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Question 1
Incorrect
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A 65-year-old gentleman comes to the clinic complaining of unilateral hearing loss accompanied by otalgia and otorrhoea in the affected ear. He reports feeling otherwise healthy. Upon examination, the ear canal is red and inflamed, but patent, and there is discharge present, indicating an infection. The external ear and mastoid appear normal, and there are no abnormalities detected in the throat or neck. The patient is worried as he is immunocompromised due to treatment for multiple sclerosis.
What is the best course of action for managing this patient's condition?Your Answer: Initiate appropriate antimicrobial treatment in primary care and arrange a review appointment in 3 days
Correct Answer: Refer routinely to an ear, nose and throat specialist
Explanation:Management of an Immunocompromised Patient with Signs of Infection
In managing an immunocompromised patient with signs of infection, it is important to consider the potential risk of deterioration related to the infection. According to NICE guidelines, the most appropriate approach would be to start appropriate treatment and arrange a review appointment in 3 days. This allows for monitoring of treatment response and early detection of any potential complications.
If the patient doesn’t respond to treatment, immediate referral to an ENT specialist is necessary. Therefore, it is crucial to closely monitor the patient’s condition and ensure prompt action is taken if necessary. By following these guidelines, healthcare professionals can effectively manage immunocompromised patients with signs of infection and minimize the risk of complications.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 2
Correct
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A 65-year-old man visits the clinic with a complaint of painful gums. Upon examination, he is found to have gingival hyperplasia. Which medication is the most probable cause of this condition?
Your Answer: Nifedipine
Explanation:Phenytoin, ciclosporin, calcium channel blockers, and AML are all associated with gingival hyperplasia.
Understanding Gingival Hyperplasia and Its Causes
Gingival hyperplasia is a condition characterized by an abnormal growth of gum tissue, resulting in an enlarged and swollen appearance. This condition can be caused by various factors, including certain medications and medical conditions. Some of the drugs that have been linked to gingival hyperplasia include phenytoin, ciclosporin, and calcium channel blockers, particularly nifedipine. These drugs can cause an overgrowth of gum tissue, leading to discomfort and difficulty in maintaining proper oral hygiene.
Aside from medication, gingival hyperplasia can also be a symptom of acute myeloid leukemia, particularly the myelomonocytic and monocytic types. This type of cancer affects the blood and bone marrow, leading to abnormal growth of white blood cells and other blood components. As a result, the gums may become swollen and inflamed, making it difficult to eat, speak, and perform other daily activities.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 3
Incorrect
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A 12-year-old girl presents with a six-month history of intermittent nosebleeds from both nostrils. She has prominent Little’s area vessels on both sides of her nasal septum. What is the most suitable course of action?
Your Answer: Ear, nose and throat specialist referral
Correct Answer: Unilateral nasal cautery and antibiotic cream
Explanation:Treatment Options for Epistaxis (Nosebleeds)
Epistaxis, or nosebleeds, can be a common occurrence and can often be managed with simple interventions. Here are some treatment options:
Unilateral Nasal Cautery and Antibiotic Cream
Chemical cautery using a silver nitrate stick can be used to produce local chemical damage in the mucosa. After cautery, Naseptin® cream should be applied to the nostrils four times daily for ten days. This treatment option is effective for most cases of epistaxis.Ear, Nose, and Throat Specialist Referral
Referral to an ear, nose, and throat specialist should be considered if the person has recurrent episodes of epistaxis and is at high risk of having a serious underlying cause.Anterior Nasal Packing
If bleeding continues despite cautery or if a bleeding point cannot be seen, the nose can be packed with nasal sponges or ribbon gauze.Bilateral Nasal Cautery
Only one side of the septum should be cauterized, as there is a small risk of septal perforation resulting from decreased vascularization to the septal cartilage. A 4–6-week interval between cautery treatments is recommended.Iron Tablets
Iron tablets are not appropriate without a diagnosis of anemia.Managing Epistaxis: Treatment Options to Consider
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 4
Correct
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A 16-year-old girl comes in with a complaint of a sore throat. She reports no cough, has a temperature of 38.4ºC, and her tonsils are enlarged with white exudate. What is the fourth component of the Centor criteria?
Your Answer: Tender anterior cervical lymphadenopathy
Explanation:The Centor criteria consist of a patient’s fever history, the existence of tonsillar exudate, the lack of a cough, and the presence of tender anterior cervical lymphadenopathy. None of the other options are included in this assessment.
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.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 5
Incorrect
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A 49-year-old woman presents with recurrent episodes of vertigo. She reports experiencing true vertigo for about 10-20 seconds at a time, which has been happening on and off for the past few days. She became frightened while driving yesterday when she turned her head and became very dizzy, causing her to stop the car. She has since stopped driving altogether, but the vertigo continues to occur throughout the day in other situations, particularly when she turns her head. She denies any hearing loss or tinnitus. On examination, her cranial nerves are normal and there are no cerebellar signs. Dix-Hallpike testing is positive when she is manoeuvred to the right side, producing rotatory vertigo and nystagmus. What is the most appropriate management strategy?
Your Answer: Refer for outpatient ENT assessment
Correct Answer: Perform the Epley manoeuvre
Explanation:Management of Benign Paroxysmal Positional Vertigo
This patient is exhibiting classic signs and symptoms of benign paroxysmal positional vertigo (BPPV). The Epley manoeuvre is a highly effective treatment option that can be taught to the patient to reduce or eliminate their symptoms. Vestibular sedatives are not recommended for the management of BPPV.
If the patient were experiencing unilateral deafness or tinnitus, an MRI would be necessary. However, at this stage, there is no indication for audiological or outpatient ENT assessment. It is important to note that early intervention and proper management can greatly improve the patient’s quality of life and prevent further complications.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 6
Incorrect
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On a Monday morning you see a 25-year-old man who has a broken nose from a fight the previous Saturday night. Apart from pain and swelling, he has no other symptoms.
Which of the following statements about the management of a fractured nose is correct?Your Answer: The patient should be referred immediately to the on-call team for manipulation under anaesthetic
Correct Answer: Manipulation under anaesthetic is best performed 5–7 days after injury
Explanation:Myths and Facts about Nasal Fractures
Nasal fractures are a common injury that can result from trauma to the face. However, there are several myths and misconceptions surrounding the diagnosis and management of these fractures. Here are some important facts to keep in mind:
Timing of Fracture Reduction
Myth: Fracture reduction can be performed immediately after injury.
Fact: Fracture reduction is best performed 5-7 days after injury, when swelling has subsided. Immediate reduction may be possible if there is little swelling.Role of Radiological Imaging
Myth: Radiological imaging is essential in confirming the diagnosis of nasal fractures.
Fact: The diagnosis of nasal fracture is usually made clinically, and imaging is usually unnecessary. X-rays are unreliable in the diagnosis of nasal fractures and do not usually affect patient management.Significance of Clear Rhinorrhoea
Myth: Clear rhinorrhoea is of no consequence.
Fact: Clear rhinorrhoea may be a sign of a cerebrospinal fluid leak and should prompt further urgent assessment.Management of Septal Haematomas
Myth: Septal haematomas usually resolve spontaneously.
Fact: Septal haematomas should be drained promptly to prevent septal perforation. Antibiotics should be prescribed after drainage.Referral for Manipulation under Anaesthetic
Myth: The patient should be referred immediately for manipulation under anaesthetic.
Fact: Further reasons for immediate referral include marked nasal deviation, persisting epistaxis, intercanthal widening, facial anaesthesia, facial or mandibular fracture, and ophthalmoplegia. -
This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 7
Incorrect
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A 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: Start oral prednisolone
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 8
Correct
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A 65-year-old man presents with left-sided hearing loss that has been gradually worsening over the past few months. He reports no pain or discharge and has been using olive oil drops for three weeks with no improvement. Upon examination, the right ear appears normal, but the left external auditory canal is obstructed by impacted earwax.
What is the best course of action for management?Your Answer: Suggest sodium bicarbonate drops
Explanation:When olive oil drops fail to remove impacted earwax, sodium bicarbonate drops can be used as an alternative treatment. This is recommended by NICE as a first line treatment for 3-5 days. Sodium bicarbonate drops can be purchased over-the-counter without a prescription.
In the past, GP surgeries would offer ear canal irrigation as a treatment option. However, this has been slowly withdrawn in recent years. If drops alone have failed, ear canal irrigation may still be recommended if there is local provision.
earwax removal by ENT is generally not funded on the NHS unless certain qualifying criteria are met, such as previous ear surgery. Antibiotic ear drops are not indicated as there is no evidence of infection.
Ear candling is not recommended as a treatment option.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 9
Incorrect
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A 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: Preceding upper respiratory tract infection
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 10
Correct
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A 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: 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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 11
Correct
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Liam is a 26-year-old man who complained of hearing loss and was diagnosed with bilateral impacted wax. Despite using olive oil drops for a week, there was no improvement.
What other options can be considered at this point?Your Answer: Sodium bicarbonate drops
Explanation:When attempting to remove impacted earwax, it is recommended to try olive oil drops first. If this method is unsuccessful, other options such as almond oil drops, sodium bicarbonate drops, and sodium chloride drops can be considered. Otomize and betamethasone ear drops are commonly used for treating otitis externa. It is important to avoid attempting to remove earwax through ear candling or the use of cotton buds.
Understanding earwax and Its Impacts
earwax is a natural substance produced by the body to protect the ear canal. However, it is not uncommon for earwax to become impacted, leading to a range of symptoms such as pain, hearing loss, tinnitus, and vertigo. In such cases, treatment is necessary to alleviate the discomfort caused by the impacted earwax. Primary care options for treatment include ear drops or irrigation, also known as ‘ear syringing’. It is important to note that treatment should not be administered if there is a suspected perforation or if the patient has grommets. Ear drops such as olive oil, sodium bicarbonate 5%, and almond oil can be used to help alleviate the symptoms of impacted earwax.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 12
Incorrect
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A 60-year-old man comes to the clinic complaining of sudden hearing loss in his right ear. He reports that this occurred over the course of a few hours yesterday and has not improved since. He denies any other symptoms and has no significant medical history or prior ear issues. Upon examination, there are no visible abnormalities in the ear canal or tympanic membrane. What is the recommended course of action for managing this patient's condition?
Your Answer: Refer immediately (to be seen within 24 hours) to an ear, nose and throat specialist
Correct Answer: Refer for an audiological assessment
Explanation:Referral Guidelines for Sudden or Rapidly Worsening Hearing Loss in Adults
Adults who experience sudden onset or rapidly worsening hearing loss in one or both ears, which cannot be explained by external or middle ear causes, require referral to an ENT or audiovestibular medicine service. The speed at which this referral needs to occur is outlined in NICE guidance. If the loss occurred suddenly within the past 30 days, immediate referral to be seen within 24 hours is necessary. For sudden hearing loss that occurred more than 30 days ago, urgent referral to be seen within 2 weeks is appropriate. Rapid hearing loss over a period of 4 to 90 days also requires urgent referral. It is important to follow these guidelines to ensure prompt evaluation and appropriate management of hearing loss in adults.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 13
Incorrect
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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: Surgical polypectomy is curative
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 14
Incorrect
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A 63-year-old woman comes to your clinic complaining of a painless, foul-smelling discharge from her left ear that has been going on for four months. She had seen another doctor a month ago who prescribed gentamicin/hydrocortisone ear drops, but they did not help alleviate her symptoms.
Upon examination, there is some wax buildup in the attic of her left ear, but otherwise, everything appears normal. Her cranial nerve examination is also unremarkable.
What would be the best course of action to take?Your Answer:
Correct Answer: Refer to ENT outpatient clinic
Explanation:If a patient has persistent unilateral ear discharge that doesn’t respond to antibiotics, it is important to consider the possibility of cholesteatoma, according to NICE guidelines. A cholesteatoma can be concealed behind wax in the attic, so a referral to an ENT clinic for microsuction and direct inspection is necessary. The urgency of the referral depends on the severity of the patient’s symptoms. In this case, a semi-urgent referral is appropriate, but if the patient experiences more advanced symptoms such as vertigo or facial nerve palsy, an urgent discussion with an on-call ENT specialist is necessary.
While olive oil may be helpful for wax buildup, it is not the main issue in this case, as the patient is experiencing discharge. Oral antibiotics are not recommended as there is no evidence of infection. An MRI of the IAMs may be necessary, but it is best to arrange this as part of an assessment by the ENT service. Ear syringing may be useful for wax buildup, but it is not advisable in this situation.
Understanding Cholesteatoma
Cholesteatoma is a benign growth of squamous epithelium that can cause damage to the skull base. It is most commonly found in individuals between the ages of 10 and 20 years old. Those born with a cleft palate are at a higher risk of developing cholesteatoma, with a 100-fold increase in risk.
The main symptoms of cholesteatoma include a persistent discharge with a foul odor and hearing loss. Other symptoms may occur depending on the extent of the growth, such as vertigo, facial nerve palsy, and cerebellopontine angle syndrome.
During otoscopy, a characteristic attic crust may be seen in the uppermost part of the eardrum.
Management of cholesteatoma involves referral to an ear, nose, and throat specialist for surgical removal. Early detection and treatment are important to prevent further damage to the skull base and surrounding structures.
In summary, cholesteatoma is a non-cancerous growth that can cause significant damage if left untreated. It is important to be aware of the symptoms and seek medical attention promptly if they occur.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 15
Incorrect
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You have a telephone consultation with a 39-year old male patient who has paralysis on the left-hand side of his face. It started 2 days ago with left sided facial and ear pain. The pain is now very severe and causing him considerable discomfort. He is unable to move his left forehead, close the left eye or move the left-hand side of his mouth. He is normally fit and well.
You suspect that he has a Bell's palsy and arrange to see him in your clinic that afternoon to examine him.
Which statement below regarding Bell's palsy is correct?Your Answer:
Correct Answer: In a patient with a Bell's palsy, severe pain might indicate Ramsay Hunt syndrome
Explanation:Severe pain in a patient with Bell’s palsy may be a sign of Ramsay Hunt syndrome, which is caused by herpes zoster and is accompanied by a painful rash and herpetic vesicles. Urgent referral to ENT is necessary if the facial paralysis has not improved after one month. Loss of taste in the anterior two-thirds of the tongue on the same side as the facial weakness may occur but doesn’t require urgent referral. Referral to a plastic surgeon with expertise in facial reconstructive surgery should be considered if there is residual paralysis after 6-9 months. Corticosteroid treatment is recommended as it has been shown to improve prognosis based on evidence from meta-analyses, while antiviral treatments are not recommended alone or in combination with prednisolone.
Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It typically affects individuals between the ages of 20 and 40, and is more common in pregnant women. The condition is characterized by a lower motor neuron facial nerve palsy that affects the forehead, while sparing the upper face. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.
The management of Bell’s palsy has been a topic of debate, with various treatment options proposed in the past. However, there is now consensus that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, with some experts recommending it for severe cases. Eye care is also crucial to prevent exposure keratopathy, and patients may need to use artificial tears and eye lubricants. If they are unable to close their eye at bedtime, they should tape it closed using microporous tape.
Follow-up is essential for patients who show no improvement after three weeks, as they may require urgent referral to ENT. Those with more long-standing weakness may benefit from a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within three to four months. However, untreated cases can result in permanent moderate to severe weakness in around 15% of patients.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 16
Incorrect
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A 55-year-old smoker of 20 cigarettes a day, presents with a three month history of persistent hoarseness. On direct questioning he admits to left-sided earache.
On examination he is hoarse and has mild stridor. Examination of his ears is normal. Endoscopy of his upper airway shows an irregular mass in the larynx.
What is the most likely diagnosis?Your Answer:
Correct Answer: Carcinoma of the larynx
Explanation:Diagnosing Laryngeal Pathology
This patient’s heavy smoking and symptoms suggest laryngeal pathology, with an irregular mass noted on nasal endoscopy. These features point to a diagnosis of laryngeal carcinoma, the most common cause of hoarseness in adults.
Laryngeal papillomatosis, caused by HPV genotypes 6 and 11, is more common in children and presents with generalised lumpiness in the larynx and trachea. Familiarity with the condition can aid diagnosis, but biopsy is usually necessary.
Laryngeal lymphoma is extremely rare and is usually accompanied by lymphoma elsewhere in the body. Laryngeal TB can resemble carcinoma but is also very rare. Thyroid cancer presents as a thyroid lump and can also cause hoarseness, but laryngeal carcinoma is the most common cause.
In summary, when presented with a patient who is a heavy smoker and exhibiting symptoms of laryngeal pathology, an irregular mass on nasal endoscopy is highly suggestive of laryngeal carcinoma. Other conditions such as laryngeal papillomatosis, lymphoma, TB, and thyroid cancer should also be considered but are much less common. Biopsy may be necessary for a definitive diagnosis.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 17
Incorrect
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A 23-year-old male patient complains of experiencing tinnitus in his left ear for the past two weeks. He describes the sound as a buzz but denies any other accompanying ear symptoms. Upon examination, Otoscopy, Rinne, and Weber tests are all normal. What is the recommended course of action for management?
Your Answer:
Correct Answer: Urgent referral to ENT
Explanation:An urgent referral to ENT is necessary for a patient experiencing unilateral tinnitus, even if their examination appears normal. This is because it could be a sign of an acoustic neuroma and requires further investigation.
While an audiogram could provide additional information, it would not alter the management plan for a GP, which would still involve an urgent referral.
CBT, reassurance, and white noise may be appropriate for chronic bilateral tinnitus, but not for this patient with unilateral tinnitus.
Tinnitus is a condition where a person perceives sounds in their ears or head that do not come from an external source. It affects approximately 1 in 10 people at some point in their lives and can be distressing for patients. While it is sometimes considered a minor symptom, it can also be a sign of a serious underlying condition. The causes of tinnitus can vary, with some patients having no identifiable underlying cause. Other causes may include Meniere’s disease, otosclerosis, conductive deafness, positive family history, sudden onset sensorineural hearing loss, acoustic neuroma, hearing loss, drugs, and impacted earwax.
To assess tinnitus, an audiologist may perform an audiological assessment to detect any underlying hearing loss. Imaging may also be necessary, with non-pulsatile tinnitus generally not requiring imaging unless it is unilateral or there are other neurological or ontological signs. Pulsatile tinnitus, on the other hand, often requires imaging as there may be an underlying vascular cause. Management of tinnitus may involve investigating and treating any underlying cause, using amplification devices if associated with hearing loss, and psychological therapy such as cognitive behavioural therapy or joining tinnitus support groups.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 18
Incorrect
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A 62-year-old Chinese man who is a smoker visits his doctor with complaints of a constantly congested nose and bloody discharge from the nose. What type of cancer is he most susceptible to?
Your Answer:
Correct Answer: Nasopharyngeal
Explanation:Differentiating Head and Neck Cancers: Understanding Risk Factors and Symptoms
Head and neck cancers can present with a variety of symptoms, making it important to understand the risk factors associated with each type of cancer. Nasopharyngeal carcinoma, for example, is more commonly found in Southeast Asia and is thought to be caused by both genetic susceptibility and environmental factors such as heavy alcohol intake and infection with Epstein-Barr virus. Symptoms include nasal obstruction, bloodstained sputum or nasal discharge, tinnitus, headache, ear fullness, and unilateral conductive hearing loss.
Oral cancers, on the other hand, tend to present with a persistent lump in the mouth or with the patient possibly complaining of ear pain or pain on chewing. Smoking, chewing tobacco, and drinking alcohol are risk factors. Laryngeal cancers are also associated with smoking, but are more common in patients of black and white ethnicities.
Malignant parotid tumors are rare, and there is no higher prevalence in patients of South Asian descent. Thyroid cancers, which are relatively common, tend to present with an unexplained lump or swelling in the front of the neck and a hoarse voice. Risk factors include exposure to ionizing radiation, thyroiditis and other thyroid diseases, as well as genetic predisposition.
Understanding the different risk factors and symptoms associated with each type of head and neck cancer can help healthcare professionals make an accurate diagnosis and provide appropriate treatment.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 19
Incorrect
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A 42-year-old female patient complains of left-sided facial muscle weakness that has been present for 72 hours. She has no known medical conditions and is not taking any medications. The symptoms started during a camping trip, and she believes that her delay in seeking medical attention may have contributed to the severity of her condition. Upon examination, she exhibits left-sided facial nerve palsy with no forehead movement. All other cranial nerves appear normal, and there are no neurological deficits in her upper or lower limbs. What is the best course of action for managing this patient's condition?
Your Answer:
Correct Answer: Commence oral prednisolone
Explanation:The recommended treatment for this woman’s symptoms and signs of Bell’s palsy is oral prednisolone, which should be prescribed within 72 hours of symptom onset. Antiviral treatments, either alone or in combination with prednisolone, are not recommended as they have been shown to be ineffective or have weak evidence of benefit. Referring to an ENT specialist is not necessary unless there are signs of worsening neurological disturbance or systemic upset. Self-care measures alone are not sufficient and additional treatment such as eye care should be provided.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 20
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 21
Incorrect
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A 3-year-old boy is brought to the General Practitioner (GP) by his parents for a consultation. He has been diagnosed with otitis media with effusion (OME), or ‘glue ear’. Insertion of ventilation tubes (grommets) has been recommended. His parents are unsure whether to proceed and ask the GP about the benefits.
According to the National Institute for Health and Care Excellence (NICE), which of the following is most improved due to this procedure?
Your Answer:
Correct Answer:
Explanation:The Short and Long-Term Effects of Grommet Insertion for Otitis Media with Effusion
Grommet insertion is a common surgical procedure for children with otitis media with effusion (OME). However, it is important to understand the short and long-term effects of this procedure.
Short-term hearing improvement is the only proven benefit of grommet insertion, with evidence showing improvement for up to 12 months after surgery. However, the effect diminishes after six months and grommets only remain effective while they are in place, which is usually an average of ten months.
In terms of behaviour and cognitive development, there is no evidence-based association between grommet insertion and improvement. Adaptations at school, such as seating arrangements, can help with educational attainment for children with OME.
Similarly, there is little evidence that grommet insertion improves speech and language development in the long term. Instead, parents and caregivers should focus on supporting speech and language development through activities such as daily reading.
Overall, while grommet insertion can provide short-term hearing improvement, it is important to consider other factors when making decisions about treatment for OME.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 22
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 23
Incorrect
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A 20-year-old woman complains of hearing difficulties over the last six months. She initially suspected it was due to earwax, but her hearing has not improved after ear syringing. You conduct an auditory system examination, including Rinne's and Weber's tests:
Rinne's test: Left ear: air conduction > bone conduction
Right ear: air conduction > bone conduction
Weber's test: Lateralises to the left side
What is the significance of these test results?Your Answer:
Correct Answer: Right sensorineural deafness
Explanation:If there is a sensorineural issue, the sound in Weber’s test will be perceived on the healthy side (left), suggesting a problem on the affected side (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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 24
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 25
Incorrect
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You are requested to conduct a home visit for Edna, a 72-year-old woman, who reports sudden onset of dizziness that started four days ago. The dizziness has been constant since then and causes her to feel unsteady while walking. She has a medical history of migraines and rheumatoid arthritis but has never experienced similar episodes before. She consumes 21 units of alcohol per week and has never smoked.
During the examination, she can stand and walk but requires support from furniture. You attempt to perform a Romberg test, but she starts to sway as soon as she closes her eyes. Both tympanic membranes appear normal. Cranial nerve examination is unremarkable except for marked nystagmus on vertical gaze. The rest of her neurological examination is normal.
What is the most probable diagnosis?Your Answer:
Correct Answer: Cerebrovascular accident
Explanation:When experiencing sudden dizziness, it can be challenging to determine if it is caused by a cerebrovascular accident (CVA). To differentiate between central (related to the central nervous system) and peripheral (related to the inner ear) causes of vertigo, doctors look for the presence of vertical nystagmus. If present, it indicates a central cause. Other signs of a central cause include the presence of other neurological symptoms and risk factors for CVAs. Labyrinthitis and benign paroxysmal positional vertigo are peripheral causes of vertigo that would cause lateral nystagmus. A space occupying lesion may cause central vertigo, but symptoms would likely have a more gradual onset. Vestibular migraines are a central cause that can cause vertical nystagmus, but the vertigo typically lasts for 4-72 hours, so the persistence of symptoms would not fit this diagnosis.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 26
Incorrect
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A 25 year old male smoker presents with multiple, painful aphthous ulcers, he puts this down to stress at work. He only gets ulcers on his tongue and oral mucosa. He is otherwise well. He has never had any joint or bowel symptoms. He reports several previous episodes similar to this one, with painful oral ulceration lasting a week or two, dating back to when he was a teenager.
What signs or symptoms should prompt an immediate referral to secondary care for this 25 year old male smoker with recurrent painful oral ulcers?Your Answer:
Correct Answer: Unexplained red and white patches of the oral mucosa that are painful, swollen, or bleeding
Explanation:To identify potential oral ulceration red flags, one should look out for unexplained ulcers or masses in the oral mucosa that persist for more than three weeks, as well as red and white patches that are painful, swollen, or bleeding. If symptoms or signs related to the oral cavity persist for more than six weeks and a definitive diagnosis of a benign lesion cannot be made, this is also a red flag. While being a smoker is a risk factor for aphthous ulcers, first onset over the age of 30 is atypical and may warrant consideration of an alternative cause, such as trauma to the mouth. However, it is not necessarily an indication for referral. It is important to note that not all ulcers respond to corticosteroids, but if an ulcer has persisted for more than three weeks, an urgent referral is necessary as prolonged ulceration could be indicative of malignancy.
Aphthous mouth ulcers are painful sores that are circular or oval in shape and are found only in the mouth. They are not associated with any systemic disease and often occur repeatedly, usually starting in childhood. These ulcers can be caused by damage to the mouth, such as biting the cheek or brushing too hard, or may be due to a genetic predisposition. Other factors that can trigger these ulcers include stress, certain foods, stopping smoking, and hormonal changes related to the menstrual cycle.
Aphthous ulcers are characterized by their round or oval shape, a clearly defined margin, a yellowish-grey slough on the floor, and a red periphery. They usually appear on non-keratinized mucosal surfaces, such as the inside of the lips, cheeks, floor of the mouth, or undersurface of the tongue. In most cases, investigations are not necessary, but they may be considered if an underlying systemic disease is suspected.
Treatment for aphthous ulcers involves avoiding any factors that may trigger them and providing symptomatic relief for pain, discomfort, and swelling. This may include using a low potency topical corticosteroid, an antimicrobial mouthwash, or a topical analgesic. Most ulcers will heal within two weeks without leaving any scars. However, if a mouth ulcer persists for more than three weeks, it is important to seek urgent referral to a specialist.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 27
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 28
Incorrect
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A 27-year-old man urgently books an appointment at your clinic. He complains of left-sided facial pain and malaise that has been ongoing for two weeks. He mentions that his symptoms initially improved after a week, but then worsened again, and he now feels worse than he did initially. He has no significant medical history.
During the examination, you note a low-grade fever of 37.9 degrees, but all other observations are normal. Anterior rhinoscopy reveals a purulent discharge from the left middle meatus, but there are no abnormalities in the eyes or periorbital tissues.
What is the most probable diagnosis?Your Answer:
Correct Answer: Bacterial sinusitis
Explanation:The man’s symptoms suggest bacterial sinusitis, as he has experienced a double sickening where his symptoms initially improved but then suddenly worsened. This is often caused by a secondary bacterial infection following a viral rhinosinusitis. The presence of a fever and purulent discharge seen on rhinoscopy further support this diagnosis.
Trigeminal neuralgia would not cause a fever, while sialadenitis would result in swelling of only one salivary gland. Cavernous sinus thrombosis is a rare complication of bacterial sinusitis and is not likely in this case.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 29
Incorrect
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A 35-year-old male visits his GP with a complaint of persistent nasal discharge on his right side and facial pressure that worsens when he bends forward. He frequently breathes through his mouth because his nose is obstructed. He has a history of asthma and has been smoking for 6 pack-years.
What is the best course of action for management?Your Answer:
Correct Answer: Referral to ENT
Explanation:Unilateral symptoms should raise concern for patients with chronic rhinosinusitis. The typical presentation includes facial pain, frontal pressure worsened by bending forward, clear nasal discharge (if due to allergies), and difficulty breathing through the nose. Post-nasal drip may also cause a chronic cough. However, if the symptoms are only on one side, it is considered a red flag and warrants a referral to an ENT specialist. The standard management for chronic sinusitis involves avoiding allergens, using intranasal corticosteroids, and irrigating the nasal passages with saline solution. Loratadine may be helpful if the cause is related to allergies.
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.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 30
Incorrect
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A 50-year-old man comes to the clinic for a follow-up of tests for hearing loss, which were arranged by another physician in the same practice. He works as a construction worker and attributes his hearing difficulties to years of exposure to loud machinery. He has no significant medical history.
Upon further questioning, he reports that his hearing loss and tinnitus only affect his left ear, while his right ear seems normal. The problem has been gradually worsening over the past six months. The hearing test confirms no hearing loss affecting the right ear.
What is the most appropriate next step?Your Answer:
Correct Answer: Contrast MRI brain
Explanation:Consider Acoustic Neuroma in Patients with Unilateral Hearing Loss and Tinnitus
Whilst acoustic neuroma is a rare condition, it should be considered in patients who present with unilateral hearing loss and tinnitus, especially if the other ear appears unaffected. A contrast MRI brain is the most appropriate next step to confirm or rule out the diagnosis.
In contrast to Ménière’s disease, which is a possible differential diagnosis but usually not associated with unilateral signs, symptoms of vertigo are not prominent in acoustic neuroma. Therefore, trials of vestibular suppressants such as betahistine are ineffective, and prochlorperazine is not recommended.
It is important to note that hearing loss in acoustic neuroma is progressive, and choosing a hearing aid option may delay intervention. Therefore, prompt diagnosis and treatment are crucial to prevent further complications.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 31
Incorrect
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A 56-year-old woman with a history of hypertension visits the surgery with a complaint of hoarseness that has been present for 3 weeks. The hoarseness started after she had an upper respiratory tract infection 7 weeks ago. She is in good health and doesn't smoke. What is the best course of action for management?
Your Answer:
Correct Answer: Urgent referral to ear, nose and throat
Explanation:Hoarseness can be caused by various factors such as overusing the voice, smoking, viral infections, hypothyroidism, gastro-oesophageal reflux, laryngeal cancer, and lung cancer. It is important to investigate the underlying cause of hoarseness, and a chest x-ray may be necessary to rule out any apical lung lesions.
If laryngeal cancer is suspected, it is recommended to refer the patient to an ENT specialist through a suspected cancer pathway. This referral should be considered for individuals who are 45 years old and above and have persistent unexplained hoarseness or an unexplained lump in the neck. Early detection and treatment of laryngeal cancer can significantly improve the patient’s prognosis.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 32
Incorrect
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A 25-year-old man presents with an obvious broken nose and an inability to breathe through either nostril. Examination reveals a cherry-red swelling in both nasal airways.
What is the best course of action for management?Your Answer:
Correct Answer: Review immediately for examination under anaesthetic
Explanation:This patient has a condition called septal hematoma, which can lead to a hole in the septum if not treated promptly. This happens because the hematoma restricts blood flow to the cartilage and can become infected. To diagnose this condition, a doctor will use a nasal speculum or otoscope to look for asymmetry and swelling in the septum. They may also need to feel the septum with a gloved finger. Septal hematoma is usually caused by significant facial trauma in adults, but even minor nasal trauma can cause it in children. If a child has this condition, it may be a sign of abuse. Immediate drainage under anesthesia is necessary to prevent long-term damage.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 33
Incorrect
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A 35-year-old male patient complains of constant sneezing, nasal congestion, and a persistent runny nose. What is not considered a part of the treatment plan for allergic rhinitis?
Your Answer:
Correct Answer: Oral decongestants
Explanation:Understanding Allergic Rhinitis
Allergic rhinitis is a condition that causes inflammation in the nose due to sensitivity to allergens such as dust mites, grass, tree, and weed pollens. It can be classified into seasonal, perennial, or occupational, depending on the timing and cause of symptoms. Seasonal rhinitis, which occurs due to pollens, is commonly known as hay fever. Symptoms of allergic rhinitis include sneezing, bilateral nasal obstruction, clear nasal discharge, post-nasal drip, and nasal pruritus.
The management of allergic rhinitis involves allergen avoidance and medication. For mild-to-moderate intermittent or mild persistent symptoms, oral or intranasal antihistamines may be prescribed. For moderate-to-severe persistent symptoms or if initial drug treatment is ineffective, intranasal corticosteroids may be recommended. In some cases, a short course of oral corticosteroids may be necessary to cover important life events. Topical nasal decongestants, such as oxymetazoline, may also be used for short periods, but prolonged use can lead to tachyphylaxis and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) upon withdrawal.
In summary, allergic rhinitis is a common condition that can cause discomfort and affect daily life. Understanding the different types of allergic rhinitis and its symptoms can help in managing the condition effectively. It is important to consult a healthcare professional for proper diagnosis and treatment.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 34
Incorrect
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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.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 35
Incorrect
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A 51-year-old woman presents with a two-week history of difficulty swallowing solid foods, particularly meat. She experiences discomfort at the lower end of the sternum and has trouble shifting it almost immediately after swallowing. The patient has a longstanding history of GORD and has intermittently taken omeprazole 20 mg/day for the past decade. She has not experienced any weight loss or vomiting. What is the best course of action for managing this patient's symptoms?
Your Answer:
Correct Answer: Refer urgently for direct access upper GI endoscopy
Explanation:Urgent Referral Needed for New Onset Dysphagia
The sudden onset of dysphagia, even in patients with a long history of GORD and dyspepsia, requires an urgent referral for upper GI endoscopy within two weeks. Delaying the referral can lead to serious complications and worsen the patient’s condition. Therefore, all other options apart from an urgent referral should be avoided. It is crucial to prioritize the patient’s health and well-being by promptly addressing any new symptoms that arise. Proper diagnosis and treatment can prevent further complications and improve the patient’s quality of life.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 36
Incorrect
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Choose from the options below the one that is an appropriate reason for ROUTINE referral to the nearby ENT department for a patient in their 60s.
Your Answer:
Correct Answer: An intermittent feeling of ‘something stuck in the throat’
Explanation:Urgent Referral Criteria for Suspicious Symptoms
When it comes to identifying potentially serious health issues, it’s important to know which symptoms require urgent referral. In the case of the last three presentations, all of them are recognized as needing immediate attention under the 2-week-wait criteria. However, it’s worth noting that acute otitis externa can typically be managed in primary care.
In terms of the throat symptom, it’s important to conduct a flexible laryngoscopy examination of the pharynx, which means that a non-urgent referral is necessary. The intermittent nature of the symptom suggests that it may be a benign problem, such as a globus sensation.
If you’re concerned about cancer, it’s worth checking out the external links for more information on upper gastrointestinal tract cancers and head and neck cancers. By staying informed and knowing when to seek medical attention, you can help ensure that you receive the care you need when you need it most.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 37
Incorrect
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You plan to study whether a simple intervention sheet for elderly patients telling them why they are not receiving antibiotics for throat infections impacts on returns to the surgery and burden of illness with respect to complications.
Which of the following statements is correct concerning this study?Your Answer:
Correct Answer: Approval for the study must be obtained from the local ethics committee
Explanation:Ethical Considerations for a Retrospective Research Study
This is not an audit, but rather a retrospective research study aimed at examining the impact of an intervention on both the burden of illness and local resource use. As such, it is necessary to obtain approval from the local ethical committee before proceeding with the study. While the study appears reasonable, it is important to note that the outcomes may differ from those of other studies, even if published elsewhere. Therefore, it may be beneficial to include a few more surgeries to increase the sample size.
It is justifiable to use the same methods as another study to validate the original publication. However, it is not necessary to obtain consent from the original authors if a similar study has already been published. Overall, it is important to consider the ethical implications of conducting a retrospective research study and to ensure that all necessary approvals are obtained before proceeding.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 38
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 39
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 40
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 41
Incorrect
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A 22-month-old girl comes in with mild unilateral ear pain that started yesterday. She keeps tugging at her left ear. There is no discharge. She has no rashes and is still eating and drinking normally. She has not had any fevers.
During the examination, her temperature is 36.9ºC and her pulse is 105 beats per minute. She appears to be in good health. Both of her ears appear to be normal.
What is the best course of action for treatment?Your Answer:
Correct Answer: Monitor symptoms
Explanation:This young boy is experiencing earache on one side for the past 24 hours. However, the rest of his medical history is normal and there are no signs of infection during the examination. The recommended management approach is to advise the use of pain relief medication such as paracetamol and ibuprofen for relief of symptoms and to monitor the situation. If the diagnosis is otitis externa, acetic acid spray and flucloxacillin can be used. For bilateral otitis media that has persisted for at least 4 days, amoxicillin is recommended. For children over 2 years of age, the British National Formulary suggests the use of dexamethasone, neomycin, and acetic acid spray.
In 2008, NICE released guidelines for the management of respiratory tract infections in primary care, specifically focusing on the prescribing of antibiotics for self-limiting infections in both adults and children. The guidelines recommend a no antibiotic or delayed antibiotic prescribing approach for acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis, and acute cough/acute bronchitis. However, an immediate antibiotic prescribing approach may be considered for certain patients, such as children under 2 years with bilateral acute otitis media or patients with acute sore throat/acute pharyngitis/acute tonsillitis who have 3 or more Centor criteria present. The guidelines also suggest advising patients on the expected duration of their respiratory tract infection. If a patient is deemed at risk of developing complications, an immediate antibiotic prescribing policy is recommended. This includes patients who are systemically unwell, have symptoms and signs suggestive of serious illness and/or complications, or are at high risk of serious complications due to pre-existing comorbidity.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 42
Incorrect
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A 60-year-old male presents to his GP with complaints of severe ear pain. He reports experiencing pain and white discharge from his left ear for the past two weeks, along with a feeling of dulled hearing. The patient has a medical history of glaucoma, hypertension, and type two diabetes, with a recent HbA1c of 59 mmol/mol.
During the examination, the patient appears to be in discomfort. The right ear appears normal, but the left external auditory canal is swollen and painful to examine, with copious amounts of white discharge. There is no swelling or erythema affecting the pinna nor mastoid. Cranial nerve exam detects a conductive hearing loss in the left ear and a subtle inability to wrinkle the forehead on the left. The patient is afebrile with a blood pressure of 142/96 mmHg.
What is the most appropriate course of action for managing this patient's symptoms?Your Answer:
Correct Answer: Arrange urgent admission for intravenous antibiotics, imaging
Explanation:If a patient has unilateral ear discharge and a facial nerve palsy on the left side, it is more likely to be a case of malignant otitis externa. This is a serious condition where the infection has spread to the temporal bone and can affect the facial nerve. The pain associated with this condition is severe and persistent, often waking the patient at night. Malignant otitis externa can be life-threatening in severe cases, and immediate referral to an ENT specialist for intravenous antibiotics and imaging is necessary.
Malignant Otitis Externa: A Rare but Serious Infection
Malignant otitis externa is a type of ear infection that is uncommon but can be serious. It is typically found in individuals who are immunocompromised, with 90% of cases occurring in diabetics. The infection starts in the soft tissues of the external auditory meatus and can progress to involve the soft tissues and bony ear canal, eventually leading to temporal bone osteomyelitis.
Key features in the patient’s history include diabetes or immunosuppression, severe and persistent ear pain, temporal headaches, and purulent otorrhea. In some cases, patients may also experience dysphagia, hoarseness, and facial nerve dysfunction.
Diagnosis is typically done through a CT scan, and non-resolving otitis externa with worsening pain should be referred urgently to an ENT specialist. Treatment involves intravenous antibiotics that cover pseudomonal infections.
In summary, malignant otitis externa is a rare but serious infection that requires prompt diagnosis and treatment. Patients with diabetes or immunosuppression should be particularly vigilant for symptoms and seek medical attention if they experience persistent ear pain or other related symptoms.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 43
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 44
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 45
Incorrect
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A 28-year-old male patient comes in with a recent onset headache that has been bothering him for the past 5 days. He reports experiencing facial pain, fevers, a dry cough, thin yellow discharge from his nose, and nasal congestion. His temperature is normal at 37.4ºC and he experiences pain when pressure is applied to his maxillary area.
Based on the probable diagnosis, what would be the best course of treatment?Your Answer:
Correct Answer: Analgesia
Explanation:For this patient with acute sinusitis, analgesia is the most appropriate treatment to alleviate facial pain. Cefalexin, a broad-spectrum antibiotic, is not typically recommended for sinusitis, especially if it is suspected to be caused by a viral trigger. Intranasal corticosteroids should only be considered for chronic sinusitis or if symptoms persist for 10 days or more. Intranasal decongestants can provide short-term relief for nasal symptoms, but their long-term use can lead to dependence. Therefore, simple analgesia is the best option for this patient.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 46
Incorrect
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You have a follow-up appointment with a 4-year-old boy. He was seen two weeks ago for left-sided ear pain and discharge, for which you prescribed amoxicillin. Today, his mother reports that he has improved and she has been able to keep his ear dry. However, upon examination of the left ear, a tympanic membrane perforation is observed. What should be done next?
Your Answer:
Correct Answer: Advise to keep ear dry and see in a further 4 weeks time
Explanation:Perforated Tympanic Membrane: Causes and Management
A perforated tympanic membrane, also known as a ruptured eardrum, is often caused by an infection but can also result from barotrauma or direct trauma. This condition can lead to hearing loss and increase the risk of otitis media.
In most cases, no treatment is necessary as the tympanic membrane will typically heal on its own within 6-8 weeks. However, it is important to avoid getting water in the ear during this time. Antibiotics may be prescribed if the perforation occurs after an episode of acute otitis media. This approach is supported by the 2008 Respiratory Tract Infection Guidelines from NICE.
If the tympanic membrane doesn’t heal by itself, myringoplasty may be performed. This surgical procedure involves repairing the perforation with a graft of tissue taken from another part of the body. With proper management, a perforated tympanic membrane can be successfully treated and hearing can be restored.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 47
Incorrect
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A 30 year old female smoker presents with painful aphthous ulcers and has been using a topical analgesic (benzydamine hydrochloride gel) for 3 weeks without relief. There is no indication of joint or bowel issues in her medical history or physical examination. She is in good health otherwise. What would be the most suitable course of action to take next?
Your Answer:
Correct Answer: Refer urgently to secondary care
Explanation:If an oral ulcer persists for more than 3 weeks without explanation, it is important to refer the patient to secondary care urgently to rule out the possibility of malignancy. While smoking is a risk factor for both oral malignancy and aphthous ulcers, it is not a reason for referral. Interestingly, quitting smoking can actually make aphthous ulcers worse. Over-the-counter local analgesics like Difflam (benzydamine hydrochloride) and Bonjela can provide relief from symptoms, but there is no evidence that they can reduce the frequency or duration of ulceration. Some evidence suggests that antibacterial mouthwashes (such as chlorhexidine) and topical corticosteroids (such as hydrocortisone oromucosal tablets) can help to shorten the duration and severity of symptoms, but they do not reduce the frequency of recurrence.
Aphthous mouth ulcers are painful sores that are circular or oval in shape and are found only in the mouth. They are not associated with any systemic disease and often occur repeatedly, usually starting in childhood. These ulcers can be caused by damage to the mouth, such as biting the cheek or brushing too hard, or may be due to a genetic predisposition. Other factors that can trigger these ulcers include stress, certain foods, stopping smoking, and hormonal changes related to the menstrual cycle.
Aphthous ulcers are characterized by their round or oval shape, a clearly defined margin, a yellowish-grey slough on the floor, and a red periphery. They usually appear on non-keratinized mucosal surfaces, such as the inside of the lips, cheeks, floor of the mouth, or undersurface of the tongue. In most cases, investigations are not necessary, but they may be considered if an underlying systemic disease is suspected.
Treatment for aphthous ulcers involves avoiding any factors that may trigger them and providing symptomatic relief for pain, discomfort, and swelling. This may include using a low potency topical corticosteroid, an antimicrobial mouthwash, or a topical analgesic. Most ulcers will heal within two weeks without leaving any scars. However, if a mouth ulcer persists for more than three weeks, it is important to seek urgent referral to a specialist.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 48
Incorrect
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A 27-year-old patient comes in for an emergency appointment reporting left-sided ear pain for the past two days. Upon waking up today, she noticed that her face was drooping on the left side and she was unable to fully close her left eye. Based on these symptoms, you suspect a diagnosis of Bell's Palsy. If you were to ask the patient to raise her left eyebrow, what would you expect to find and why?
Your Answer:
Correct Answer: Inability to raise the left eyebrow as Bell's palsy is due to a lower motor neuron lesion
Explanation: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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 49
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 50
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 51
Incorrect
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Olivia is a 42-year-old woman who came to see you 6 weeks ago with vertigo following a viral infection. You diagnosed vestibular neuronitis and prescribed a course of prochlorperazine for symptom control.
Olivia comes to see you today with ongoing vertigo. This improved with prochlorperazine but she still experiences attacks of vertigo which usually last hours. There are no new symptoms and neurological examination is normal.
What is the most important aspect of ongoing management for Olivia?Your Answer:
Correct Answer: Refer for vestibular rehabilitation exercises
Explanation:Vestibular rehabilitation exercises are the recommended treatment for chronic symptoms in vestibular neuronitis, as they are both safe and effective in improving functioning in the medium term. It is important to avoid prolonged use of medication, as it may interfere with the body’s compensatory mechanisms and delay recovery. While a short course of promethazine may help with symptom control, it is unlikely to provide long-term relief for vertigo. Betahistine is only indicated for vertigo, tinnitus, and hearing loss associated with Ménière’s disease, and is therefore not appropriate for Marcus’s case. Hospital admission is not necessary, as Marcus is not acutely unwell and his symptoms are likely to resolve within a few weeks. However, it is important to refer chronic or recurrent cases for further evaluation to rule out any underlying serious conditions.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 52
Incorrect
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A 25-year-old patient presents to you with concerns about burning and irritation of their tongue, as well as rapid changes in its color. Upon examination, you observe multiple irregular but smooth red plaques on the dorsum of their tongue. The patient is anxious about these changes and seeks your advice.
What is the most probable diagnosis in this case?Your Answer:
Correct Answer: Geographic tongue
Explanation:Common Oral Conditions and Their Symptoms
Geographic tongue is a common oral condition that presents with mild burning and irritation of the tongue. It is characterized by single or multiple well-demarcated irregular but smooth red plaques on the dorsum of the tongue. Stress and spicy food may exacerbate the condition.
Angular chelitis, on the other hand, presents with irritation of the corners of the lips and dryness. Aphthous stomatitis describes solitary or multiple painful ulcers on the mucosal membranes. Oral hairy leukoplakia is an asymptomatic white thickening and accentuation of the folds of the lateral margins of the tongue.
Lastly, acute necrotising ulcerative gingivitis presents with punched-out ulcers, necrosis, and bleeding of areas between teeth. It is important to be aware of these common oral conditions and their symptoms to seek appropriate management and treatment.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 53
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 54
Incorrect
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A 25-year-old man comes to his General Practitioner complaining of a painful discharging right ear and a mild unilateral right-sided hearing loss that has been going on for 3 days. During examination, the doctor observes an intact tympanic membrane and copious purulent liquid discharge. The patient has a normal heart rate of 70 bpm and is not running a fever.
What is the most suitable course of action for this patient?Your Answer:
Correct Answer: Prescribe topical antibiotics
Explanation:Management Options for Otitis Externa
Otitis externa is a common condition characterized by pain, itching, and discharge in the ear canal. Here are some management options for this condition:
Prescribe Topical Antibiotics: Topical antibiotics are the first-line treatment for otitis externa. Neomycin or clioquinol are recommended, and they may be combined with a topical corticosteroid if there is inflammation and eczema. Aminoglycosides should be used cautiously as second line if there is perforation of the eardrum.
Prescribe Oral Antibiotics: Oral antibiotics may be necessary if the patient is systemically unwell or there is preauricular lymphadenitis or cellulitis. Flucloxacillin or erythromycin is the drug of choice.
Refer to Ear, Nose and Throat (ENT) for Ear Wick Insertion: If there is extensive swelling of the auditory canal, an ear wick may be used. This is impregnated with antibiotic-steroid combination and is inserted into the auditory canal. However, if the tympanic membrane is visible, topical antibiotics would be the first-line treatment.
Prescribe Analgesia Only: Paracetamol or ibuprofen is usually sufficient for analgesia in cases of otitis externa. However, analgesia should be used in combination with antibiotics to aid in curing and preventing the worsening of symptoms.
Do Not Prescribe Topical Antifungals: Topical antifungals are not indicated in simple cases of otitis externa. They may be necessary if there is a secondary fungal infection, but this is not described in this case.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 55
Incorrect
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A 5-year-old girl is brought to the GP clinic by her mother. She is on day 7 post-tonsillectomy and was recovering well until this morning when her mother noticed a small amount of blood on her pillow and fresh red blood in her mouth. Upon examination, the girl appears to be in good health, but there is a blood clot in her right tonsillar fossa with no active bleeding. Her vital signs are as follows:
Systolic blood pressure: 100 mmHg (normal range: 75-110)
Pulse: 96 bpm (normal range: 80-150)
Temperature: 36.8ºC (normal range: 35.5-37.5)
Respiratory rate: 24/min (normal range: 17-30)
What is the appropriate course of action?Your Answer:
Correct Answer: Immediate referral to ENT
Explanation:ENT assessment is necessary for all cases of post-tonsillectomy haemorrhage.
Any haemorrhage occurring more than 24 hours after a tonsillectomy is considered a secondary haemorrhage and can be life-threatening. Therefore, it is crucial that all patients are managed by ENT in a hospital setting. Children may have difficulty quantifying blood loss as they may swallow the blood, making bleeding less noticeable.
It is incorrect to review the patient in 24 hours as this is an emergency situation. Similarly, reassuring the patient or referring them to paediatrics is not appropriate. Although tranexamic acid may be helpful, hospital admission is necessary for this surgical emergency and should be managed by ENT.
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.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 56
Incorrect
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A 38-year-old man visits his primary care physician complaining of persistent blockage of his right nostril, accompanied by sneezing and rhinorrhea, six weeks after recovering from a cold. Upon examination, a large polyp is observed in the right nostril, while the left nostril appears normal. What is the most suitable course of action for managing this condition?
Your Answer:
Correct Answer: Urgent referral to ENT
Explanation: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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 57
Incorrect
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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.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 58
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 59
Incorrect
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A 45-year-old woman comes to your GP clinic complaining of recurrent episodes of dizziness, which she describes as a sensation of the room spinning. She has experienced five such episodes in the past month, each lasting for one or two days and accompanied by nausea, which has prevented her from going to work. She reports no symptoms between episodes and has a history of migraines in her 20s but is otherwise healthy. During these episodes, she is sensitive to loud noises but denies any hearing loss or tinnitus. Neurological examination, Dix-Hallpike, and examination of both ear canals are unremarkable. What is the most likely diagnosis?
Your Answer:
Correct Answer: Vestibular migraine
Explanation:Consider vestibular migraine as a possible cause of episodic vertigo in patients with a history of migraines. The timing and duration of vertigo symptoms can help differentiate between different causes. Benign paroxysmal positional vertigo typically causes brief episodes of vertigo, while Meniere’s disease causes longer episodes with accompanying hearing loss, tinnitus, or ear fullness. Labyrinthitis and vestibular neuronitis can cause sudden onset of constant vertigo, but not the episodic nature described in this case. Given the duration, episodic nature, phonophobia, and history of migraines, vestibular migraine is the most likely diagnosis. The International Classification of Headache Disorders provides diagnostic criteria for vestibular migraine, including a history of migraines and moderate to severe vestibular symptoms lasting between 5 minutes and 72 hours, with at least half of the episodes associated with migrainous features such as headache, photophobia, phonophobia, or visual aura. Other potential causes should be ruled out.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 60
Incorrect
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A 6-year-old girl with Down syndrome is brought to see the General Practitioner by her mother who is concerned that she seems to be struggling to hear normal volume voices on the television and in conversation. On examination she is afebrile and there is a loss of the light reflex on both tympanic membranes.
Which of the following is the most appropriate management plan?
Your Answer:
Correct Answer: Refer to Ear, Nose and Throat (ENT) specialist
Explanation:The patient is showing classic signs of bilateral otitis media with effusion, which is common in children with Down syndrome or a cleft palate. The NICE recommends immediate referral to an ENT specialist for children with these conditions presenting with otitis media with effusion. For other children, watchful waiting for three months is advised, with hearing tests and tympanometry carried out during this period. Antibiotics are not recommended for the treatment of otitis media with effusion, and topical antibiotics have no role in treatment. Intranasal corticosteroids are not recommended for this condition, as their efficacy has not been proven.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 61
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 62
Incorrect
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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.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 63
Incorrect
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You see a 65-year-old man with vertigo. He describes the repeated sensation that his surroundings are spinning when he moves his head. This has been occurring for the last 2 weeks and the episodes last approximately 30 seconds. He has hypertension but no other past medical history. He had a viral illness 3 weeks ago. You believe the history is consistent with benign paroxysmal positional vertigo (BPPV).
Which statement is correct regarding BPPV?Your Answer:
Correct Answer: BPPV often has a relapsing and remitting course
Explanation:BPPV can have a recurrent pattern of symptoms that come and go. To diagnose BPPV, the Dix-Hallpike maneuver is used, which can trigger vertigo and a specific type of eye movement called torsional upbeating nystagmus. Treatment for BPPV includes the Epley maneuver and Brandt-Daroff exercises, but medication is typically not effective. While many people recover from BPPV within a few weeks, symptoms can persist and return over time.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 64
Incorrect
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A 25-year-old female patient comes in for a follow-up appointment one week after being prescribed a combination antibiotic and steroid spray for otitis externa. Despite the medication, her symptoms have not improved and the redness has spread to her ear. What is the recommended course of treatment?
Your Answer:
Correct Answer: Oral flucloxacillin
Explanation:When the erythema spreads, it is a sign that oral antibiotics are necessary. The preferred initial treatment is Flucloxacillin.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 65
Incorrect
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Samantha is a 7-year-old girl who has presented with impacted earwax which has failed to improve with olive oil drops. Ear irrigation has been recommended.
Which of the following would be a contraindication to this?Your Answer:
Correct Answer: Grommets in situ
Explanation:Ear irrigation should not be performed on patients with grommets as it is a contraindication. Additionally, individuals who have had otitis media within the past 6 weeks should also avoid ear irrigation. However, there are no other listed conditions that would prevent someone from undergoing this procedure.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 66
Incorrect
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A 22-year-old male with a past history of depression is brought by his roommate to the emergency room with an overdose of an unknown substance.
His roommate found him unconscious in their apartment this morning and immediately called for an ambulance. There was an empty bottle of unlabelled pills on the kitchen counter which the patient admitted to taking.
The patient is currently unresponsive and has shallow breathing. He is hooked up to a ventilator and his vital signs are being closely monitored. There is evidence of recent vomiting and he has a high fever.
The patient has a history of suicidal ideation and his roommate is not sure where he obtained the pills from. Which of the following has he taken in overdose?Your Answer:
Correct Answer: Aspirin
Explanation:Aspirin Overdose: Symptoms and Management
Aspirin overdose can be potentially fatal, as its effects are dose-related. Unlike with paracetamol, there are many early clinical features of aspirin overdose. These include nausea and vomiting, sweating, hyperventilation, vertigo, and tinnitus. More severe manifestations of overdose include lethargy, coma, seizures, hypotension, heart block, and pulmonary edema.
Immediate referral to the hospital and close monitoring with supportive measures are necessary for managing aspirin overdose. In severe cases, dialysis may be indicated.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 67
Incorrect
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A 32-year-old male surfer from Australia presents with recurrent ear infections. He has recently moved to the US and is generally healthy. The patient complains of difficulty in removing water from his ears after a shower and left ear discomfort. Upon examination, there appears to be an object protruding into the canal in the left ear, obstructing a clear view of the tympanic membrane. The right tympanic membrane appears normal, and there is no inflammation in either canal. What is the probable diagnosis?
Your Answer:
Correct Answer: Exostosis (Surfer's ear)
Explanation:The bony protrusion observed in the left ear canal is known as an exostosis or a bone prominence. Although spending a lot of time in water may increase the risk of otitis externa, the patient doesn’t exhibit the typical signs of inflamed canals or debris. Cholesteatoma, which is characterized by a foul-smelling discharge and an abnormality in the attic, is also ruled out as it is not evident on examination. Wax or foreign body are not considered as they were not found during the examination.
Surfer’s Ear: A Condition Caused by Repeated Exposure to Cold Water
Surfer’s ear, also known as exostosis, is a condition that occurs as a result of repeated exposure to cold water. This condition is commonly seen in surfers, divers, and kayakers, and is more prevalent in countries such as New Zealand and the USA. However, cases have also been reported in some areas of the United Kingdom, such as Cornwall. Patients with surfer’s ear may experience recurrent ear infections, reduced hearing, and water plugging.
Surfer’s ear is a progressive condition, and it is essential to take preventative measures to avoid repeated exposure. Wearing hoods, ear plugs, or swim caps can help to protect the ears from cold water. In severe cases, surgery may be necessary to remove the bony growths that have developed in the ear canal. By taking the necessary precautions, individuals can reduce their risk of developing surfer’s ear and prevent further complications.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 68
Incorrect
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A 15-year-old girl comes to your clinic with her father for an urgent appointment. Yesterday, while playing basketball, she injured her left ear. Initially, she didn't feel much discomfort and continued playing. However, this morning she woke up with a swollen left ear. She reports no hearing loss or discharge from the ear. She appears to be in good health.
Upon examination, you notice a significant hematoma on her left ear. Otoscopy reveals no damage to the eardrum, and basic hearing tests are normal.
What is the most appropriate course of action?Your Answer:
Correct Answer: Refer for same day ENT assessment
Explanation:If you have an auricular hematoma, it is important to seek assessment by an ENT specialist on the same day. These hematomas are often caused by injuries sustained during rugby or boxing, and if left untreated, can result in a deformity known as cauliflower ear. To achieve the best results, it is recommended to undergo early incision and drainage rather than needle aspiration, which is why immediate referral to an ENT specialist is necessary.
Auricular haematomas are frequently observed in individuals who participate in rugby or wrestling. It is crucial to seek immediate medical attention to prevent the development of ‘cauliflower ear’. The management of auricular haematomas necessitates an evaluation by an ENT specialist on the same day. Incision and drainage have been demonstrated to be more effective than needle aspiration.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 69
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 70
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 71
Incorrect
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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.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 72
Incorrect
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You see a 30-year-old man who reports an acute onset of reduced hearing in his left ear. This started suddenly yesterday. He is otherwise well with no ear pain, fevers or systemic upset. Examination of ears and cranial nerves were unremarkable.
Which is the most appropriate next step in management?Your Answer:
Correct Answer: Refer to on-call ENT team
Explanation:NICE Guidelines for Managing Sudden Hearing Loss in Adults
The National Institute for Health and Care Excellence (NICE) released guidelines in June 2018 to provide recommendations on managing sudden or rapid onset hearing loss in adults. This type of hearing loss is not explained by external or middle ear causes.
According to the guidelines, an immediate referral is recommended if the hearing loss developed suddenly within the past 30 days. If the hearing loss developed suddenly but it has been over 30 days or if it worsened rapidly, a two-week wait referral is advised. The guidelines also provide further recommendations if there are additional symptoms or signs such as facial droop.
It is important to note that NICE defines sudden hearing loss as within 3 days and rapid worsening as 4-90 days. These guidelines aim to improve the management and treatment of sudden hearing loss in adults.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 73
Incorrect
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What is the correct option regarding nasal polyps?
Your Answer:
Correct Answer: Have a pinkish red appearance
Explanation:Nasal Polyps: Causes, Symptoms, and Treatment
Nasal polyps are growths that develop in the nasal passages, with the majority arising in the ethmoid sinuses. While allergy is the main cause, there may also be an infective component. Antrochoanal polyps, which are associated with chronic infection, are much rarer and arise from the maxillary sinuses. These growths have a yellowish-grey appearance, and any pink or red polyps should be regarded as suspicious.
Symptoms of nasal polyps include blockage of the nasal passages, leading to anosmia or loss of smell. Treatment typically involves the use of topical steroids, which can help to reduce the size of the polyps. However, surgical removal may be necessary in some cases, and recurrence is common. While smell is usually restored after treatment, it may not always be fully regained. Overall, understanding the causes, symptoms, and treatment options for nasal polyps can help individuals to manage this condition effectively.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 74
Incorrect
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A 2-year-old girl is brought to the clinic by her mother. She has a history of recurrent otitis media and has been touching her right ear frequently for the past 3 days. She was restless and had a fever overnight, and now has a red, boggy swelling behind her right ear that is more prominent than on the left. During the examination, the child appears unhappy, with a temperature of 39.2ºC, a heart rate of 170 beats/minute, and a respiratory rate of 28 breaths/minute. Due to her distress, it is difficult to examine her ears, but the left ear canal and tympanic membrane appear normal, while the right ear canal and tympanic membrane appear red. What is the most probable diagnosis?
Your Answer:
Correct Answer: Mastoiditis
Explanation:Mastoiditis is a bacterial infection that is particularly serious and commonly affects children. It often occurs as a result of prolonged otitis media. The infection can cause the porous bone to deteriorate, and severe cases may require surgery and intravenous antibiotics. Acute otitis media is an infection of the inner ear and typically doesn’t cause swelling. However, mastoiditis can develop as a complication of otitis media. The patient in question has no history of trauma that could explain the described swelling, which is also not in the correct location to be a parotid swelling. While lymphadenitis can cause an erythematous swelling, it is usually described as soft, fluctuant, and tender and is typically found post auricularly rather than over the mastoid process.
In 2008, NICE released guidelines for the management of respiratory tract infections in primary care, specifically focusing on the prescribing of antibiotics for self-limiting infections in both adults and children. The guidelines recommend a no antibiotic or delayed antibiotic prescribing approach for acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis, and acute cough/acute bronchitis. However, an immediate antibiotic prescribing approach may be considered for certain patients, such as children under 2 years with bilateral acute otitis media or patients with acute sore throat/acute pharyngitis/acute tonsillitis who have 3 or more Centor criteria present. The guidelines also suggest advising patients on the expected duration of their respiratory tract infection. If a patient is deemed at risk of developing complications, an immediate antibiotic prescribing policy is recommended. This includes patients who are systemically unwell, have symptoms and signs suggestive of serious illness and/or complications, or are at high risk of serious complications due to pre-existing comorbidity.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 75
Incorrect
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A 5-year-old girl attends surgery with a febrile illness. Her mother tells you that she has been unwell for almost 24 hours and has been complaining of right-sided ear pain. The child is usually healthy with no significant past medical history.
On examination you find a temperature of 38.5°C and the right eardrum is red and bulging. The rest of the clinical examination is unremarkable.
What is the most suitable course of action?Your Answer:
Correct Answer: Advice on symptomatic treatment should be given with a delayed antibiotic script (antibiotic to be collected at parents' discretion after 72 hours if the child has not improved) as back up
Explanation:Middle Ear Infection Caused by Upper Respiratory Tract Infection
The bacteria responsible for an upper respiratory tract infection (URTI) can travel up the eustachian tubes and cause an infection in the middle ear. This can lead to the tympanic membrane becoming retracted, making the handle and short process of the malleus more prominent. As pressure builds up in the middle ear, the eardrum may become distended and bulge outwards, accompanied by severe otalgia, systemic toxicity, fever, and tachycardia.
If the tympanic membrane perforates, severe pain followed by a sudden improvement is likely to occur. The raised pressure within the middle ear is the main cause of the severe pain, often accompanied by systemic symptoms. Once the tympanic membrane ruptures, the pressures will equalize, and the pain will decrease dramatically. For more information on acute otitis media, visit the NICE Clinical Knowledge Summaries website.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 76
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 77
Incorrect
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What are the indications for tonsillectomy?
Your Answer:
Correct Answer: Parental pressure
Explanation:Indications for Tonsillectomy
The SIGN guidelines for tonsillectomy have been updated to suggest seven acute attacks of proven tonsillitis in one year or five in each of two successive years as an indication for the procedure. Weight loss alone is not a sufficient indication, but complications such as nephritis and rheumatic fever, as well as peritonsillar abscess, are. Children with obstructive sleep apnoea have also been shown to benefit from tonsillectomy. Malignancy is an absolute indication. However, three attacks in two years and two attacks in two months are considered too short a period to warrant tonsillectomy. It is important to note that while children may experience an improvement in general health post-tonsillectomy, weight loss alone is not a valid indication for the procedure.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 78
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 79
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 80
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 81
Incorrect
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You see a 40-year-old male patient with right sided facial paralysis. It started about 3 days ago and has slowly become worse. He is unable to raise his right forehead, close his right eye or move the right-hand side of his mouth. He has also noticed that his taste has been altered on the right-hand side of his tongue.
He is not particularly worried about it as it happened 12 months ago and you diagnosed Bell's palsy. He would like some more treatment as he feels it helped his recovery last time. He is normally fit and well and has no allergies.
You arrange to see the patient in your afternoon clinic to examine him.
Regarding Bell's palsy, which statement below is correct?Your Answer:
Correct Answer: A patient with a recurrent Bell's palsy needs urgent referral to ENT
Explanation:Referral to ENT is urgently needed for a patient experiencing recurrent Bell’s palsy. Treatment with corticosteroids is recommended for Bell’s palsy, as it has been shown to improve prognosis in meta-analyses. Antiviral treatments are not recommended. Loss of taste in the anterior two-thirds of the tongue on the same side as the facial weakness may occur with Bell’s palsy, but doesn’t require urgent referral to ENT. It is important to note that a bilateral palsy is not a Bell’s palsy and requires urgent referral to ENT or neurology.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 82
Incorrect
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A 7-year-old child has a foul-smelling unilateral nasal discharge, which he has had for the last week. Nothing obvious is visible apart from discharge.
What is the most appropriate management option?Your Answer:
Correct Answer: Examination of the nose under general anaesthetic
Explanation:Management of Nasal Foreign Bodies in Children: An Overview
Nasal foreign bodies are a common occurrence in Preschool children, with beads, buttons, sweets, nuts, and seeds being the most commonly encountered objects. The management of nasal foreign bodies involves careful removal of the object without causing any further harm to the child. In cases where the foreign body is visible, a hook or thin forceps can be used to grasp and remove the object. However, if the foreign body is not visible, an examination under general anaesthetic may be necessary.
It is important to note that certain foreign bodies, such as small button batteries, can cause tissue damage if left in the nasal cavity. In such cases, immediate removal of the battery is necessary. Nasal decongestant, CT scans, oral antibiotics, and saline nasal washouts are not appropriate management strategies for nasal foreign bodies. Nasal congestion may only be used as an adjunct to examination and removal of the foreign body. CT scans should be avoided in children due to their high X-ray exposure. The use of oral antibiotics may delay removal of the foreign body, and saline nasal washouts carry a significant risk of aspiration or choking.
In conclusion, the management of nasal foreign bodies in children requires careful and prompt removal of the object. An examination under general anaesthetic may be necessary in cases where the foreign body is not visible. It is important to avoid unnecessary interventions and to prioritize the safety and well-being of the child.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 83
Incorrect
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Which of the following is the least acknowledged cause of vertigo?
Your Answer:
Correct Answer: Motor neuron disease
Explanation: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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 84
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 85
Incorrect
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You assess a 65-year-old heavy smoker who has just been diagnosed with cancer and is hesitant to undergo surgery. He is interested in exploring the option of radiotherapy. Which tumour from the following list is most suitable for potentially curative treatment with RADIOTHERAPY ALONE? Choose only ONE option.
Your Answer:
Correct Answer: Laryngeal carcinoma
Explanation:Curative Treatment Options for Various Types of Cancer
Laryngeal Carcinoma:
The management of laryngeal cancer involves preserving the larynx whenever possible. For early-stage disease, transoral laser microsurgery or radiotherapy is used. For more advanced disease, radiotherapy with concomitant chemotherapy is the treatment of choice. Total laryngectomy may still be required for some cases.Breast Cancer:
Radiotherapy is used as an adjuvant to primary surgery in breast cancer. It significantly reduces breast-cancer-related deaths and local recurrence rates.Colonic Carcinoma:
Surgical resection of the tumor is the main curative treatment for colonic carcinoma in patients with localized disease. Radiotherapy is limited by the risk of damage to surrounding structures.Gastric Carcinoma:
Partial or total gastrectomy is the only curative treatment for gastric carcinoma. Radiotherapy is ineffective.Lung Cancer:
Surgical excision is the curative treatment for localised non-small cell carcinoma. Radiotherapy with curative intent may be offered to patients unsuitable for surgery with stage I, II or III non-small cell carcinoma and good performance status if there is no undue risk of normal tissue damage.Curative Treatment Options for Different Types of Cancer
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 86
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 87
Incorrect
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You are evaluating a middle-aged woman who has come in with sudden onset of facial weakness on one side. What is the most significant risk factor for developing Bell's palsy in this patient?
Your Answer:
Correct Answer: Pregnancy
Explanation:Bell’s palsy is three times more likely to occur in pregnant women. While sarcoidosis can lead to facial nerve palsy, it is not directly linked to Bell’s palsy.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 88
Incorrect
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You come across a 16-year-old student who has been experiencing vertigo for the past 2 days. She complains of feeling like the room is spinning and experiencing nausea. She has been suffering from a severe cold for the last 10 days but denies any other symptoms. Upon examination and hearing tests, you suspect that she has vestibular neuronitis.
What is a correct statement about vestibular neuronitis?Your Answer:
Correct Answer: Hearing is normal in vestibular neuronitis
Explanation: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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 89
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 90
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 91
Incorrect
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You encounter a 50-year-old woman during your afternoon clinic. She reports experiencing sudden episodes where the room spins uncontrollably, accompanied by nausea and occasional vomiting. Additionally, she feels as though her hearing is impaired on the right side and experiences a ringing sound and a feeling of fullness on that side. Based on these symptoms, you suspect that she may have Meniere's disease. What is a true statement about this condition?
Your Answer:
Correct Answer: Sensorineural hearing loss is a symptom of Meniere's disease
Explanation:Meniere’s disease is characterized by sensorineural hearing loss, which can worsen over time and eventually result in profound bilateral hearing loss.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 92
Incorrect
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A 50-year-old man presents with vertigo, reporting a recurrent feeling that the environment is spinning. What is the leading cause of vertigo?
Your Answer:
Correct Answer: Benign paroxysmal positional vertigo
Explanation:Vertigo is most commonly caused by BPPV.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 93
Incorrect
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A red swelling is observed in the lower lateral wall of the nostrils of a young patient during anterior rhinoscopy. The swelling is tender to the touch and appears to be blocking the airway. What is the most probable diagnosis?
Your Answer:
Correct Answer: Inferior turbinate
Explanation:Understanding the Inferior Turbinate: Causes of Enlargement and Treatment Options
The inferior turbinate is a structure in the nasal cavity that is prone to enlargement, leading to nasal obstruction. This can be caused by various factors, including allergic rhinitis, inflammation, and the prolonged use of nasal sprays. If the obstruction is severe, treatment with nasal corticosteroids may be necessary.
It is important to note that the inferior turbinate is often mistaken for other pathologies during examination. Nasal polyps, for example, are insensitive and light grey in color, while foreign bodies are usually unilateral and accompanied by a nasal discharge, and are more common in children. The middle turbinate is located higher up and further back in the nasal cavity than the inferior turbinate, while the superior turbinate is rarely visible on anterior rhinoscopy.
Understanding the causes and symptoms of inferior turbinate enlargement can help healthcare professionals provide appropriate treatment options for their patients.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 94
Incorrect
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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:
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.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 95
Incorrect
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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.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 96
Incorrect
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Samantha, aged 55, presents with sudden onset dizziness described as 'the room spinning' which started three days ago. She has been unable to leave her home due to constant dizziness and nausea that accompanies it. She reports that movement seems to worsen her symptoms and denies any changes to her hearing. Apart from a recent cold, she has had no other health problems in recent years and has no past medical history except for a hysterectomy ten years ago.
After conducting a Dix-Hallpike test and examining her ear canals, which both proved normal, you diagnose her with vestibular neuronitis. She asks if there is anything she can take to alleviate her symptoms.
What advice would you give her?Your Answer:
Correct Answer: One week trial of prochlorperazine
Explanation:Patients with peripheral vertigo may experience distressing symptoms, such as those caused by vestibular neuronitis and labyrinthitis. To alleviate these symptoms in the short term, a sedating antihistamine like prochlorperazine can be prescribed for up to one week. However, longer courses of treatment may delay vestibular compensation and hinder recovery.
Haloperidol, which has a low affinity for histamine receptors, may not be effective in treating vertigo and could cause unwanted side effects. Cetirizine, a non-sedating antihistamine, would not address the nausea or vertigo symptoms. Betahistine, a histamine analogue, is only licensed for treating vertigo, tinnitus, and hearing loss associated with Meniere’s disease. While it may be considered for persistent symptoms, it is an unlicensed use and not recommended by NICE guidance.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 97
Incorrect
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A 50-year-old woman comes to her GP complaining of recurrent vertigo that has been going on for 6 months. She reports experiencing episodes that last from a few minutes to several hours, accompanied by tinnitus and decreased hearing in her left ear. She denies any identifiable triggers that worsen her symptoms. She has no significant medical history. Her ear and cranial nerve examinations are normal.
What is the probable diagnosis?Your Answer:
Correct Answer: Ménière's disease
Explanation:Meniere’s disease is characterized by spontaneous episodes of vertigo lasting minutes to hours, accompanied by unilateral hearing loss and tinnitus. This clinical presentation suggests a diagnosis of Meniere’s disease, which should be confirmed by referral to an ENT specialist and formal audiometry. The cause of Meniere’s disease is unknown, but it may be associated with raised endolymph pressure in the inner ear. Benign paroxysmal positional vertigo, labyrinthitis, and vestibular neuronitis are not likely diagnoses, as they present with different symptoms and characteristics.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 98
Incorrect
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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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 99
Incorrect
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A 7-year-old girl comes to the GP with her mother because she has been experiencing hearing difficulties in her left ear. She has a history of glue ear and has had grommets inserted in the past. During an otoscopy of the left ear, there is a significant buildup of earwax in the external auditory canal, and although the grommet is visible, the tympanic membrane is obscured. The right ear appears normal.
What would be the best course of action for management?Your Answer:
Correct Answer: Referral to ENT
Explanation:If a patient has a grommet in their ear, ear irrigation and the use of almond or olive oil drops are not recommended for managing excessive earwax, according to NICE guidelines. Using a cotton bud to remove earwax is also not advised as it can push the wax further into the auditory canal and increase the risk of infection. Similarly, ear candles are not beneficial and can cause serious injury. In such cases, the best course of action is to refer the patient to an ENT specialist.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 100
Incorrect
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A 47-year-old woman visits her GP complaining of constant right-sided hearing difficulty, tinnitus, and vertigo that have been present for the past two months and have worsened recently. Upon examination, there is no wax in either auditory canal, and the tympanic membranes appear normal.
What would be the most suitable course of action for management?Your Answer:
Correct Answer: Refer urgently to ENT
Explanation:If a patient is suspected to have an acoustic neuroma, it is crucial to refer them to an ENT specialist as soon as possible. The ENT specialist can conduct necessary tests such as audiograms and imaging to confirm or rule out the diagnosis. An ECG is not required based on the patient’s history, and hospitalization is not necessary. While an audiogram may be helpful, it is best to refer the patient directly to ENT for an MRI Head and audiogram together. A trial of medication and follow-up would not be appropriate in this case, as prompt initiation of further investigations is necessary. Meniere’s disease is a potential alternative diagnosis, but the constant and progressive nature of the patient’s symptoms is not typical of Meniere’s, which is usually episodic.
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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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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