29-year-old man presents with decreased hearing in his left ear. Upon examination,...

    Incorrect

    • A 29-year-old man presents with decreased hearing in his left ear. Upon examination, there are no signs of acute infection, but both eardrums appear dull. Tuning-fork tests are performed, revealing that bone conduction is heard better than air conduction on the left side (the affected ear) during Rinne's test, while Weber's test localizes to the left ear. Rinne's test on the right side shows air conduction better than bone conduction. What type of hearing loss is present in this patient?

      Your Answer:

      Correct Answer: Right-sided conductive hearing loss

      Explanation:

      Differentiating Types of Hearing Loss: A Case Study

      In this case study, the patient presents with hearing loss in their right ear. To determine the type of hearing loss, various tests were conducted.

      Right-sided conductive hearing loss was ruled out as bone conduction was better than air conduction in the affected ear. Left-sided conductive hearing loss was also ruled out as Rinne’s test was normal on the left side.

      Non-organic hearing loss was considered but ultimately ruled out as the patient’s history was convincing and their tympanic membrane appeared normal.

      Left-sided sensorineural hearing loss and right-sided sensorineural hearing loss were both ruled out as they would have caused a reduction in both air and bone conduction.

      The final diagnosis was right-sided conductive hearing loss. It is important to differentiate between the types of hearing loss as treatment options vary depending on the cause.

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  • Question 20 - A 50-year-old woman presents with a large thyroid swelling, difficulty breathing on lying...

    Incorrect

    • A 50-year-old woman presents with a large thyroid swelling, difficulty breathing on lying flat and slight dysphagia. What is the most appropriate investigation to delineate the size and extent of the goitre?

      Your Answer:

      Correct Answer: Computed tomography (CT) scan

      Explanation:

      Diagnostic Imaging Techniques for Thyroid Evaluation

      Thyroid evaluation involves the use of various diagnostic imaging techniques to determine the size, extent, and function of the thyroid gland. Computed tomography (CT) scanning is a precise method that provides a better assessment of the effect of the thyroid gland on nearby structures. Barium swallow is useful in assessing oesophageal obstruction, while chest X-ray can determine the extent of goitre and the presence of calcification. Ultrasound is commonly used to guide biopsy of the thyroid and detect and characterise thyroid nodules. Radionuclide uptake and scanning using technetium isotope are used to evaluate thyroid function and anatomy in hyperthyroidism, including the assessment of thyroid nodules. These diagnostic imaging techniques play a crucial role in the accurate diagnosis and management of thyroid disorders.

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  • Question 21 - A 16-year-old female presents with a four day history of fever, sore throat...

    Incorrect

    • A 16-year-old female presents with a four day history of fever, sore throat and rash on the front of her left leg. On examination she has tonsillar enlargement with cervical lymphadenopathy and has erythema nodosum on her left shin.

      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Beta-haemolytic streptococcus

      Explanation:

      Strep. pyogenes and its Characteristics

      This girl exhibits features that are consistent with Strep. pyogenes, a beta-haemolytic streptococcus. The bacterium is known to cause pharyngitis, and erythema nodosum is also commonly associated with the infection. Additionally, it is responsible for acute rheumatic fever, which is described by the Jones criteria. The treatment of choice for this infection is Penicillin V.

      While Epstein-Barr may be a consideration, it is not typically associated with erythema nodosum. It is important to identify the causative agent in order to provide appropriate treatment and prevent further complications.

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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 22 - Liam is a 26-year-old man who complained of hearing loss and was diagnosed...

    Incorrect

    • 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:

      Correct 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.

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  • Question 23 - Which of the following is MOST LIKELY to be a feature of uncomplicated...

    Incorrect

    • Which of the following is MOST LIKELY to be a feature of uncomplicated cholesteatoma in elderly patients?

      Your Answer:

      Correct Answer: Otorrhoea

      Explanation:

      Cholesteatoma: Symptoms and Complications

      Cholesteatoma is a condition characterized by the collection of epidermal and connective tissues within the middle ear. It can be dangerous as it may cause damage to adjacent vital structures such as the dura, lateral sinus, facial nerve, and semi-circular canal. In severe cases, it may lead to fatal central nervous system complications such as brain abscess and meningitis.

      The hallmark symptom of cholesteatoma is a painless otorrhoea, which may be continuous or recurrent. When infected, the infection may be difficult to treat. Hearing loss is also a common symptom, as the cholesteatoma can fill the middle ear space with desquamated epithelium, interfering with sound transmission and causing ossicular damage.

      Dizziness and facial nerve palsy may occur as the cholesteatoma grows and erodes into adjacent structures. These symptoms are worrisome as they may indicate more serious complications.

      A retracted intact tympanic membrane is not a specific feature of cholesteatoma and may be seen in other conditions such as otitis media with effusion. In cholesteatoma, pearly, white, glistening debris may be visible through the otorrhoea, occupying a perforation in the tympanic membrane, usually in the pars flaccida. Alternatively, there may just be crusting in the uppermost part of the drum beneath which lies a cholesteatoma.

      Rhinorrhoea is not a feature of cholesteatoma.

      In summary, cholesteatoma is a serious condition that requires prompt medical attention. Its symptoms include painless otorrhoea, hearing loss, and possible complications such as dizziness and facial nerve palsy.

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  • Question 24 - A 70-year-old man presents to your clinic with a complaint of recurrent nosebleeds...

    Incorrect

    • A 70-year-old man presents to your clinic with a complaint of recurrent nosebleeds from his right nostril over the past week. The bleeding lasts for about 30 minutes but is not severe. The patient has a history of ischemic heart disease and is on regular medication of aspirin 75 mg and atorvastatin 40 mg. He denies any allergies and has no other significant medical history. On examination, there is no visible bleeding point, and all vital signs are normal. What is the most appropriate management for this patient, in addition to general epistaxis advice?

      Your Answer:

      Correct Answer: Prescribe topical Naseptin (chlorhexidine/neomycin) cream

      Explanation:

      Recurrent nosebleeds without any concerning symptoms can be effectively treated with Naseptin cream, which contains chlorhexidine and neomycin. While severe cases may require emergency care, mild cases can be managed in primary care. According to NICE guidelines, topical treatment with Naseptin cream is a suitable first-line approach.

      If the nosebleeds are heavy but not currently active, persist despite topical treatment, or the patient is taking anticoagulant medication, referral to an ENT ‘hot clinic’ may be necessary. If the nosebleeds continue to recur despite treatment, referral to an ENT outpatient clinic for SPA ligation may be considered.

      In primary care, silver nitrate cautery may be attempted if a clear bleeding point can be identified and the healthcare provider has the appropriate skills and experience. However, patients should not stop taking antiplatelet medication without consulting their healthcare provider.

      Understanding Epistaxis: Causes and Management

      Epistaxis, commonly known as nosebleeds, can be categorized into anterior and posterior bleeds. Anterior bleeds usually have a visible source of bleeding and occur due to an injury to the network of capillaries that form Kiesselbach’s plexus. On the other hand, posterior haemorrhages tend to be more severe and originate from deeper structures. They are more common in older patients and pose a higher risk of aspiration and airway obstruction.

      Most cases of epistaxis are benign and self-limiting. However, exacerbation factors such as nose picking, nose blowing, trauma to the nose, insertion of foreign bodies, bleeding disorders, and immune thrombocytopenia can trigger nosebleeds. Other causes include hereditary haemorrhagic telangiectasia, granulomatosis with polyangiitis, and cocaine use.

      If the patient is haemodynamically stable, bleeding can be controlled with first aid measures such as sitting with their torso forward and their mouth open, pinching the cartilaginous area of the nose firmly for at least 20 minutes, and using a topical antiseptic to reduce crusting and the risk of vestibulitis. If bleeding persists, cautery or packing may be necessary. Cautery should be used initially if the source of the bleed is visible, while packing may be used if cautery is not viable or the bleeding point cannot be visualized.

      Patients that are haemodynamically unstable or compromised should be admitted to the emergency department, while those with a bleed from an unknown or posterior source should be admitted to the hospital. Epistaxis that has failed all emergency management may require sphenopalatine ligation in theatre. Overall, understanding the causes and management of epistaxis is crucial in providing effective care for patients experiencing nosebleeds.

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  • Question 25 - A 25-year-old man presents to the General Practitioner with a swollen ear. He...

    Incorrect

    • A 25-year-old man presents to the General Practitioner with a swollen ear. He plays amateur rugby and was punched during a match the previous day. The upper pinna is fluctuant and mildly erythematous, but there are no other injuries. What is the most suitable management option?

      Your Answer:

      Correct Answer: Early drainage and compression

      Explanation:

      Auricular Haematoma: Causes, Symptoms, and Treatment

      Auricular haematoma is a common facial injury that results from direct trauma to the anterior auricle. It is often seen in athletes such as wrestlers, rugby players, and footballers. The condition occurs when shearing forces cause separation of the perichondrium from the underlying cartilage, leading to tearing of the perichondrial blood vessels and hematoma formation.

      If left untreated, the haematoma can lead to avascular necrosis of the auricular cartilage, resulting in a ‘cauliflower ear’ deformity. To prevent this, evacuation of the haematoma is necessary. This can be done through aspiration with a 10 ml syringe attached to a wide needle or by incision and drainage. Compression is also necessary to prevent reoccurrence.

      However, infection may be a complication, and if it worsens, patients may need to be admitted to the hospital for intravenous antibiotics and surgical exploration. Patients with recurrent haematomas or haematomas more than seven days old may also need surgical debridement.

      In conclusion, auricular haematoma is a serious condition that requires prompt treatment to prevent complications. Athletes and individuals who engage in activities that put them at risk of this injury should take precautions to avoid it.

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  • Question 26 - A 44-year-old man presents with acute onset vertigo which started yesterday and has...

    Incorrect

    • A 44-year-old man presents with acute onset vertigo which started yesterday and has persisted.

      The presence of which of the following features would most strongly suggest a diagnosis of labyrinthitis rather than vestibular neuronitis?

      Your Answer:

      Correct Answer: Unsteadiness

      Explanation:

      Understanding the Difference between Vestibular Neuronitis and Labyrinthitis

      Vestibular neuronitis and labyrinthitis are two conditions that can cause vertigo, but they have different underlying causes and symptoms. Vestibular neuronitis is caused by inflammation of the vestibular nerve, while labyrinthitis is caused by inflammation of the labyrinth. Both conditions often develop after a viral infection and can cause acute onset, spontaneous, prolonged vertigo.

      The key difference between the two conditions is that labyrinthitis also causes hearing loss and tinnitus, while hearing is unaffected in vestibular neuronitis and tinnitus doesn’t occur. It is important to differentiate between the two conditions because the treatment and management may differ.

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  • Question 27 - A 32-year-old woman presents to the General Practitioner with sudden onset of unilateral...

    Incorrect

    • A 32-year-old woman presents to the General Practitioner with sudden onset of unilateral sensorineural deafness. She has no prior history of ear issues and is not currently taking any medications.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Idiopathic

      Explanation:

      Idiopathic Unilateral Sudden Sensorineural Hearing Loss: Causes, Symptoms, and Treatment Options

      Idiopathic unilateral sudden sensorineural hearing loss (ISSHL) is a rare condition characterized by a sudden loss of hearing in one ear, often accompanied by tinnitus, vertigo, and aural fullness. The exact cause of ISSHL is not well understood, but it may be linked to viral infections, vascular issues, or immune-mediated inner ear disease.

      Patients with ISSHL should be referred for urgent treatment, typically involving corticosteroids. Other treatment options include low molecular weight dextran, carbogen, hyperbaric oxygen, low-density lipid apheresis, aciclovir, and stellate ganglion block. However, there is limited evidence to support the effectiveness of any one treatment.

      Many patients with ISSHL are admitted to the hospital, but fortunately, spontaneous recovery rates are generally good. Studies have reported recovery rates ranging from 47-63%, although different criteria for recovery were used in each study.

      In summary, ISSHL is a rare but serious condition that requires prompt medical attention. While treatment options exist, the evidence for their effectiveness is limited, and many patients may recover spontaneously.

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  • Question 28 - You encounter a 45-year-old man who complains of a painful mouth. He reveals...

    Incorrect

    • You encounter a 45-year-old man who complains of a painful mouth. He reveals that he has been experiencing a mouth ulcer for about 3 weeks. It started as a small painless sore but has now grown in size and is causing him discomfort. Despite trying various mouthwashes, he has not found any relief. He is in good health and has no other symptoms. Although he is not overly concerned about the ulcer, he would like you to prescribe something to help it heal.

      Upon examination, you notice a 4mm ulcer in his oral cavity, surrounded by a white plaque. There is no lymphadenopathy.

      How would you approach the management of this patient?

      Your Answer:

      Correct Answer: Refer urgently (for an appointment within 2 weeks) to ENT

      Explanation:

      If a person has had a mouth ulcer for more than three weeks, it is important to refer them to secondary care urgently. In cases where there is unexplained ulceration in the oral cavity lasting for more than three weeks or a persistent and unexplained lump in the neck, a suspected cancer pathway referral should be considered for an appointment within two weeks. This is also true for patients with a lump on the lip or in the oral cavity, or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia, who should be urgently referred for assessment for possible oral cancer by a dentist within two weeks. In this particular case, the patient with a solitary ulcer for more than three weeks should be seen by an ENT specialist within two weeks.

      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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  • Question 29 - A 55-year-old man presents with unilateral nasal obstruction caused by soft tissue swelling...

    Incorrect

    • A 55-year-old man presents with unilateral nasal obstruction caused by soft tissue swelling and bleeding from the same side of the nose. What is the most suitable next step?

      Your Answer:

      Correct Answer: Direct specialist visualisation of the nasal passages

      Explanation:

      Unilateral Nasal Obstruction: Possible Causes and Management

      Unilateral nasal obstruction can be caused by various factors, including nasal polyps, infection, and neoplastic processes. If the obstruction is accompanied by soft tissue blockage and unilateral epistaxis, the possibility of a neoplastic process should be considered, and direct visualisation of the area in an ear, nose, and throat clinic is necessary. Nasopharyngeal carcinoma is a rare but possible cause of unilateral nasal obstruction.

      Aside from neoplastic processes, other nasal tumors that may cause unilateral nasal obstruction include inverted papilloma, sarcoma, lymphoma, olfactory neuroblastoma, and juvenile nasopharyngeal angiofibroma.

      Using nasal decongestants for prolonged periods is not recommended as it may cause rebound congestion of the nasal mucosa. Antibiotics are not normally indicated for nasal blockage caused by the common cold, influenza virus, or rhinosinusitis. Topical corticosteroids may be beneficial in allergic rhinitis and some cases of vasomotor rhinitis, while corticosteroid drops are used in the medical management of nasal polyps. Oral steroids are not typically used in the management of any form of nasal obstruction.

      In summary, the management of unilateral nasal obstruction depends on the underlying cause, and direct specialist visualisation of the nasal passages is necessary for proper diagnosis and treatment.

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  • Question 30 - A 56-year-old woman visits the General Practitioner for a check-up. She mentions that...

    Incorrect

    • A 56-year-old woman visits the General Practitioner for a check-up. She mentions that her friends have informed her about her bad breath. From where is this patient's issue most likely originating?

      Your Answer:

      Correct Answer: Mouth

      Explanation:

      Causes and Treatment of Halitosis

      Halitosis, commonly known as bad breath, affects 80-90% of people with persistent symptoms. The National Institute for Health and Care Excellence identifies poor oral hygiene, smoking, periodontal disease, dry mouth, dentures, and poor denture hygiene as the primary causes of halitosis. In such cases, referral to a dentist and a trial of antibacterial mouthwash and toothpaste may be appropriate.

      Less common causes of halitosis include sinusitis, foreign body in the nasal cavities, tonsillitis, tonsil stones in the throat, bronchiectasis in the respiratory tract, acid reflux, and Helicobacter pylori in the gastrointestinal tract. Pseudo-halitosis is a condition in which people falsely believe they have bad breath.

      In conclusion, halitosis can be caused by various factors, and treatment depends on the underlying cause. Maintaining good oral hygiene and seeking medical attention when necessary can help alleviate symptoms and improve overall oral health.

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  • Question 31 - A 26-year-old man presents to your emergency clinic with worsening pain in his...

    Incorrect

    • A 26-year-old man presents to your emergency clinic with worsening pain in his right ear. He had previously been diagnosed with otitis externa and started on antibiotic ear drops by another physician four days ago. However, he reports that the pain has only gotten worse and he has been unable to apply the drops for the past 24 hours due to swelling of the canal. Upon examination, you notice that the right external auditory canal is completely swollen shut and you are unable to see any further. The patient's vital signs are normal.

      What is the most appropriate course of action for management?

      Your Answer:

      Correct Answer: Refer to on-call ENT

      Explanation:

      If topical antibiotics do not provide relief for otitis externa, it is recommended to refer the patient to an ear, nose, and throat (ENT) specialist. This is because the infection can cause swelling and narrowing of the ear canal, making it difficult for antibiotic drops to be effective. In such cases, microsuction and insertion of a pope wick may be necessary, which requires the expertise of an ENT specialist.

      Ear syringing should not be performed during an active infection as it will not be helpful.

      Steroids are often included in antibiotic ear drops, but they will not be effective if the drops cannot reach the ear canal.

      Oral antibiotics, such as ciprofloxacin, may be prescribed alongside topical antibiotics if there is concern of a deep tissue infection. However, this is unlikely in a young and otherwise healthy patient, and the primary treatment remains antibiotic drops.

      If necrotising otitis externa is suspected, a CT scan may be helpful, but this would be arranged by an ENT specialist and is not necessary in most cases.

      Understanding Otitis Externa: Causes, Features, and Management

      Otitis externa is a prevalent condition that often prompts primary care visits in the UK. It is characterized by ear pain, itch, and discharge, and can be caused by bacterial or fungal infections, seborrhoeic dermatitis, or contact dermatitis. Swimming is also a common trigger for otitis externa. Upon examination, the ear canal may appear red, swollen, or eczematous.

      The recommended initial management for otitis externa is 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. If there is canal debris, removal may be necessary, and if the canal is extensively swollen, an ear wick may be inserted. Second-line options include taking a swab inside the ear canal, considering contact dermatitis secondary to neomycin, or using oral antibiotics such as flucloxacillin if the infection is spreading. Empirical use of an antifungal agent may also be considered.

      It is important to note that if a patient fails to respond to topical antibiotics, they should be referred to an ENT specialist. Malignant otitis externa is a more severe form of the 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. While some ENT doctors disagree, concerns about ototoxicity may arise with the use of aminoglycosides in patients with perforated tympanic membranes.

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  • Question 32 - A 42-year-old woman who is typically healthy visits her GP complaining of hearing...

    Incorrect

    • A 42-year-old woman who is typically healthy visits her GP complaining of hearing difficulties over the last 2 months. She has been an avid swimmer for the past 20 years. During the examination, Rinne's test is positive on her left ear but negative on her right ear. Weber's test shows sound localizing to the right side.

      What is the type of hearing loss that this patient is experiencing?

      Your Answer:

      Correct Answer: Left-sided conductive hearing loss

      Explanation:

      If Rinne’s test is negative, it indicates that bone conduction is greater than air conduction, resulting in a conductive hearing loss in the affected ear. A positive test is considered normal when air conduction is greater than bone conduction. Therefore, the diagnosis of left-sided conductive hearing loss is correct, and Weber’s test would localize to the affected side in unilateral conductive hearing loss.

      Left-sided mixed hearing loss is an incorrect diagnosis because Weber’s test would localize to the right, and on an audiogram, mixed hearing loss would show both bone and air conduction at abnormal levels (>20 dB) with a difference of at least >15 dB between them.

      Left-sided sensorineural hearing loss is also an incorrect diagnosis because Weber’s test would localize to the right, and Rinne’s test would be positive in the left ear.

      Right-sided conductive hearing loss is an incorrect diagnosis because a positive Rinne’s test indicates that air conduction is greater than bone conduction, which is considered normal.

      Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness

      Rinne’s and Weber’s tests are used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test indicates that BC is better than AC, suggesting conductive deafness.

      Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking the patient which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.

      The table below summarizes the interpretation of Rinne and Weber tests. A normal result indicates that AC is greater than BC bilaterally and the sound is midline. Conductive hearing loss is indicated by BC being greater than AC in the affected ear and AC being greater than BC in the unaffected ear, with the sound lateralizing to the affected ear. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, with the sound lateralizing to the unaffected ear.

      Overall, Rinne’s and Weber’s tests are useful tools for differentiating between conductive and sensorineural deafness, allowing for appropriate management and treatment.

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  • Question 33 - A 52-year-old woman presents with complaints of sore gums. She reports that her...

    Incorrect

    • A 52-year-old woman presents with complaints of sore gums. She reports that her gums have been bleeding and sore on and off for several years, but she has not sought dental care. Upon examination, there is evidence of recent bleeding and receding gums.

      What is the most suitable INITIAL course of action?

      Your Answer:

      Correct Answer: Advise the patient to go to a general dental practitioner

      Explanation:

      Treatment Options for Chronic Gingivitis

      Chronic gingivitis is a common condition that can lead to gum inflammation, bleeding, and discomfort. Here are some treatment options for patients with chronic gingivitis:

      1. Go to a general dental practitioner: Regular oral hygiene advice and treatment from a general dental practitioner can help manage chronic gingivitis.

      2. Avoid prescribing antibiotics: Antibiotics are not indicated for chronic gingivitis, and their overuse can lead to antibiotic resistance.

      3. Avoid prescribing mouthwash: While mouthwash can help prevent plaque and gingivitis, it is not effective for established plaque and cannot stop periodontitis from progressing.

      4. Consider temporary pain relief: Saline mouthwash can provide temporary pain and swelling relief.

      5. Prescribe metronidazole for acute necrotising ulcerative gingivitis: If the patient has punched-out gingival ulcers covered with a white, yellowish, or grey pseudomembrane, metronidazole 400 mg three times daily for one week may be necessary.

      6. Refer to oral surgery for severe symptoms or suspicion of malignancy: Referral to oral surgery would only be necessary for severe or rapidly progressive symptoms or suspicion of malignancy.

      By following these treatment options, patients with chronic gingivitis can manage their symptoms and improve their oral health.

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  • Question 34 - You see a 28-year-old female patient with painful mouth ulcers. She has been...

    Incorrect

    • You see a 28-year-old female patient with painful mouth ulcers. She has been experiencing coryzal symptoms for the past week. The patient has around 5 small shallow ulcers scattered around her gums and inside her cheeks. The ulcers have been present for 2 days, and she is having difficulty eating and drinking. The patient has no significant medical history and is generally healthy. She smokes 5-10 cigarettes daily.

      What is the accurate statement about aphthous mouth ulcers?

      Your Answer:

      Correct Answer: Aphthous ulcers are more common in non-smokers

      Explanation:

      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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  • Question 35 - A 26-year-old man with sinusitis inquires about the safety of using Sudafed (pseudoephedrine)....

    Incorrect

    • A 26-year-old man with sinusitis inquires about the safety of using Sudafed (pseudoephedrine). Is there any medication that would make Sudafed use inappropriate?

      Your Answer:

      Correct Answer: Monoamine oxidase inhibitor

      Explanation:

      The combination of a monoamine oxidase inhibitor and pseudoephedrine may lead to a dangerous increase in blood pressure known as a hypertensive crisis.

      Acute sinusitis is a condition where the mucous membranes of the paranasal sinuses become inflamed. This inflammation is usually caused by infectious agents such as Streptococcus pneumoniae, Haemophilus influenza, and rhinoviruses. Certain factors can predispose individuals to this condition, including nasal obstruction, recent local infections, swimming/diving, and smoking. Symptoms of acute sinusitis include facial pain, nasal discharge, and nasal obstruction. Treatment options include analgesia, intranasal decongestants or nasal saline, and intranasal corticosteroids. Oral antibiotics may be necessary for severe presentations, but they are not typically required. In some cases, an initial viral sinusitis can worsen due to secondary bacterial infection, which is known as double-sickening.

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  • Question 36 - A 50-year-old chef presents for a follow-up appointment after experiencing a left-sided Bell's...

    Incorrect

    • A 50-year-old chef presents for a follow-up appointment after experiencing a left-sided Bell's palsy three months ago. The patient was treated with prednisolone and has seen some improvement in their facial weakness, but still experiences some weakness in their left facial muscles (power 4/5). The patient is interested in knowing if there are any additional tests or referrals that could be beneficial.

      What is the most suitable next step?

      Your Answer:

      Correct Answer: Reassure, but explain that if symptoms persist in four months' time you will refer to plastic surgery

      Explanation:

      If a patient with Bell’s palsy experiences residual weakness after six months, it is appropriate to refer them to a plastics specialist. It is important to provide reassurance and safety netting regarding the referral. However, ordering an MRI head is not necessary if the symptoms are consistent with Bell’s palsy and the patient has responded to treatment. Neurology referral is also not necessary unless there is doubt about the initial diagnosis or if there are other clinical features suggestive of stroke. It is important to monitor patients with persistent symptoms and refer them to a specialist if necessary. Simply reassuring the patient may not be appropriate in cases where specialist review is required.

      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.

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  • Question 37 - A 5-year-old girl presents with a six-month history of constant snoring and seems...

    Incorrect

    • A 5-year-old girl presents with a six-month history of constant snoring and seems to ‘talk through her nose.’ Her nose seems clear on anterior examination.
      What is the most appropriate management intervention?

      Your Answer:

      Correct Answer: A period of watchful waiting

      Explanation:

      Management of Enlarged Adenoids in Children

      Explanation:
      Enlarged adenoids are a common condition in children, which usually resolve on their own by the age of eight years. In cases where there is no history of sleep apnea or significant impairment of hearing or speech, a period of watchful waiting for six months or longer is appropriate. Nasal corticosteroids are not effective in treating enlarged adenoids as they do not affect the postnasal space. Adenoidectomy may be considered if the problem persists despite the waiting period. Tonsillectomy is not necessary unless there are frequent throat infections. The use of an albuterol inhaler is not recommended as there is no indication of asthma in the child. Overall, careful monitoring and appropriate intervention can effectively manage enlarged adenoids in children.

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  • Question 38 - A 40-year-old female patient presents with vestibular neuronitis after a recent viral respiratory...

    Incorrect

    • A 40-year-old female patient presents with vestibular neuronitis after a recent viral respiratory infection. She reports experiencing vertigo, nausea, and vomiting. What is the initial treatment recommended for her symptoms?

      Your Answer:

      Correct Answer: Prochlorperazine for 7 days

      Explanation:

      To relieve vertigo, nausea, and vomiting caused by vestibular neuronitis, it is advised to use Prochlorperazine. It should be taken for three days on a regular basis and then as needed for a maximum of seven days. However, caution should be exercised as it may cause dystonic reactions, particularly in young women. Other treatment options are not recommended for individuals with vestibular neuronitis.

      Understanding Vestibular Neuronitis

      Vestibular neuronitis is a type of vertigo that typically occurs after a viral infection. It is characterized by recurrent episodes of vertigo that can last for hours or days, accompanied by nausea and vomiting. Horizontal nystagmus is also a common symptom, but there is no hearing loss or tinnitus.

      It is important to differentiate vestibular neuronitis from other conditions such as viral labyrinthitis and posterior circulation stroke. The HiNTs exam can be used to distinguish between these conditions.

      Treatment for vestibular neuronitis typically involves medication to alleviate symptoms, such as buccal or intramuscular prochlorperazine for severe cases, or a short course of oral medication for less severe cases. Vestibular rehabilitation exercises are also recommended for patients who experience chronic symptoms.

      Understanding the symptoms and treatment options for vestibular neuronitis can help individuals manage this condition and improve their quality of life.

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  • Question 39 - A 26-year-old male presents with benign paroxysmal positional vertigo that has persisted for...

    Incorrect

    • A 26-year-old male presents with benign paroxysmal positional vertigo that has persisted for 3 weeks after a recent upper respiratory tract infection. He requests the Epley manoeuvre to alleviate his symptoms as he is currently unable to operate a vehicle. What is the success rate of the Epley manoeuvre in patients with this condition?

      Your Answer:

      Correct Answer: 80%

      Explanation:

      Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo that occurs suddenly when there is a change in head position. It is more prevalent in individuals over the age of 55 and is less common in younger patients. Symptoms of BPPV include dizziness and vertigo, which can be accompanied by nausea. Each episode typically lasts for 10-20 seconds and can be triggered by rolling over in bed or looking upwards. A positive Dix-Hallpike manoeuvre, which is indicated by vertigo and rotatory nystagmus, can confirm the diagnosis of BPPV.

      Fortunately, BPPV has a good prognosis and usually resolves on its own within a few weeks to months. Treatment options include the Epley manoeuvre, which is successful in around 80% of cases, and vestibular rehabilitation exercises such as the Brandt-Daroff exercises. While medication such as Betahistine may be prescribed, it tends to have limited effectiveness. However, it is important to note that around half of individuals with BPPV may experience a recurrence of symptoms 3-5 years after their initial diagnosis.

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  • Question 40 - A 50-year-old woman comes in with a complaint of experiencing dizzy spells for...

    Incorrect

    • A 50-year-old woman comes in with a complaint of experiencing dizzy spells for the past 4 days. She reports feeling nauseous and seeing the room spinning for a brief period before returning to normal. The patient specifically notes that looking down seems to trigger these episodes. Upon examination, there are no abnormalities found in the ears or cranial nerves. Her blood pressure measures at 126/82 mmHg. What diagnostic test can be conducted to confirm the diagnosis?

      Your Answer:

      Correct Answer: Dix- Hallpike manoeuvre

      Explanation:

      The Dix-Hallpike manoeuvre is employed for the diagnosis of benign paroxysmal positional vertigo (BPPV), while the Epley manoeuvre or Brandt Daroff exercises are utilized for its treatment. It should be noted that these manoeuvres are not used for the diagnosis of BPPV. Simmond’s test is utilized for the diagnosis of Achilles tendon rupture, while Finkelstein’s test is employed for the diagnosis of De Quervain’s tenosynovitis.

      Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo that occurs suddenly when there is a change in head position. It is more prevalent in individuals over the age of 55 and is less common in younger patients. Symptoms of BPPV include dizziness and vertigo, which can be accompanied by nausea. Each episode typically lasts for 10-20 seconds and can be triggered by rolling over in bed or looking upwards. A positive Dix-Hallpike manoeuvre, which is indicated by vertigo and rotatory nystagmus, can confirm the diagnosis of BPPV.

      Fortunately, BPPV has a good prognosis and usually resolves on its own within a few weeks to months. Treatment options include the Epley manoeuvre, which is successful in around 80% of cases, and vestibular rehabilitation exercises such as the Brandt-Daroff exercises. While medication such as Betahistine may be prescribed, it tends to have limited effectiveness. However, it is important to note that around half of individuals with BPPV may experience a recurrence of symptoms 3-5 years after their initial diagnosis.

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  • Question 41 - A 60-year-old man comes to the clinic 3 days after being hit on...

    Incorrect

    • A 60-year-old man comes to the clinic 3 days after being hit on the left side of his head. He reports experiencing muffled hearing on the left side since the incident. Upon examination, there are no visible bruises, but both ears are covered by a thin, translucent layer of wax. Rinne's test reveals that the tuning fork is more audible when placed on the mastoid bone on the left side. On Weber's test, the sound is heard most clearly on the left side. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Perforated eardrum

      Explanation:

      Differentiating between tympanic membrane perforation and sensorineural hearing loss due to skull trauma is crucial. Rinne’s test can help identify conductive hearing loss in the affected ear, while Weber’s test can rule out sensorineural hearing loss on the right.

      Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness

      Rinne’s and Weber’s tests are used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test indicates that BC is better than AC, suggesting conductive deafness.

      Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking the patient which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.

      The table below summarizes the interpretation of Rinne and Weber tests. A normal result indicates that AC is greater than BC bilaterally and the sound is midline. Conductive hearing loss is indicated by BC being greater than AC in the affected ear and AC being greater than BC in the unaffected ear, with the sound lateralizing to the affected ear. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, with the sound lateralizing to the unaffected ear.

      Overall, Rinne’s and Weber’s tests are useful tools for differentiating between conductive and sensorineural deafness, allowing for appropriate management and treatment.

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  • Question 42 - You review a patient who you diagnosed with Meniere's disease last week. Her...

    Incorrect

    • You review a patient who you diagnosed with Meniere's disease last week. Her vertigo has settled but she still has hearing loss and tinnitus on the right side. She is still waiting to be seen by the ENT department but has a few questions about Meniere's disease.

      Which statement below regarding Meniere's disease is correct?

      Your Answer:

      Correct Answer: Around half of people with Meniere's disease have bilateral involvement after 5 years if not treated

      Explanation:

      Meniere’s disease is a condition that affects the inner ear and its cause is 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 the excessive pressure and progressive dilation of the endolymphatic system. The main symptoms of Meniere’s disease are recurrent episodes of vertigo, tinnitus, and sensorineural hearing loss. Vertigo is usually the most prominent symptom, but patients may also experience 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 is that symptoms usually resolve in the majority of patients after 5-10 years. However, most patients will be left with some degree of hearing loss, and psychological distress is common. ENT assessment is required to confirm the diagnosis, and patients should inform the DVLA as the current advice is to cease driving until satisfactory control of symptoms is achieved. Acute attacks can be managed with buccal or intramuscular prochlorperazine, and admission to the hospital may be required. Prevention strategies include the use of betahistine and vestibular rehabilitation exercises, which may be beneficial.

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  • Question 43 - A 50-year-old woman comes to her General Practitioner with concerns about a lump...

    Incorrect

    • 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:

      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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  • Question 44 - You encounter a 50-year-old male patient who complains of left-sided facial pain, along...

    Incorrect

    • You encounter a 50-year-old male patient who complains of left-sided facial pain, along with left-sided hearing loss, tinnitus, and vertigo that have persisted for about a month. During the examination, you observe an absent corneal reflex on the left side. What is the most probable diagnosis that could explain these symptoms?

      Your Answer:

      Correct Answer: An acoustic neuroma

      Explanation:

      If a patient is experiencing symptoms of hearing loss, vertigo, tinnitus, and an absent corneal reflex, the most likely diagnosis is an acoustic neuroma. Facial pain may also be present.

      When herpes zoster affects the first branch of the trigeminal nerve, it is known as herpes zoster ophthalmicus. Prior to the blistering rash associated with shingles, the patient may experience numbness, pain, or tingling around the eye.

      Facial nerve palsy typically results in drooping of one side of the face and loss of blinking control. However, this doesn’t match the symptoms described in this scenario.

      Trigeminal neuralgia is characterized by episodes of severe, shooting or jabbing pain that may feel like an electric shock. Vertigo and an absent corneal reflex are not typical symptoms of trigeminal neuralgia.

      Vertigo is a condition characterized by a false sensation of movement in the body or environment. There are various causes of vertigo, each with its own unique characteristics. Viral labyrinthitis, for example, is typically associated with a recent viral infection, sudden onset, nausea and vomiting, and possible hearing loss. Vestibular neuronitis, on the other hand, is characterized by recurrent vertigo attacks lasting hours or days, but with no hearing loss. Benign paroxysmal positional vertigo is triggered by changes in head position and lasts for only a few seconds. Meniere’s disease, meanwhile, is associated with hearing loss, tinnitus, and a feeling of fullness or pressure in the ears. Elderly patients with vertigo may be experiencing vertebrobasilar ischaemia, which is accompanied by dizziness upon neck extension. Acoustic neuroma, which is associated with hearing loss, vertigo, and tinnitus, is also a possible cause of vertigo. Other causes include posterior circulation stroke, trauma, multiple sclerosis, and ototoxicity from medications like gentamicin.

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  • Question 45 - You see a 50-year-old woman who has come to see you after the...

    Incorrect

    • You see a 50-year-old woman who has come to see you after the nurse was unable to remove all the earwax from her left ear. She came to see you for advice on what to do next.

      According to NICE, which is the most appropriate next step in management?

      Your Answer:

      Correct Answer: Offer manual syringing

      Explanation:

      Guidelines for earwax Removal

      According to NICE guidelines, if earwax irrigation is unsuccessful, patients should repeat the use of wax softeners or instil water into the ear canal 15 minutes before attempting ear irrigation again. If the second attempt is also unsuccessful, patients should be referred to a specialist ear care service or ENT. It is important to note that manual syringing should not be offered as a method of earwax removal. These guidelines aim to ensure safe and effective earwax removal practices.

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  • Question 46 - A 55-year-old man presents to his General Practitioner (GP) with multiple symptoms affecting...

    Incorrect

    • A 55-year-old man presents to his General Practitioner (GP) with multiple symptoms affecting his nose and throat. He has long-standing nasal congestion, but over the past week has also been suffering from a painful lesion in his mouth, sore throat and hoarse voice. On examination, he has bilateral, grey nasal swellings, a solitary yellow ulcer of 4 mm diameter on the oral mucosa, a multinodular goitre and unilateral parotid enlargement. He states that the parotid lump has been there for a few months, at least. His GP suspects cancer.
      Which of the following presentations warrants specialist referral under the 2-week rule?

      Your Answer:

      Correct Answer: The discrete slow-growing lump in the right parotid gland

      Explanation:

      Common Head and Neck Symptoms and Referral Guidelines

      The following are common head and neck symptoms and the appropriate referral guidelines:

      1. Discrete slow-growing lump in the right parotid gland: Any unexplained lump in the head or neck requires a 2-week rule referral. A discrete, persistent, unilateral lump in the parotid gland requires an urgent referral, imaging, and further investigation to determine the nature of the mass.

      2. Solitary, painful ulcer on the oral mucosa, of 1-week duration: This is most likely to be an aphthous ulcer. An unexplained oral ulceration lasting more than three weeks, or an unexplained neck lump, would warrant a 2-week wait referral.

      3. A 7-day history of hoarseness and sore throat: Patients over the age of 45 with persistent unexplained hoarseness should be referred using the cancer pathway. After seven days, this is most likely to be an upper respiratory tract infection.

      4. Diffuse multinodular thyroid swelling: For suspected thyroid cancer, the single referral criterion is an ‘unexplained thyroid lump’. The most likely diagnosis in this patient is a multinodular goitre.

      5. Nasal obstruction and bilateral grey swellings visible by nasal speculum: Bilateral nasal swellings of this description are almost certainly polyps. These can initially be managed in primary care. Unilateral polyps should be referred to the ear, nose and throat clinic.

      Head and Neck Symptoms and Referral Guidelines

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  • Question 47 - A 30-year-old woman visits her GP complaining of gradual hearing loss and worsening...

    Incorrect

    • A 30-year-old woman visits her GP complaining of gradual hearing loss and worsening tinnitus over the past year. She has no significant medical history but reports that her father also experienced hearing loss at a young age. On neurological examination, she has mild bilateral conductive hearing loss, but her tympanic membrane appears normal. What is the probable cause of her symptoms?

      Your Answer:

      Correct Answer: Otosclerosis

      Explanation:

      Otosclerosis, which is an inherited condition, can cause hearing loss in young adults. The symptoms of slowly progressing bilateral conductive hearing loss and a positive family history are typical of otosclerosis.

      Presbyacusis, on the other hand, is a type of hearing loss that occurs with aging and is unlikely to affect a young woman. Sensorineural hearing loss is caused by acoustic neuroma, while Meniere’s disease is characterized by episodes of vertigo.

      Understanding Otosclerosis: A Progressive Conductive Deafness

      Otosclerosis is a medical condition that occurs when normal bone is replaced by vascular spongy bone. This condition leads to a progressive conductive deafness due to the fixation of the stapes at the oval window. It is an autosomal dominant condition that typically affects young adults, with onset usually occurring between the ages of 20-40 years.

      The main features of otosclerosis include conductive deafness, tinnitus, a normal tympanic membrane, and a positive family history. In some cases, patients may also experience a flamingo tinge, which is caused by hyperemia and affects around 10% of patients.

      Management of otosclerosis typically involves the use of a hearing aid or stapedectomy. A hearing aid can help to improve hearing, while a stapedectomy involves the surgical removal of the stapes bone and replacement with a prosthesis.

      Overall, understanding otosclerosis is important for individuals who may be at risk of developing this condition. Early diagnosis and management can help to improve hearing and prevent further complications.

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  • Question 48 - A 27-year-old female is seeking your help as her seasonal allergic rhinitis (grass...

    Incorrect

    • A 27-year-old female is seeking your help as her seasonal allergic rhinitis (grass pollen allergy) has just started. Despite starting her nasal steroid, nasal antihistamine, and oral antihistamine 2 weeks ago, she has not experienced significant relief from her symptoms. She is getting married in a few days and is looking for a quick solution to improve her nasal itching and watery discharge.

      What would you recommend as a possible option for her?

      Your Answer:

      Correct Answer: Offer short course of oral prednisolone

      Explanation:

      When standard treatment fails to control allergic rhinitis, it may be necessary to use short courses of steroids to manage important life events. However, it is important to note that oral steroids should only be used for a brief period if the symptoms are severe and significantly impacting the person’s quality of life. There is no evidence to suggest that switching to a different steroid nasal spray would be more effective. Chlorphenamine, a sedating antihistamine, would not be suitable in this situation. Intramuscular steroids are not recommended due to the risk of avascular necrosis from repeated doses. While immunotherapy may be an option in the long term, it will not provide immediate relief in time for a significant event such as a wedding.

      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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  • Question 49 - A 26-year-old female presents with nasal symptoms.

    She has no significant past medical history....

    Incorrect

    • A 26-year-old female presents with nasal symptoms.

      She has no significant past medical history. She reports frequent sneezing, a permanent feeling of nasal blockage, and intermittent bilateral non-purulent rhinorrhoea which have been a problem on and off for the last few years. There is no systemic unwellness. She has not identified any specific pattern to her symptoms which she describes are 'fairly persistent'.

      On further questioning there doesn't appear to be a seasonal pattern to her symptoms, she doesn't own or have contact with any pets, and she works in an office where there doesn't seem to be any form of occupational trigger. She has no respiratory symptoms and examination of her chest including peak flow measurement is normal.

      She has recently been using oral cetirizine regularly and also sodium cromoglycate eye drops both of which she has purchased over the counter. Despite daily use of both for the last four to six weeks her symptoms are no better and remain persistent. Examination reveals no anatomical abnormalities or red flag features.

      You discuss further investigation to look into possible allergen identification and also further treatment options.

      Which of the following is the next most appropriate pharmacological step in trying to manage her symptoms?

      Your Answer:

      Correct Answer: Add in an intranasal corticosteroid (for example, mometasone)

      Explanation:

      Guidelines recommend oral non-sedating antihistamines, topical nasal corticosteroids or antihistamines, and anti-inflammatory eye drops for the treatment of allergic and non-allergic rhinitis. Mild symptoms can be treated with oral and/or topical antihistamines, while intranasal corticosteroids are the treatment of choice for moderate to severe symptoms. Short courses of oral corticosteroids may be used in conjunction with intranasal corticosteroids for severe nasal blockage. Topical ipratropium and leukotriene receptor antagonists may also be added for persistent symptoms.

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  • Question 50 - A 6-year-old-girl presents with persistent hearing loss. Her mother reports concerns from her...

    Incorrect

    • A 6-year-old-girl presents with persistent hearing loss. Her mother reports concerns from her teachers that she doesn't seem to pay attention in class. She reports the girl often turns up the volume of the television while at home. On examination, the right eardrum is retracted and there is loss of the light reflex. You suspect otitis media with effusion and arrange pure tone audiometry which reveals moderate hearing loss particularly at low frequencies. She presented to your colleague 10 weeks previously with similar symptoms, with similar audiometry findings.

      What is the next most appropriate management in primary care according to the current NICE CKS guidance?

      Your Answer:

      Correct Answer: Refer to an ear, nose and throat (ENT) specialist for further management

      Explanation:

      If a child has significant hearing loss due to glue ear on two separate occasions, it is recommended to refer them to an ear, nose and throat (ENT) specialist. The current NICE CKS guidance suggests observing children with otitis media with effusion for 6-12 weeks as spontaneous resolution is common. However, if the signs and symptoms persist after this period, referral to an ENT specialist is necessary. It is important to inquire about any concerns regarding the child’s hearing or language development and for any complications. Immediate referral is required for children with Down’s syndrome or cleft palate who are suspected to have otitis media with effusion. Antibiotics are not recommended for the treatment of otitis media with effusion. The most common surgical option is myringotomy and insertion of grommets, but non-surgical management options are also considered by the ENT specialist. As the child in question has already presented with persistent hearing loss after 12 weeks, referral to ENT is appropriate at this point.

      Understanding Glue Ear

      Glue ear, also known as serous otitis media, is a common condition among children, with most experiencing at least one episode during their childhood. It is characterized by the accumulation of fluid in the middle ear, leading to hearing loss, speech and language delay, and behavioral or balance problems. The risk factors for glue ear include male sex, siblings with the condition, bottle feeding, day care attendance, and parental smoking. It is more prevalent during the winter and spring seasons.

      The condition typically peaks at two years of age and is the most common cause of conductive hearing loss and elective surgery in childhood. Treatment options include grommet insertion, which allows air to pass through into the middle ear, and adenoidectomy. However, grommets usually stop functioning after about ten months. It is important to understand the symptoms and risk factors of glue ear to seek appropriate treatment and prevent further complications.

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  • Question 51 - An 77-year-old-man presents to your clinic with complaints of persistent right ear pain...

    Incorrect

    • An 77-year-old-man presents to your clinic with complaints of persistent right ear pain and discharge. He was previously diagnosed with otitis externa and prescribed antibiotic ear drops by a colleague, followed by further antibiotic drops and tramadol by an out of hours doctor. However, his symptoms have not improved and the pain has become unbearable.

      The patient has a medical history of type-2 diabetes mellitus and hypertension, and takes metformin, gliclazide, ramipril, and atorvastatin regularly. He has no known drug allergies and doesn't smoke or drink alcohol.

      Upon examination, debris is observed in the right ear canal, but the tympanic membrane remains visible. There is no erythema of the pinna or mastoid swelling, and cranial nerve examination is normal.

      What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Refer urgently to on-call ENT team

      Explanation:

      If a patient with otitis externa experiences worsening pain that doesn’t respond to strong painkillers, it is important to refer them urgently to an ENT specialist. This is especially true if the patient has a history of diabetes, as they are at a higher risk of developing malignant (necrotising) otitis externa. In advanced stages, this condition can cause facial nerve palsy on the same side as the affected ear. Treatment typically involves a long course of intravenous antibiotics, which is why prompt ENT assessment is crucial.

      While oral antibiotics such as ciprofloxacin may be prescribed alongside ear drops if there is concern about deep tissue infection, most patients will require IV antibiotics. However, the priority in this situation is to escalate the case to an ENT specialist rather than focusing on pain relief or swabbing the ear canal. It is also important to avoid syringing the ear, as this can worsen the condition.

      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 pseudomonas 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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  • Question 52 - You diagnose a left-sided sudden sensorineural hearing loss (SSNHL) in a normally fit...

    Incorrect

    • You diagnose a left-sided sudden sensorineural hearing loss (SSNHL) in a normally fit and well 36-year-old woman who has come to see you in your GP clinic. She developed her symptoms over a few hours yesterday and now can not hear at all through her left ear. Her examination shows no obvious external or middle ear causes.

      What is your next step?

      Your Answer:

      Correct Answer: Refer her for assessment within 24 hours by an ENT specialist

      Explanation:

      Immediate referral to an ENT specialist or emergency department is necessary for individuals experiencing acute sensorineural hearing loss. This is considered an emergency and requires urgent audiology assessment and a brain MRI. According to NICE CKS guidelines, individuals with sudden onset hearing loss (unilateral or bilateral) within the past 30 days, without any external or middle ear causes, should be referred within 24 hours. Additionally, those with unilateral hearing loss accompanied by focal neurology, head or neck injury, or severe infections such as necrotising otitis externa or Ramsay Hunt syndrome should also be referred urgently. Referral to a specialist other than ENT or non-urgent referral options are incorrect.

      When a patient experiences a sudden loss of hearing, it is crucial to conduct a thorough examination to determine whether it is conductive or sensorineural hearing loss. If it is the latter, known as sudden-onset sensorineural hearing loss (SSNHL), it is imperative to refer the patient to an ear, nose, and throat (ENT) specialist immediately. The majority of SSNHL cases have no identifiable cause, making them idiopathic. To rule out the possibility of a vestibular schwannoma, an MRI scan is typically performed. ENT specialists administer high-dose oral corticosteroids to all patients with SSNHL.

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  • Question 53 - A 20-year-old woman presents with a painful throat. She has been experiencing a...

    Incorrect

    • A 20-year-old woman presents with a painful throat. She has been experiencing a sore throat and painful swallowing for the past few days, but her symptoms have worsened over the last 24 hours. She now has neck pain and difficulty opening her mouth fully.
      Upon examination, her temperature is 38.9 °C and her throat shows a displaced uvula, an enlarged right tonsil, and swelling around the right tonsil.
      What is the best initial management strategy for this patient?

      Your Answer:

      Correct Answer: Arrange hospital admission

      Explanation:

      Peritonsillar Abscess: A Serious Complication of Sore Throat

      When evaluating a patient with a sore throat, it is crucial for clinicians to be aware of any potential serious causes or complications. One such condition is a peritonsillar abscess, which requires hospital admission and immediate treatment.

      A peritonsillar abscess can lead to airway obstruction, deeper spread of infection, and abscess rupture. Therefore, it is important to check for clinical features such as difficulty swallowing, fever, and severe throat pain.

      The initial management for a peritonsillar abscess is to arrange hospital admission. Once admitted, the patient can receive inpatient treatment in a safe environment with immediate care and monitoring. Treatment typically involves aspiration or drainage of the abscess, along with antibiotic use and pain relief.

      In summary, a peritonsillar abscess is a serious complication of sore throat that requires prompt recognition and management. Hospital admission is necessary to ensure the patient’s safety and prevent further complications.

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  • Question 54 - A 27-year-old man presents with persistent foul-smelling left ear discharge. This is the...

    Incorrect

    • A 27-year-old man presents with persistent foul-smelling left ear discharge. This is the 3rd time he has been seen over the last few months with this problem and each time he has been treated with topical treatment for otitis externa. The discharge has never settled and he now feels that his hearing is reduced in the left ear.

      On examination, he is afebrile and systemically well. There is no otalgia. There is discharge in the left ear canal obstructing visualisation of the left eardrum. Aside from the discharge there is nothing else focal to be seen. The right ear is normal. The external ears and mastoids are normal. There is no facial nerve palsy or neurological symptoms.

      What is the most appropriate management approach?

      Your Answer:

      Correct Answer: Refer him for examination with an otomicroscope and micro-suctioning of the ear

      Explanation:

      Cholesteatoma: A Potential Diagnosis for Persistent Ear Discharge

      This patient’s symptoms suggest the possibility of a cholesteatoma, a buildup of keratin in the middle ear or mastoid air cell spaces. Common symptoms include persistent or recurrent foul-smelling discharge from the ear, conductive hearing loss, and potential complications such as vertigo, facial nerve palsy, and intracranial infection. Diagnosis requires visualizing the tympanic membrane, which may show a deep retraction pocket, crust/keratin, or perforation. In cases where discharge prevents visualization, referral for examination with an otomicroscope and micro-suctioning is appropriate. If discharge persists despite treatment, referral to a specialist should not be delayed. Given this patient’s persistent symptoms, referral is the most appropriate approach to investigate the potential underlying diagnosis of a cholesteatoma.

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  • Question 55 - A middle-aged woman of Chinese origin presents to you in surgery to discuss...

    Incorrect

    • A middle-aged woman of Chinese origin presents to you in surgery to discuss her recurrent nosebleeds. They started 3 months ago and have been occurring unprovoked with increasing frequency. She is not on any anticoagulants, has never had any previous episodes of unexplained or excessive bleeding, and has no family history of any bleeding disorders. On further questioning, the nosebleeds always seem to be from the right nostril which feels a bit blocked. She has tried 2 weeks of Naseptin (chlorhexidine dihydrochloride and neomycin sulfate nasal cream) with no change in her symptoms. She mentions that the previous GP she saw asked about weight loss which she denied at the time, however, she volunteers that she has been tightening her belt more now. Blood tests reveal normal coagulation screen, haemoglobin within the normal range and a thrombocytosis. What condition is it most important to investigate for?

      Your Answer:

      Correct Answer: Nasopharyngeal cancer

      Explanation:

      The NICE guidelines advise referring patients with recurrent epistaxis and a high risk of underlying disorders to ear, nose and throat for investigation. This patient, who is of Chinese origin and has recurrent nosebleeds, nasal obstruction, and weight loss, is at high risk of nasopharyngeal cancer due to his ethnicity and age. The full blood count results show thrombocytosis, which may indicate malignancy. Hereditary telangiectasia and Von Willebrand’s disease are unlikely due to the absence of a family history and the onset of nosebleeds in later life. Nasal polyps do not typically cause epistaxis, but may present with nasal obstruction, postnasal drip, snoring, or obstructive sleep apnoea. The patient’s age rules out angiofibroma as a possible cause, as this benign tumour typically occurs in pre-pubescent and adolescent males and is rare over the age of 25.

      Understanding Nasopharyngeal Carcinoma

      Nasopharyngeal carcinoma is a type of squamous cell carcinoma that affects the nasopharynx. It is a rare form of cancer that is more common in individuals from Southern China and is associated with Epstein Barr virus infection. The presenting features of nasopharyngeal carcinoma include cervical lymphadenopathy, otalgia, unilateral serous otitis media, nasal obstruction, discharge, and/or epistaxis, and cranial nerve palsies such as III-VI.

      To diagnose nasopharyngeal carcinoma, a combined CT and MRI scan is typically used. The first line of treatment for this type of cancer is radiotherapy. It is important to catch nasopharyngeal carcinoma early to increase the chances of successful treatment.

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  • Question 56 - A 48-year-old woman presents to the clinic for follow-up. She reports feeling increasingly...

    Incorrect

    • A 48-year-old woman presents to the clinic for follow-up. She reports feeling increasingly fatigued and overwhelmed with caring for her grandchild. Additionally, she has noticed a hoarse voice and persistent tiredness. She has no significant medical history and has never smoked. She has also been experiencing constipation and has started taking daily senna. On examination, her blood pressure is 115/75 mmHg, pulse is 55 and regular, and BMI is 29 kg/m2. She has a smooth, non-tender goiter. Laboratory results show Hb 118 g/L (115-165), WCC 8.0 ×109/L (4.5-10), PLT 180 ×109/L (150-450), Na 131 mmol/L (135-145), K 4.3 mmol/L (3.5-5.5), and Cr 99 µmol/L (70-110). What test or investigation would be most helpful in clarifying the diagnosis?

      Your Answer:

      Correct Answer: C reactive protein

      Explanation:

      Diagnosis and Management of Hypothyroidism

      In this case, the patient presents with symptoms of tiredness, weight gain, and bradycardia on examination, along with a smooth non-tender goitre and low sodium on U&E testing. These clues suggest a diagnosis of hypothyroidism, which can be confirmed through thyroid function testing. C reactive protein is a nonspecific result that may indicate possible infection or inflammation, while a chest x-ray can help rule out chest pathology as an alternative cause for the hyponatraemia. If the thyroid function testing is normal and the chest x-ray is unremarkable, an ENT referral may be appropriate. Ultrasound is indicated if there is a suspicion of nodularity within the thyroid gland. By following these steps, healthcare professionals can effectively diagnose and manage hypothyroidism in patients.

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  • Question 57 - A 60-year-old man who is a smoker presents with hoarseness of his voice,...

    Incorrect

    • A 60-year-old man who is a smoker presents with hoarseness of his voice, firm cervical nodes and difficulty in swallowing.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Squamous cell carcinoma of the larynx

      Explanation:

      Types of Head and Neck Cancer: Symptoms and Characteristics

      Squamous cell carcinoma is the most common type of cancer in the upper airway, with the larynx being the most likely location. Symptoms may include pain radiating to the ear, weight loss, and stridor in advanced cases. Small cell carcinoma of the larynx is rare. Adenocarcinoma of the hypopharynx is relatively rare and usually squamous cell carcinoma. Adenocarcinoma and squamous cell carcinoma are common varieties of oesophageal cancer, with dysphagia, anorexia, weight loss, vomiting, and gastrointestinal bleeding being red flag features. Squamous cell carcinoma is the most common type of tonsillar cancer, with symptoms including a sore throat, ear pain, a foreign body sensation, bleeding, and a neck mass. Tonsillar enlargement may be the only sign if the tumour growth is below the surface, or there may be a fungating mass.

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  • Question 58 - Which of the following patients is most likely to develop nasal polyps? ...

    Incorrect

    • Which of the following patients is most likely to develop nasal polyps?

      Your Answer:

      Correct Answer: A 40-year-old man

      Explanation:

      Male adults are the most commonly affected by nasal polyps.

      Understanding Nasal Polyps

      Nasal polyps are a relatively uncommon condition affecting around 1% of adults in the UK. They are more commonly seen in men and are not typically found in children or the elderly. There are several associations with nasal polyps, including asthma (particularly late-onset asthma), aspirin sensitivity, infective sinusitis, cystic fibrosis, Kartagener’s syndrome, and Churg-Strauss syndrome. When asthma, aspirin sensitivity, and nasal polyposis occur together, it is known as Samter’s triad.

      The most common features of nasal polyps include nasal obstruction, rhinorrhoea, sneezing, and a poor sense of taste and smell. However, if a patient experiences unilateral symptoms or bleeding, further investigation is always necessary.

      If a patient is suspected of having nasal polyps, they should be referred to an ear, nose, and throat (ENT) specialist for a full examination. Treatment typically involves the use of topical corticosteroids, which can shrink polyp size in around 80% of patients. With proper management, most patients with nasal polyps can experience relief from their symptoms.

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  • Question 59 - A 42-year-old woman comes to the clinic with a left facial palsy. She...

    Incorrect

    • A 42-year-old woman comes to the clinic with a left facial palsy. She reports that the weakness developed gradually over a few days. She is waiting for a referral to the hospital for a nodular swelling in the left parotid salivary gland, suspected to be caused by a stone. Her husband is currently taking oral aciclovir for shingles.

      During the examination, a hard nodular mass is found over the tail of the left parotid gland, along with a lower motor neurone seventh nerve palsy.

      What is the most appropriate next step?

      Your Answer:

      Correct Answer: Urgent surgical referral

      Explanation:

      Parotid Tumour with Facial Palsy

      The presence of a hard, nodular mass over the tail of the parotid gland and facial palsy strongly suggest a parotid tumour with nerve infiltration. Urgent referral to a hospital for surgical review and possible biopsy under ultrasound guidance is necessary. Unfortunately, facial nerve function recovery is unlikely.

      There is no indication of zoster infection or underlying inflammation, so aciclovir and prednisolone are not appropriate treatments. Sialography is useful for investigating salivary gland ducts and stones, but not for neoplastic disease.

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  • Question 60 - A 63-year-old man comes to the clinic with his wife for evaluation. He...

    Incorrect

    • A 63-year-old man comes to the clinic with his wife for evaluation. He has been experiencing a change in his voice with constant hoarseness and a chronic dry cough for the past six weeks. He attributes this to a previous cold and chest infection and believes it will improve over time.
      He is a heavy smoker, consuming 25 cigarettes per day for the past 50 years. He has a history of COPD and is currently taking a high dose Seretide inhaler. On examination, his BP is 145/85 mmHg, pulse is 75 and regular, and chest auscultation reveals scattered wheezing.
      Investigations reveal:
      Hb 134 g/L (135-180)
      WCC 8.0 ×109/L (4.5-10)
      PLT 179 ×109/L (150-450)
      Na 137 mmol/L (135-145)
      K 4.7 mmol/L (3.5-5.5)
      Cr 122 µmol/L (70-110)
      ECG shows sinus rhythm.
      CXR (arranged by another GP partner) shows no mass lesion identified.
      What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Urgent ENT referral

      Explanation:

      Urgent Investigation for Hoarseness

      Under NICE guidance, patients who present with hoarseness for more than three weeks require urgent investigation for possible cancer. In this case, a chest x-ray did not show an underlying cancer, but an ENT referral for laryngoscopy is warranted.

      While inadequate oral hygiene after inhaler use leading to candida infection is a possibility, the absence of oral candida makes it unlikely. Speech therapy is an option to maximize vocal effectiveness, and it is effective for hoarseness related to organic pathology such as nodules or polyps, and non-organic laryngeal dysfunction (for example, muscle tension dysphonia).

      Stopping the use of Seretide is inappropriate because it is likely to worsen symptoms of COPD and is unlikely to elucidate the underlying cause of the hoarseness. It is important to investigate the cause of hoarseness to ensure prompt and appropriate treatment.

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  • Question 61 - A 42-year-old man who is a smoker presents with a 6-week history of...

    Incorrect

    • A 42-year-old man who is a smoker presents with a 6-week history of hoarseness of voice. He is otherwise well with no weight loss or sore throat, and has a normal-looking oropharynx and oral cavity.
      What is the MOST APPROPRIATE management option?

      Your Answer:

      Correct Answer: Urgent referral to the local hospital ENT department under the 2-week-wait criteria

      Explanation:

      Importance of Prompt Referral for Laryngeal Carcinoma

      Laryngeal carcinoma is a serious condition that requires prompt diagnosis and treatment. If left untreated, it can lead to severe complications and even death. One of the most common symptoms of laryngeal carcinoma is persistent hoarseness, which is why it is important to seek medical attention if you experience this symptom.

      In addition to hoarseness, an unexplained lump in the neck is another sign that you may be at risk of laryngeal carcinoma. If you experience either of these symptoms, it is important to seek a 2-week-wait cancer referral as soon as possible.

      The priority in diagnosing laryngeal carcinoma is to exclude it by direct visualisation of the larynx, which can only be done in an ENT department. Therefore, it is crucial to seek medical attention and get referred to an ENT department for further evaluation and treatment. Early detection and treatment can greatly improve the chances of a successful outcome.

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  • Question 62 - A mother whose 12-year-old son had a history of glue ear when younger...

    Incorrect

    • A mother whose 12-year-old son had a history of glue ear when younger requests a copy of his medical records from the practice manager. Which of the following statements regarding access to medical records is not accurate?

      Your Answer:

      Correct Answer: A fee can be charged for a print out of her medical records

      Explanation:

      Under the General Data Protection Regulations and the Data Protection Act 2018, it is no longer permissible to charge a fee for obtaining a basic copy of medical records.

      Accessing Medical Records: Patients’ Rights and Key Principles

      Accessing medical records is a fundamental right of patients, which is protected by the 1998 Data Protection Act and the 1990 Access to Health Records Act. The key principles governing this right include the patient’s right to view their medical records, the right of competent children to access their records, and the right of parents to request access to their children’s records if they are under 16 years old.

      Doctors have a responsibility to ensure that they do not release information that may harm a patient’s emotional or physical health. Additionally, under the Data Protection Act, access to medical records should be granted within 28 days. It is important to note that following the General Data Protection Regulations and the Data Protection Act 2018, a fee cannot be charged for a simple copy of medical notes.

      In summary, patients have the right to access their medical records, and doctors have a responsibility to ensure that this access is granted in a timely and appropriate manner. The key principles outlined above provide a framework for ensuring that patients’ rights are respected and protected.

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  • Question 63 - A 4-year-old girl has had frequent upper respiratory tract infections and also frequently...

    Incorrect

    • A 4-year-old girl has had frequent upper respiratory tract infections and also frequently complains of earache.
      Select from the list the single feature that would most suggest a diagnosis of otitis media with effusion (OME) rather than acute otitis media.

      Your Answer:

      Correct Answer: Presence of bubbles and a fluid level behind the eardrum

      Explanation:

      Understanding Otitis Media with Effusion (Glue Ear)

      Otitis media with effusion, commonly known as glue ear, is a condition characterized by inflammation of the middle ear and the accumulation of fluid in the middle-ear cleft. This condition is prevalent in young children, with most experiencing at least one episode during early childhood. Although most episodes are brief, symptoms such as earache and hearing loss can occur. Hearing loss can be significant, especially if it persists for more than a month and affects both ears. However, not all cases of glue ear present with hearing loss.

      It is important to note that a normal-looking eardrum doesn’t necessarily exclude the possibility of OME. Otoscopic features of OME may include opacification of the drum, loss of the light reflex, indrawn or retracted drum, decreased mobility of the drum, bubbles or fluid level behind the drum, yellow or amber color change to the drum, and fullness or bulging of the drum. It is worth noting that acute otitis media may also present with earache and hearing loss, and the eardrum may appear redder and bulge.

      In conclusion, understanding the symptoms and signs of OME is crucial in diagnosing and managing this condition. If you suspect that you or your child may have glue ear, seek medical attention promptly.

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  • Question 64 - A 42-year-old woman presents to her GP for a follow-up appointment. She was...

    Incorrect

    • A 42-year-old woman presents to her GP for a follow-up appointment. She was diagnosed with Bell's palsy three weeks ago after experiencing left-sided facial weakness. The GP prescribed a 10-day course of oral prednisolone and provided eye care advice. However, the patient reports no improvement in her symptoms since then.

      During the examination, the patient appears healthy but still has left-sided facial weakness without forehead sparing. The rest of her cranial nerve examination is normal, and there is no indication of middle ear disease.

      What would be the most appropriate next step?

      Your Answer:

      Correct Answer: Refer urgently to ear, nose and throat (ENT) specialist

      Explanation:

      If a patient with Bell’s palsy doesn’t show any improvement in paralysis after 3 weeks, it is recommended to urgently refer them to an ENT specialist. This will allow for further investigation into other potential causes of facial weakness, including neuroimaging. It is not appropriate to reassure the patient that symptoms can take up to 3 months to resolve if there has been no improvement. Prescribing a further course of prednisolone or treating with oral aciclovir is not recommended. Referring to a plastic surgeon may be appropriate for facial reconstructive surgery, but usually only after a longer period of residual paralysis.

      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.

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  • Question 65 - A 26-year-old man comes to you with complaints of a persistent sore throat...

    Incorrect

    • A 26-year-old man comes to you with complaints of a persistent sore throat and occasional hoarseness that has been bothering him for a few months. He expresses concern that there may be something lodged in his throat, but he is able to swallow without difficulty. He denies any significant weight loss and has no notable medical or family history.

      During your examination, you observe mild redness in the oropharynx, but the neck appears normal and there are no palpable masses.

      What would be the best course of action in this case?

      Your Answer:

      Correct Answer: Prescribe a trial of a proton pump inhibitor

      Explanation:

      Understanding Laryngopharyngeal Reflux

      Laryngopharyngeal reflux (LPR) is a condition that occurs when stomach acid flows back into the throat, causing inflammation in the larynx and hypopharynx mucosa. It is a common diagnosis, accounting for approximately 10% of ear, nose, and throat referrals. Symptoms of LPR include a sensation of a lump in the throat, hoarseness, chronic cough, dysphagia, heartburn, and sore throat. The external examination of the neck should be normal, with no masses, and the posterior pharynx may appear erythematous.

      Diagnosis of LPR can be made without further investigations in the absence of red flags. However, the NICE cancer referral guidelines should be reviewed for red flags such as persistent, unilateral throat discomfort, dysphagia, and persistent hoarseness. Lifestyle measures such as avoiding fatty foods, caffeine, chocolate, and alcohol can help manage LPR. Additionally, proton pump inhibitors and sodium alginate liquids like Gaviscon can also be used to manage symptoms.

      In summary, Laryngopharyngeal reflux is a common condition that can cause discomfort and inflammation in the throat. It is important to be aware of the symptoms and seek medical attention if red flags are present. Lifestyle measures and medication can help manage symptoms and improve quality of life.

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  • Question 66 - A 43-year-old man presents to you with complaints of tinnitus and hearing loss...

    Incorrect

    • 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:

      Correct 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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  • Question 67 - A 20-year-old woman has been experiencing recurrent painful mouth ulceration for several years....

    Incorrect

    • A 20-year-old woman has been experiencing recurrent painful mouth ulceration for several years. The ulcers typically heal in just over a week, and she remains symptom-free until the next recurrence. She denies any associated symptoms or rash, and her father had a similar history as a teenager. She doesn't smoke and denies excessive alcohol use or drug use. Although there is no dental or periodontal disease, she has three discrete, 4-mm-round ulcers with inflammatory haloes on the buccal mucosa.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Apthous ulcers

      Explanation:

      There are several types of oral ulcers that can occur. Recurrent aphthous ulcers are the most common, affecting up to 66% of people at some point in their life. These ulcers appear on movable oral tissue and can recur frequently. Treatment options include topical corticosteroids, antimicrobial mouthwash, and topical analgesics. Herpes simplex stomatitis is another type of oral ulcer that mostly affects children and is caused by the herpes simplex virus. Symptoms include fever, malaise, and painful intraoral vesicles that can lead to ulcers. Oral candidiasis, or thrush, presents as white patches on the oral mucosa and tongue that can be wiped off to reveal a raw, erythematous base. Oral hairy leukoplakia is a white patch on the side of the tongue with a hairy appearance that is caused by Epstein-Barr virus and usually occurs in immunocompromised individuals. Oral lichen planus presents as a symmetrical, white, lace-like pattern on the buccal mucosa, tongue, and gums, and may be accompanied by erosions and ulcers.

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  • Question 68 - A 50-year-old man complains of dizziness and loss of hearing on the right...

    Incorrect

    • A 50-year-old man complains of dizziness and loss of hearing on the right side during his visit to the GP. Which test is most likely to suggest the presence of an acoustic neuroma?

      Your Answer:

      Correct Answer: Absent corneal reflex

      Explanation:

      Consider acoustic neuroma if there is a loss of corneal reflex.

      Vestibular schwannomas, also known as acoustic neuromas, make up about 5% of intracranial tumors and 90% of cerebellopontine angle tumors. These tumors typically present with a combination of vertigo, hearing loss, tinnitus, and an absent corneal reflex. The specific symptoms can be predicted based on which cranial nerves are affected. For example, cranial nerve VIII involvement can cause vertigo, unilateral sensorineural hearing loss, and unilateral tinnitus. Bilateral vestibular schwannomas are associated with neurofibromatosis type 2.

      If a vestibular schwannoma is suspected, it is important to refer the patient to an ear, nose, and throat specialist urgently. However, it is worth noting that these tumors are often benign and slow-growing, so observation may be appropriate initially. The diagnosis is typically confirmed with an MRI of the cerebellopontine angle, and audiometry is also important as most patients will have some degree of hearing loss. Treatment options include surgery, radiotherapy, or continued observation.

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  • Question 69 - A 14-year-old boy presents with intermittent epistaxis and no identifiable triggers. He has...

    Incorrect

    • A 14-year-old boy presents with intermittent epistaxis and no identifiable triggers. He has a history of adenoid surgery and anaphylaxis to peanuts. On examination, no bleeding focus is found, and his lab results show:

      Hb 130 g/L Male: (135-180)
      Female: (115 - 160)
      Platelets 280 * 109/L (150 - 400)
      WBC 6 * 109/L (4.0 - 11.0)

      What would be the most appropriate suggestion for this patient?

      Your Answer:

      Correct Answer: Recommend first aid measures during nosebleeds

      Explanation:

      Given the patient’s normal examination and blood counts, the most suitable option would be to provide first aid measures for nosebleeds. It is important to note that Naseptin cream contains peanut oil, which is contraindicated for this patient due to her anaphylaxis to peanuts.

      Performing cautery of a bleeding focus can be considered by a primary care practitioner with experience, but only if a bleeding focus is identified and not bilaterally to avoid perforation. However, since no abnormalities were found during examination, cautery is not recommended.

      If the clinician is uncertain about management, referring the patient to an ENT surgeon is a viable option. This may not be the best initial management, but it is appropriate if the issue recurs.

      If the bleeding persists despite appropriate first aid measures, it is recommended to advise the patient to go to the emergency department. The first aid measures would include applying pressure below the nasal bones on the nasal cartilage while sitting forward for 20 minutes.

      Understanding Epistaxis: Causes and Management

      Epistaxis, commonly known as nosebleeds, can be categorized into anterior and posterior bleeds. Anterior bleeds usually have a visible source of bleeding and occur due to an injury to the network of capillaries that form Kiesselbach’s plexus. On the other hand, posterior haemorrhages tend to be more severe and originate from deeper structures. They are more common in older patients and pose a higher risk of aspiration and airway obstruction.

      Most cases of epistaxis are benign and self-limiting. However, exacerbation factors such as nose picking, nose blowing, trauma to the nose, insertion of foreign bodies, bleeding disorders, and immune thrombocytopenia can trigger nosebleeds. Other causes include hereditary haemorrhagic telangiectasia, granulomatosis with polyangiitis, and cocaine use.

      If the patient is haemodynamically stable, bleeding can be controlled with first aid measures such as sitting with their torso forward and their mouth open, pinching the cartilaginous area of the nose firmly for at least 20 minutes, and using a topical antiseptic to reduce crusting and the risk of vestibulitis. If bleeding persists, cautery or packing may be necessary. Cautery should be used initially if the source of the bleed is visible, while packing may be used if cautery is not viable or the bleeding point cannot be visualized.

      Patients that are haemodynamically unstable or compromised should be admitted to the emergency department, while those with a bleed from an unknown or posterior source should be admitted to the hospital. Epistaxis that has failed all emergency management may require sphenopalatine ligation in theatre. Overall, understanding the causes and management of epistaxis is crucial in providing effective care for patients experiencing nosebleeds.

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  • Question 70 - A 32-year-old man presents with recurrent itchy ears.
    Which of the following statements about...

    Incorrect

    • A 32-year-old man presents with recurrent itchy ears.
      Which of the following statements about this condition is correct?

      Your Answer:

      Correct Answer: It may be precipitated by overzealous use of cotton buds

      Explanation:

      Understanding Otitis Externa: Myths and Facts

      Otitis externa, commonly known as swimmer’s ear, is a condition that affects the skin of the external ear canal. Here are some common myths and facts about this condition:

      Myth: Otitis externa is always bacterial in origin.
      Fact: While bacterial pathogens are frequently involved, viral and fungal pathogens may also be seen, particularly after prolonged use of corticosteroid drops.

      Myth: If adequately treated, otitis externa is unlikely to recur.
      Fact: Otitis externa is commonly recurrent, especially in the presence of a predisposing factor, such as a chronic underlying skin disease, immunodeficiency or diabetes.

      Myth: Systemic complications are common.
      Fact: Severe infections may cause local lymphadenitis or cellulitis. Rarely, infection may invade the deeper adjacent structures and progress to necrotising (malignant) otitis externa, a condition that can cause serious morbidity and also mortality. This is mainly seen in immunocompromised individuals, particularly people with diabetes.

      Myth: The use of aminoglycoside antibiotics is contraindicated.
      Fact: In a patient who doesn’t have grommets or a perforated eardrum, aminoglycosides (eg gentamicin) or polymyxin drops are not contraindicated. When the eardrum is not intact, there is concern about ototoxicity. If necessary, they can be used in these circumstances, with caution, by specialists.

      Debunking Myths About Otitis Externa

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  • Question 71 - 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:

      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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  • Question 72 - A 25-year-old man presents with a three-month history of weight loss, night sweats,...

    Incorrect

    • A 25-year-old man presents with a three-month history of weight loss, night sweats, and painful lumps in his neck that worsen with alcohol consumption. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Hodgkin’s lymphoma

      Explanation:

      Differential Diagnosis of Painful Lymphadenopathy

      Painful lymphadenopathy can be a rare but significant symptom in the diagnosis of certain conditions. In Hodgkin’s lymphoma, pain on alcohol ingestion in involved lymph nodes is a strong indication of the disease, although the reasons for the pain are unknown. On the other hand, glandular fever, lymph node metastases from laryngeal cancer, recurrent tonsillitis, and tuberculosis are incorrect differential diagnoses for painful lymphadenopathy.

      Glandular fever, caused by the Epstein-Barr virus, presents with fever, lymphadenopathy, pharyngitis, rash, and periorbital edema. However, lymphadenopathy is always bilateral and symmetrical, and the disease is usually self-limiting. Lymph node metastases from laryngeal cancer may present with a lump in the neck, but chronic hoarseness is the most common early symptom, and systemic symptoms are not present. Recurrent tonsillitis may cause anterior cervical lymph nodes to enlarge and become tender, but it is usually accompanied by a sore throat. Finally, while cervical nodes are commonly affected in tuberculous lymphadenitis, they may present as abscesses with discharging sinuses, and lymph node pain on drinking alcohol doesn’t occur in tuberculosis.

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  • Question 73 - A 30-year-old football player comes in for evaluation the day after a game....

    Incorrect

    • 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:

      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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  • Question 74 - You are reviewing a patient who presented to a colleague about eight weeks...

    Incorrect

    • You are reviewing a patient who presented to a colleague about eight weeks ago. He is a 65-year-old male with mild to moderate symptoms of nasal congestion and persistent feeling of a blocked nose. He reports ongoing problems of a similar nature. He informs you that as well as the above he gets intermittent clear nasal discharge which can alternate between nostrils and he has had periods of nasal and ocular 'itch'.
      At his last appointment he was prescribed a daily non-sedating antihistamine which he has been using regularly. He was also given advice on nasal douching. Despite these measures he is still suffering from persistent nasal symptoms. He has heard that steroid medication can be used to treat his symptoms and asks for a prescription.
      Which of the following is the most appropriate next pharmacological option to add in to his treatment in trying to manage his symptoms?

      Your Answer:

      Correct Answer: Intranasal corticosteroid spray (for example, fluticasone propionate 100 mcgs each nostril once daily)

      Explanation:

      Treatment Guidelines for Allergic and Non-Allergic Rhinitis

      Guidelines for the treatment of allergic and non-allergic rhinitis recommend the use of oral non-sedating antihistamines, topical nasal corticosteroids or antihistamines, and anti-inflammatory eye drops either in isolation or in combination. For mild symptoms, oral and/or topical antihistamines are recommended, with regular use being more effective than as-required use. Sedating antihistamines should be avoided due to their negative effects on academic and work performance.

      In moderate to severe symptoms, intranasal corticosteroids are the treatment of choice if antihistamine treatment has been ineffective. Different preparations have different degrees of systemic absorption, with mometasone and fluticasone having negligible systemic absorption. Intranasal corticosteroids have an onset of action of six to eight hours after the first dose, but regular use for at least two weeks may be needed to see the maximal effects.

      If treatment with the above doesn’t improve things, it is important to review technique and compliance and increase the dosage where appropriate. Short courses of oral corticosteroids may be used to gain control in severe nasal blockage or if the patient has a very important upcoming event. They should be used in conjunction with intranasal corticosteroids, and a burst of prednisolone at a dose of 0.5 mg/kg/day for 5-10 days can be used.

      In addition to the above, watery rhinorrhoea may respond to topical ipratropium, and catarrh in those with co-existent asthma may be helped by a leukotriene receptor antagonist. These guidelines provide a comprehensive approach to the treatment of allergic and non-allergic rhinitis, with a range of options available depending on the severity of symptoms.

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  • Question 75 - A 56-year-old woman presents to the clinic for evaluation. She has been experiencing...

    Incorrect

    • A 56-year-old woman presents to the clinic for evaluation. She has been experiencing bloody, serous discharge from her left nostril for the past three weeks and reports that her nose feels constantly congested. The patient has a 30-year history of smoking 20 cigarettes per day and a medical history of COPD. On examination, her blood pressure is 132/72 mmHg, pulse is regular at 85 beats per minute, and she is unable to breathe through her left nostril. Laboratory results show a hemoglobin level of 120 g/L (normal range 115-160), white blood cell count of 7.0 ×109/L (normal range 4.5-10), and platelet count of 199 ×109/L (normal range 150-450). Her sodium level is 138 mmol/L (normal range 135-145), potassium level is 4.5 mmol/L (normal range 3.5-5.5), and creatinine level is 105 µmol/L (normal range 70-110). An electrocardiogram reveals sinus rhythm. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: ENT referral within 2 weeks

      Explanation:

      Suspected Nasopharyngeal Carcinoma

      The suspicion is that the patient may have an underlying nasopharyngeal carcinoma, likely related to smoking, which is causing a blocked left nostril and bloody, serous discharge. It is important not to delay referral to an ear, nose, and throat (ENT) specialist by performing investigations through the GP outpatient radiology service. Imaging of the sinuses may be appropriate to determine the extent of any tumor, but this would be done as part of the pre-surgery workup rather than as outpatient GP investigations. A trial of intranasal steroids is not appropriate as a diagnosis of allergic rhinitis is unlikely, and this would waste valuable time in addressing any underlying tumor. Nasopharyngeal cancers are more common in people from southern China, including Hong Kong, Singapore, Vietnam, Malaysia, and the Philippines.

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  • Question 76 - A 50-year-old woman comes in with complaints of hearing loss. Tuning fork tests...

    Incorrect

    • A 50-year-old woman comes in with complaints of hearing loss. Tuning fork tests are performed, revealing a Rinne-positive result on both sides (air conduction heard better than bone conduction) and lateralisation of the Weber test to the left ear. How should these tuning fork test results be interpreted?

      Your Answer:

      Correct Answer: Left-sided sensorineural hearing loss

      Explanation:

      Tuning Fork Tests for Hearing Loss

      Tuning fork tests are commonly used to differentiate between conductive and sensorineural hearing loss. Two tests are usually performed: the Rinne test and the Weber test. The Rinne test compares air conduction to bone conduction by placing the tuning fork against the mastoid and adjacent to the ear canal on both sides. Normally, sound is heard better by air conduction than bone conduction, resulting in a Rinne-positive outcome. Conductive hearing loss, however, causes a Rinne-negative pattern, where bone conduction is better than air conduction. A Rinne-positive result is also seen in sensorineural hearing loss and normal hearing, which is why the Weber test is necessary to provide further information.

      The Weber test involves placing the tuning fork on the forehead and checking if sound waves are transmitted equally to both ears. In normal hearing, the sound is heard equally in both ears. Conductive hearing loss in one ear causes the sound to be heard on the same side as the conductive loss. On the other hand, sensorineural hearing loss causes sound to be heard on the opposite side.

      In this case, the Rinne test resulted in a positive outcome on both sides, indicating no conductive hearing loss. However, the Weber test showed lateralization to the right, suggesting left-sided sensorineural hearing loss.

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  • Question 77 - A 45-year-old man presents with decreased hearing in his right ear. Upon examination,...

    Incorrect

    • A 45-year-old man presents with decreased hearing in his right ear. Upon examination, you observe that his right ear canal is obstructed with wax, while the left ear is unobstructed. What results would you anticipate when conducting Rinne and Weber tests?

      Your Answer:

      Correct Answer: Weber: sound localises to the right; Rinne: BC > AC on the right and AC > BC on the left

      Explanation:

      The Rinne and Weber tests are utilized to differentiate between conductive and sensorineural hearing loss.

      In the case of this individual, there is an obstruction of wax in the right ear canal, which would result in a conductive hearing loss on the right side.

      During the Weber test, the patient should be able to locate the sound to the side of a conductive hearing loss, as bone conduction is enhanced. The sound will be located away from a sensorineural hearing loss.

      If there is a conductive hearing loss, the Rinne test will be negative, as bone conduction is better than air conduction. It will be positive if air conduction is better than bone conduction, which may be the case for mild-moderate sensorineural hearing loss or if there is normal hearing.

      In this instance, the wax blockage causes a conductive hearing loss on the right side. Therefore, during the Weber test, the sound should be localized to the right, and Rinne should be negative on the right side and positive on the left.

      Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness

      Rinne’s and Weber’s tests are used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test indicates that BC is better than AC, suggesting conductive deafness.

      Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking the patient which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.

      The table below summarizes the interpretation of Rinne and Weber tests. A normal result indicates that AC is greater than BC bilaterally and the sound is midline. Conductive hearing loss is indicated by BC being greater than AC in the affected ear and AC being greater than BC in the unaffected ear, with the sound lateralizing to the affected ear. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, with the sound lateralizing to the unaffected ear.

      Overall, Rinne’s and Weber’s tests are useful tools for differentiating between conductive and sensorineural deafness, allowing for appropriate management and treatment.

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  • Question 78 - Sarah is an 80-year-old woman who visits your clinic with complaints of hearing...

    Incorrect

    • Sarah is an 80-year-old woman who visits your clinic with complaints of hearing difficulty. During the examination, you observe that she has impacted earwax in both ear canals. You suggest using olive oil ear drops, but she informs you that she has previously tried them without success.

      What would be your next course of action in managing the earwax?

      Your Answer:

      Correct Answer: Sodium bicarbonate ear drops

      Explanation:

      If using olive oil drops to remove impacted earwax is unsuccessful, an alternative option is to use sodium bicarbonate drops to soften the wax.

      It is important to note that Otomize ear spray contains neomycin, an antibiotic that can be harmful to patients with a perforated eardrum. Therefore, caution should be exercised when using these drops.

      While ear syringing is a possibility, it is recommended to soften the wax with drops for at least two weeks prior to attempting the procedure.

      Since the patient’s hearing is affected by the wax, a wait-and-see approach is not advisable. Referral to audiology is also unnecessary as the cause of the hearing loss is already known, and delaying treatment may worsen the condition.

      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.

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  • Question 79 - A 25-year-old woman comes to the clinic complaining of headaches and unilateral sensorineural...

    Incorrect

    • A 25-year-old woman comes to the clinic complaining of headaches and unilateral sensorineural deafness. She reports that her headaches have started recently and are accompanied by vomiting and a change in posture. Additionally, she experiences pulse synchronous tinnitus and feels that her headaches are becoming more severe.

      Upon examination, there is no papilloedema and her blood pressure is within normal limits. The patient has been taking oral contraceptive pills for the past five years.

      What is the appropriate management plan for this patient?

      Your Answer:

      Correct Answer: Urgent direct access MRI scan of the brain (or CT scan if MRI is contraindicated) (to be performed within 2 weeks)

      Explanation:

      Suspected Intracranial Tumour in a Middle-Aged Woman

      The patient in question is a middle-aged woman who is showing signs of a unilateral Intracranial tumour, such as an acoustic neuroma. However, given her age, a more aggressive cerebellopontine angle tumour may be more likely. The absence of papilloedema doesn’t rule out the possibility of an Intracranial tumour.

      According to NICE guidelines, urgent direct access MRI or CT scan should be considered within two weeks for adults with progressive, subacute loss of central neurological function to assess for brain or central nervous system cancer. While admitting the patient as an emergency may be a practical option, adhering to NICE guidance suggests that an urgent direct access MRI is the most appropriate course of action.

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  • Question 80 - A 63-year-old man presents to the clinic with a persistent sore throat. He...

    Incorrect

    • A 63-year-old man presents to the clinic with a persistent sore throat. He had visited three weeks ago and was diagnosed with acute tonsillitis by another doctor, for which he was prescribed amoxicillin. At that time, some left submandibular swelling was observed.

      The patient is a heavy smoker, consuming around 40 cigarettes per day. Upon further questioning, he reveals that he has been experiencing a sore throat and pain while swallowing for the past three months.

      During the examination, his blood pressure is 145/82 mmHg, pulse is 85 and regular. He has heavily nicotine-stained fingers and appears very thin with a BMI of 20 kg/m2. There is noticeable left submandibular gland enlargement, which has apparently grown even more since his last consultation.

      Investigations reveal:

      - Hb 114 g/L (135-180)
      - WCC 6.0 ×109/L (4.5-10)
      - PLT 189 ×109/L (150-450)
      - Na 138 mmol/L (135-145)
      - K 4.8 mmol/L (3.5-5.5)
      - Cr 122 µmol/L (70-110)

      A chest x-ray taken three months earlier was normal.

      What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Viscosity and autoimmune profile

      Explanation:

      Referral for Suspicion of Squamous Cell Carcinoma

      In patients who are heavy smokers, squamous cell carcinoma should be considered as a possible diagnosis until proven otherwise. If a patient presents with an unexplained lump in the neck, persistent swelling in the parotid or submandibular gland, persistently sore or painful throat, or unexplained ulceration or patches in the oral mucosa, referral within two weeks is advised. Waiting for outpatient imaging results may cause an unacceptable delay in therapeutic intervention. In such cases, direct referral to the ENT department is recommended. Further oral antibiotics are unlikely to be of value, and checking viscosity may only add to the delay in referral. Therefore, prompt referral is crucial for timely diagnosis and treatment.

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  • Question 81 - A 72-year-old man presents with a four month history of left sided hearing...

    Incorrect

    • A 72-year-old man presents with a four month history of left sided hearing loss. He denies any pain, discharge tinnitus, vertigo or other symptoms of note. He is an ex-smoker with a 45 year pack history.

      On examination otoscopy of the right ear appears normal whilst the left ear shows a dullness to the tympanic membrane with air bubbles within the middle ear, the external auditory canal is clear. Rinne's test shows bone conduction better than air conduction in the left ear and air conduction better than bone conduction in the right ear. Weber's test lateralises to the left.

      What is the most appropriate cause of action?

      Your Answer:

      Correct Answer: Two week wait referral to local ENT service

      Explanation:

      Understanding Head and Neck Cancer: Symptoms and Referral Criteria

      Head and neck cancer is a broad term that encompasses various types of cancer, including oral cavity cancers, pharynx cancers, and larynx cancers. Some of the common symptoms of head and neck cancer include a persistent sore throat, hoarseness, neck lump, and mouth ulcer.

      To ensure timely diagnosis and treatment, the National Institute for Health and Care Excellence (NICE) has established referral criteria for suspected cancer pathways. For instance, individuals aged 45 and above with persistent unexplained hoarseness or an unexplained lump in the neck should be referred for an appointment within two weeks to rule out laryngeal cancer.

      Similarly, people with unexplained ulceration in the oral cavity lasting for more than three weeks or a persistent and unexplained lump in the neck should be referred for an appointment within two weeks to assess for possible oral cancer. Dentists should also consider an urgent referral for people with a lump on the lip or in the oral cavity or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

      Lastly, individuals with an unexplained thyroid lump should be referred for an appointment within two weeks to rule out thyroid cancer. By following these referral criteria, healthcare professionals can ensure that individuals with head and neck cancer receive prompt and appropriate care.

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  • Question 82 - A 25-year-old woman comes to the clinic with a single enlarged lymph node...

    Incorrect

    • A 25-year-old woman comes to the clinic with a single enlarged lymph node on the left side of her neck. She reports first noticing it during a cold she had about four weeks ago, and it has since increased in size, causing her to become more worried. During the examination, you observe a cervical lymph node with a diameter of 3 cm. There are no other abnormal findings. Routine blood tests reveal mild normochromic normocytic anemia and an elevated ESR of 72, but are otherwise normal.

      What is the most appropriate next step to confirm the diagnosis?

      Your Answer:

      Correct Answer: CXR

      Explanation:

      Suspected Hodgkin’s Lymphoma in Primary Care

      This patient’s presentation of a solitary enlarged lymph node, mild anaemia, and raised ESR falls within the age range for possible Hodgkin’s lymphoma. While constitutional symptoms are only present in a minority of cases, it is important to consider this diagnosis and refer urgently for excision biopsy of the lymph node. CXR and CT are important for staging, but not for confirming the diagnosis in primary care. Rapidly enlarging neck masses of greater than three weeks duration should be referred urgently to a specialist without first arranging imaging. Upper GI pathology is less likely given the absence of symptoms, and routine referral to haematology is not appropriate. NICE guidelines recommend considering a suspected cancer pathway referral for Hodgkin’s lymphoma in adults presenting with unexplained lymphadenopathy, taking into account any associated symptoms.

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  • Question 83 - A 14-year-old boy with nasal obstruction presents to you in surgery. Examining him,...

    Incorrect

    • A 14-year-old boy with nasal obstruction presents to you in surgery. Examining him, you find what you think are nasal polyps.
      Which of the following statements regarding nasal polyps is correct?

      Your Answer:

      Correct Answer: Polyps may be associated with cystic fibrosis

      Explanation:

      Understanding Nasal Polyps: Causes, Symptoms, and Treatment

      Nasal polyps are growths that develop in the nasal cavity or paranasal sinuses. They are often a sign of underlying inflammation and can cause progressive nasal obstruction. While they can occur at any age, they are relatively uncommon in children. However, in children with cystic fibrosis, rates of nasal polyps can be as high as 50%.

      Symptoms of nasal polyps include nasal obstruction, loss of smell, and postnasal drip. They are not typically associated with pain or bleeding, which may suggest neoplastic growths or foreign bodies. While surgical polypectomy can provide temporary relief, recurrence is common. The underlying inflammation should be targeted with topical corticosteroids, which can improve symptoms and reduce the risk of recurrence.

      If a child presents with nasal polyps, it is important to test for cystic fibrosis. While there is no single curative treatment for nasal polyps, early detection and management can improve quality of life and prevent complications.

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  • Question 84 - A 49-year-old man presents to you with concerns about a sudden hearing loss...

    Incorrect

    • A 49-year-old man presents to you with concerns about a sudden hearing loss in his left ear. He was watching TV with his wife the previous night when he went to the bathroom. Upon returning, he noticed that he could no longer hear speech or music from his left ear and instead, he could only hear a loud hissing sound.

      Upon examination, both ears, ear canals, and tympanic membranes appear normal. Combined Weber's and Rinne's tests reveal that he has a sensorineural hearing loss on the left side.

      What is the most probable cause of this man's symptoms?

      Your Answer:

      Correct Answer: Idiopathic

      Explanation:

      Sudden sensorineural hearing loss in the UK is mostly idiopathic, with potential underlying causes being URTI-related viral infections and microvascular obstruction to the blood flow in the cochlea. However, there are also much rarer causes such as acoustic neuroma or other intracranial tumors, trauma, blasts and loud noise, barotrauma from SCUBA diving and flights, meningitis, herpes zoster, syphilis, immunological disease, AIDS, MS, Meniere’s disease, Lyme disease, and stroke. It is important not to assume that a man married to another man has a disease related to this, even in exam questions.

      When a patient experiences a sudden loss of hearing, it is crucial to conduct a thorough examination to determine whether it is conductive or sensorineural hearing loss. If it is the latter, known as sudden-onset sensorineural hearing loss (SSNHL), it is imperative to refer the patient to an ear, nose, and throat (ENT) specialist immediately. The majority of SSNHL cases have no identifiable cause, making them idiopathic. To rule out the possibility of a vestibular schwannoma, an MRI scan is typically performed. ENT specialists administer high-dose oral corticosteroids to all patients with SSNHL.

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  • Question 85 - Choose from the options below the one that is an appropriate reason for...

    Incorrect

    • 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:

      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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  • Question 86 - During a routine cranial nerve examination of a different patient, the following results...

    Incorrect

    • During a routine cranial nerve examination of a different patient, the following results were obtained:

      Rinne's test: Air conduction > bone conduction in both ears
      Weber's test: Localises to the left side

      What do these test results indicate?

      Your Answer:

      Correct Answer: Left sensorineural deafness

      Explanation:

      If there is a sensorineural issue during Weber’s test, the sound will be perceived on the healthy side (right), suggesting a problem on the opposite side (left).

      Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness

      Rinne’s and Weber’s tests are used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test indicates that BC is better than AC, suggesting conductive deafness.

      Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking the patient which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.

      The table below summarizes the interpretation of Rinne and Weber tests. A normal result indicates that AC is greater than BC bilaterally and the sound is midline. Conductive hearing loss is indicated by BC being greater than AC in the affected ear and AC being greater than BC in the unaffected ear, with the sound lateralizing to the affected ear. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, with the sound lateralizing to the unaffected ear.

      Overall, Rinne’s and Weber’s tests are useful tools for differentiating between conductive and sensorineural deafness, allowing for appropriate management and treatment.

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  • Question 87 - A 2-year-old boy has cerebral palsy. He presents with profuse rhinorrhoea, pyrexia and...

    Incorrect

    • A 2-year-old boy has cerebral palsy. He presents with profuse rhinorrhoea, pyrexia and noisy respiration. The noise is a heavy-snoring inspiratory sound. His tonsils are enlarged and inflamed.
      Which of the following describes the sound that this child is making?

      Your Answer:

      Correct Answer: Stertorous

      Explanation:

      Stertorous refers to a noisy and laboured breathing sound, often heard during deep sleep or coma, caused by obstruction in the upper airways. Hypernasal speech is an abnormal voice resonance due to increased airflow through the nose during speech, caused by an incomplete closure of the soft palate and/or velopharyngeal sphincter. Rales, also known as crackles or crepitations, are clicking or crackling noises heard during auscultation, caused by the popping open of small airways and alveoli collapsed by fluid or exudate during expiration. Stridor is a high-pitched sound occurring during inhalation or exhalation, indicating respiratory obstruction, commonly caused by croup, foreign bodies, or allergic reactions. Wheezing is a high-pitched whistling sound made while breathing, caused by narrowed airways, typically in asthma.

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  • Question 88 - A 42-year-old man presents with tinnitus. No subjective hearing loss or other symptoms...

    Incorrect

    • A 42-year-old man presents with tinnitus. No subjective hearing loss or other symptoms are reported. He is systemically well. He has had tinnitus for several years but over time the tinnitus has had an increasing psychological effect on his well-being. He has previously been seen recently for the first time with regards his tinnitus and was given tinnitus support (information provision and discussion of management options) and was also referred for audiological assessment which is pending.

      He is not suicidal but has become increasingly distressed by the tinnitus which is persistent and intrusive. He struggles to sleep and has become increasingly depressed. It has got to the point over the last week where due to his tinnitus he can't cope to go to work and is spending days at home feeling unable to do anything productive. He has no past history of any mental health problems and just wants to feel better and for his tinnitus to be less intrusive.

      Which of the following is the most appropriate management strategy?

      Your Answer:

      Correct Answer: Refer urgently (to be seen within 2 weeks) for specialist assessment

      Explanation:

      NICE Guidelines for Tinnitus Management

      NICE has recently released guidelines for the assessment, investigation, and management of tinnitus. Tinnitus support is a crucial aspect of these guidelines, which involves healthcare professionals discussing difficulties, goals, and management plans with patients. It is important to note that the psychological impact of tinnitus should not be overlooked, and the guidelines include consideration of psychological aspects. Those with tinnitus associated with a high risk of suicide should be referred immediately for crisis mental health input. Additionally, those with tinnitus that affects their mental well-being and prevents them from carrying out daily activities should be referred for further assessment and management within two weeks. It is important to note that betahistine should not be used to treat tinnitus alone, as evidence suggests that it doesn’t improve symptoms and may cause adverse effects.

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  • Question 89 - A 42-year-old man presents with a 'neck lump' that he has noticed over...

    Incorrect

    • A 42-year-old man presents with a 'neck lump' that he has noticed over the past two months. On examination, you palpate a diffuse midline swelling which moves with swallowing but not with tongue protrusion. There are no other neck lumps or focal nodules, and the patient's voice is normal with no hoarseness. There is no cervical lymphadenopathy or stridor. The patient has no significant past medical history or family history.
      He reports feeling slightly more fatigued and has gained some weight over the past few months but otherwise feels well. He notes that the swelling in his neck has not changed in size since he first noticed it.
      Thyroid function tests reveal hypothyroidism. What is the most appropriate management plan?

      Your Answer:

      Correct Answer: Repeat the thyroid function test in four to six weeks

      Explanation:

      Thyroid Swelling: Recognizing and Referring Suspected Cancer

      Note that it is important to clarify descriptions and findings during a patient’s history and examination. For instance, a patient may describe a lump when it is actually a diffuse swelling. According to NICE guidelines, an unexplained thyroid lump warrants a suspected cancer pathway referral within two weeks. However, other factors to consider during the assessment include a solitary nodule increasing in size, a history of neck irradiation, family history of an endocrine tumor, unexplained hoarseness or voice changes, cervical lymphadenopathy, very young or elderly patients. Patients with symptoms of tracheal compression should be admitted immediately to the hospital.

      In cases where a thyroid swelling doesn’t meet any of the urgent or immediate referral criteria, a thyroid function blood test should be conducted. If the test reveals hypothyroidism, it may explain the patient’s weight gain and tiredness. Patients with abnormal thyroid function and a goitre are unlikely to have thyroid cancer and can be managed in primary care. Those with a goitre and normal thyroid function tests can be referred non-urgently to a thyroid surgeon.

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  • Question 90 - A 23-year-old female presents with severe right-sided ear pain, muffled hearing, and watery...

    Incorrect

    • A 23-year-old female presents with severe right-sided ear pain, muffled hearing, and watery discharge for the past 3 days. The patient also reports intense itching in the affected ear. Upon examination, the tympanic membrane is intact, but the external auditory canal is inflamed, red, and swollen with purulent debris and wax. Pulling the pinna causes the patient significant pain. The mastoid process is normal and not tender to palpation. Rinne's and Weber's tests confirm conductive hearing loss. What is the recommended first-line treatment for this patient?

      Your Answer:

      Correct Answer: Topical antibiotic + a topical steroid for 1-2 weeks

      Explanation:

      Understanding Otitis Externa: Causes, Features, and Management

      Otitis externa is a prevalent condition that often prompts primary care visits in the UK. It is characterized by ear pain, itch, and discharge, and can be caused by bacterial or fungal infections, seborrhoeic dermatitis, or contact dermatitis. Swimming is also a common trigger for otitis externa. Upon examination, the ear canal may appear red, swollen, or eczematous.

      The recommended initial management for otitis externa is 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. If there is canal debris, removal may be necessary, and if the canal is extensively swollen, an ear wick may be inserted. Second-line options include taking a swab inside the ear canal, considering contact dermatitis secondary to neomycin, or using oral antibiotics such as flucloxacillin if the infection is spreading. Empirical use of an antifungal agent may also be considered.

      It is important to note that if a patient fails to respond to topical antibiotics, they should be referred to an ENT specialist. Malignant otitis externa is a more severe form of the 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. While some ENT doctors disagree, concerns about ototoxicity may arise with the use of aminoglycosides in patients with perforated tympanic membranes.

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  • Question 91 - A 42-year-old man comes to your clinic complaining of ear pain. He had...

    Incorrect

    • A 42-year-old man comes to your clinic complaining of ear pain. He had visited the emergency department 3 days ago but was only given advice. He has been experiencing ear pain for 5 days now.

      During the examination, his temperature is recorded at 38.5ºC, and his right eardrum appears red and bulging. What is the appropriate course of action for this patient?

      Your Answer:

      Correct Answer: Start amoxicillin

      Explanation:

      To improve treatment without antibiotics, guidelines suggest waiting 2-3 days before considering treatment if symptoms do not improve. This is especially important when a patient has a fever, indicating systemic involvement. Therefore, recommending regular paracetamol is not appropriate in this case.

      While erythromycin is a useful alternative for patients with a penicillin allergy, it should not be the first choice for those who can take penicillin. It is particularly useful as a syrup for children due to its lower cost compared to other alternatives.

      Penicillin V is the preferred antibiotic for tonsillitis, as amoxicillin can cause a rash in cases of glandular fever. However, it is not typically used for otitis media.

      For otitis media, amoxicillin is the recommended first-line medication at a dosage of 500mg three times a day for seven days.

      Co-amoxiclav is only used as a second-line option if amoxicillin is ineffective and is not typically used as a first-line treatment according to current guidelines.

      References: NICE Guidelines, Clinical Knowledge Summaries

      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.

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  • Question 92 - A 5-year-old child presents with a sore throat and polymorphous rash. He has...

    Incorrect

    • A 5-year-old child presents with a sore throat and polymorphous rash. He has had a fever for five to six days. He is well, drinking fluids, not vomiting, and passing urine normally.

      On examination, he is alert, well hydrated with no photophobia or neck stiffness. His temperature is 38.7°C, HR 140, RR 30, and CRT<2 sec. His chest is clear.

      He has generalised blanching macular rash and bilateral conjunctival injection. His lips are dry and chapped, tonsils are erythematous with no exudate. His eardrums look normal and he has moderate cervical lymphadenopathy. Urine dipstick is positive for protein and leucocytes.

      What is the most appropriate management?

      Your Answer:

      Correct Answer: Give penicillin V, take throat swab and send home with worsening advice

      Explanation:

      Understanding Kawasaki Disease

      Kawasaki disease is a leading cause of acquired heart disease in children in the UK. Although its prevalence is low, the risk of complications is high due to late diagnosis. As such, it is important to have a good understanding of the disease, which may be tested in the AKT exam.

      The exact cause of Kawasaki disease is unknown, but it is believed to be due to a microbiological toxin. If left untreated, it can lead to coronary aneurysms. To diagnose Kawasaki disease, consider it in children with fever lasting over five days and who have four of the following five features: bilateral conjunctival injection, change in mucous membranes in the upper respiratory tract, change in the extremities, polymorphous rash, or cervical lymphadenopathy. In rare cases, incomplete or atypical Kawasaki disease may be diagnosed with fewer features.

      To help remember the features of Kawasaki disease, think All Red + Cervical Lymphadenopathy. This stands for red eyes, red mouth, red rash, red hands, and cervical lymphadenopathy. By being aware of these symptoms, healthcare professionals can diagnose and treat Kawasaki disease promptly, reducing the risk of complications.

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  • Question 93 - A 6-year-old boy comes to you complaining of sudden and severe pain in...

    Incorrect

    • A 6-year-old boy comes to you complaining of sudden and severe pain in his right ear after recently having an ear infection. During examination, you notice a perforated eardrum. He has a soccer game next week and is eager to play. What advice would you give him regarding this situation?

      Your Answer:

      Correct Answer: Avoid swimming until the perforation is completely healed

      Explanation:

      It is recommended to refrain from swimming until a perforated tympanic membrane has fully healed, which typically takes longer than a week. Using a swimming cap may not offer adequate protection. Antibiotics should only be prescribed if there is an infection present, and oral antibiotics are preferred over drops.

      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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  • Question 94 - A 67-year-old man comes to the clinic complaining of vertigo that has been...

    Incorrect

    • A 67-year-old man comes to the clinic complaining of vertigo that has been present for the past 5 weeks after a recent respiratory tract infection. He reports feeling nauseous and unsteady on his feet, especially when turning over in bed. He denies any hearing loss or ringing in his ears. A cerebellar stroke was ruled out when he was initially evaluated at the hospital.

      During the examination, you observe fine-horizontal nystagmus. However, the neurological examination is otherwise unremarkable, and his hearing and otoscopy results are normal. You suspect that he may be suffering from vestibular neuronitis.

      What would be the most appropriate next step in managing this patient's condition?

      Your Answer:

      Correct Answer: Refer the patient to a balance specialist for consideration of vestibular rehabilitation exercises

      Explanation:

      Vestibular rehabilitation exercises are the recommended treatment for chronic symptoms of vestibular neuronitis. While short-term use of oral prochlorperazine or antihistamines can provide relief, they should not be used for more than three days as they may hinder the body’s compensatory mechanisms and delay recovery.

      NICE CKS guidance advises against the use of corticosteroids, benzodiazepines, or antiviral medication as there is no evidence of their effectiveness.

      If symptoms persist for six weeks or more, patients should be referred to a specialist for further investigation and vestibular rehabilitation exercises. It is crucial to note that urgent referral is necessary if symptoms do not improve within one week of initial treatment to rule out other potential causes.

      Understanding Vestibular Neuronitis

      Vestibular neuronitis is a type of vertigo that typically occurs after a viral infection. It is characterized by recurrent episodes of vertigo that can last for hours or days, accompanied by nausea and vomiting. Horizontal nystagmus is also a common symptom, but there is no hearing loss or tinnitus.

      It is important to differentiate vestibular neuronitis from other conditions such as viral labyrinthitis and posterior circulation stroke. The HiNTs exam can be used to distinguish between these conditions.

      Treatment for vestibular neuronitis typically involves medication to alleviate symptoms, such as buccal or intramuscular prochlorperazine for severe cases, or a short course of oral medication for less severe cases. Vestibular rehabilitation exercises are also recommended for patients who experience chronic symptoms.

      Understanding the symptoms and treatment options for vestibular neuronitis can help individuals manage this condition and improve their quality of life.

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  • Question 95 - An 80-year-old man presents to the emergency department with worsening pain and fever...

    Incorrect

    • 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:

      Correct 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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  • Question 96 - A 19-year-old female presents to you with complaints of a sore throat. She...

    Incorrect

    • A 19-year-old female presents to you with complaints of a sore throat. She reports feeling sick for the past three days with a high fever and painful throat. She has been self-medicating with an over-the-counter flu remedy containing paracetamol. Upon examination, she has a temperature of 37.1°C, tender anterior cervical lymphadenopathy, visible tonsillar exudate, and a dry cough. What is this patient's Centor score?

      Your Answer:

      Correct Answer: 3

      Explanation:

      Understanding the Centor Score for Tonsillitis

      The Centor score is a tool used by clinicians to differentiate between viral and bacterial tonsillitis, which helps guide the use of antibiotics. It consists of four criteria: the presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, a history of fever, and absence of cough. If at least three out of the four criteria are met, it suggests a bacterial infection and antibiotics may be beneficial. Conversely, if less than three criteria are met, antibiotics are unlikely to be needed. It’s important to note that the Centor score is based on a history of fever, not necessarily a fever at the time of being seen. The McIsaac modification adds a point for patients under 15 years old and deducts a point for those over 45 years old. The Centor score is a helpful tool, but it should not replace clinical judgement.

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  • Question 97 - A 20-year-old man comes to you complaining of bilateral sneezing, watery nasal discharge,...

    Incorrect

    • A 20-year-old man comes to you complaining of bilateral sneezing, watery nasal discharge, and nasal itching. He reports experiencing these symptoms at this time of year for the past few years, but this year they are worse and are interfering with his college attendance. He has no trouble breathing, no other medical issues, and takes no regular medications. His mother suggested he try putting vaseline around his nose, and he has taken some cetirizine, but it has not been effective thus far.

      What is the most appropriate initial management for this patient?

      Your Answer:

      Correct Answer: Intranasal fluticasone furoate and continue regular antihistamine

      Explanation:

      For individuals with moderate-to-severe or persistent symptoms of allergic rhinitis, intranasal steroids are the recommended first-line treatment. They have been found to be more effective than oral antihistamines. Combining intranasal steroids with oral antihistamines can provide even better results.

      If a person experiences persistent watery rhinorrhea despite using both intranasal steroids and oral antihistamines, an intranasal anticholinergic like ipratropium bromide can be added to the treatment plan.

      In cases where symptoms are severe and significantly impacting quality of life despite optimal treatment, a short course of oral steroids may be considered. However, this should only be used for important life events.

      If symptoms remain uncontrolled despite optimal management, immunotherapy may be considered as a future option.

      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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  • Question 98 - A 60-year-old male presents to his GP with complaints of severe ear pain....

    Incorrect

    • 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:

      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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  • Question 99 - A 50-year-old woman comes to the clinic complaining of persistent tinnitus in her...

    Incorrect

    • A 50-year-old woman comes to the clinic complaining of persistent tinnitus in her left ear for the past 5 months. She has also observed a gradual decline in her hearing ability in the same ear. Upon examination, both ears appear normal. Rinne's test shows air conduction greater than bone conduction in the left ear, and Weber's test lateralises to the right ear. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Acoustic neuroma

      Explanation:

      The typical presentation of vestibular schwannoma involves a combination of symptoms such as vertigo, hearing loss, tinnitus, and an absent corneal reflex. On the other hand, the symptoms of acoustic neuroma may vary depending on the cranial nerve affected. In this case, the patient’s tinnitus and hearing loss suggest that the vestibulocochlear nerve is affected, and vertigo may also be present. Sensorineural hearing loss is observed in acoustic neuroma, whereas otosclerosis, impacted wax, and cholesteatoma cause conductive hearing loss. Meniere’s disease is characterized by progressive hearing loss that fluctuates in severity depending on the attacks.

      Vestibular schwannomas, also known as acoustic neuromas, make up about 5% of intracranial tumors and 90% of cerebellopontine angle tumors. These tumors typically present with a combination of vertigo, hearing loss, tinnitus, and an absent corneal reflex. The specific symptoms can be predicted based on which cranial nerves are affected. For example, cranial nerve VIII involvement can cause vertigo, unilateral sensorineural hearing loss, and unilateral tinnitus. Bilateral vestibular schwannomas are associated with neurofibromatosis type 2.

      If a vestibular schwannoma is suspected, it is important to refer the patient to an ear, nose, and throat specialist urgently. However, it is worth noting that these tumors are often benign and slow-growing, so observation may be appropriate initially. The diagnosis is typically confirmed with an MRI of the cerebellopontine angle, and audiometry is also important as most patients will have some degree of hearing loss. Treatment options include surgery, radiotherapy, or continued observation.

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  • Question 100 - Which medication is most strongly linked to an increased risk of cleft palate...

    Incorrect

    • Which medication is most strongly linked to an increased risk of cleft palate during pregnancy?

      Your Answer:

      Correct Answer: Phenytoin

      Explanation:

      Medications and their effects on pregnancy

      The incidence of orofacial malformations such as cleft lip and cleft palate is about 1:1000. While some cases are obvious due to external appearance, isolated palatal defects require close inspection and palpation of the palate during neonatal examination to be detected.

      Phenytoin has been linked to congenital defects, particularly cleft lip and palate. Antiepileptic drugs, in general, have been studied closely with regard to congenital malformations, and evidence suggests that monotherapy with an antiepileptic drug during pregnancy doubles the risk of major congenital malformation, while polytherapy triples the risk.

      Aspirin can be used in pregnancy, but caution should be exercised as it can cause impaired platelet function and risk of haemorrhage. Carbimazole can be used for the treatment of hyperthyroidism, but it has been linked to aplasia cutis of the newborn. Selective serotonin reuptake inhibitors (SSRIs) should only be used during pregnancy if the benefits of treatment outweigh the risks. Methyldopa is a centrally acting antihypertensive agent that can be used for the management of hypertension in pregnancy.

      It is important to consider the potential effects of medications on pregnancy and to weigh the risks and benefits before prescribing them. Close monitoring and follow-up are also necessary to ensure the health and safety of both the mother and the developing fetus.

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