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Question 1
Correct
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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: 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 2
Incorrect
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You encounter a 45-year-old man who complains of a painful mouth. He reveals that he has been experiencing a mouth ulcer for about 3 weeks. It started as a small painless sore but has now grown in size and is causing him discomfort. Despite trying various mouthwashes, he has not found any relief. He is in good health and has no other symptoms. Although he is not overly concerned about the ulcer, he would like you to prescribe something to help it heal.
Upon examination, you notice a 4mm ulcer in his oral cavity, surrounded by a white plaque. There is no lymphadenopathy.
How would you approach the management of this patient?Your Answer:
Correct Answer: Refer urgently (for an appointment within 2 weeks) to ENT
Explanation:If a person has had a mouth ulcer for more than three weeks, it is important to refer them to secondary care urgently. In cases where there is unexplained ulceration in the oral cavity lasting for more than three weeks or a persistent and unexplained lump in the neck, a suspected cancer pathway referral should be considered for an appointment within two weeks. This is also true for patients with a lump on the lip or in the oral cavity, or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia, who should be urgently referred for assessment for possible oral cancer by a dentist within two weeks. In this particular case, the patient with a solitary ulcer for more than three weeks should be seen by an ENT specialist within two weeks.
Aphthous mouth ulcers are painful sores that are circular or oval in shape and are found only in the mouth. They are not associated with any systemic disease and often occur repeatedly, usually starting in childhood. These ulcers can be caused by damage to the mouth, such as biting the cheek or brushing too hard, or may be due to a genetic predisposition. Other factors that can trigger these ulcers include stress, certain foods, stopping smoking, and hormonal changes related to the menstrual cycle.
Aphthous ulcers are characterized by their round or oval shape, a clearly defined margin, a yellowish-grey slough on the floor, and a red periphery. They usually appear on non-keratinized mucosal surfaces, such as the inside of the lips, cheeks, floor of the mouth, or undersurface of the tongue. In most cases, investigations are not necessary, but they may be considered if an underlying systemic disease is suspected.
Treatment for aphthous ulcers involves avoiding any factors that may trigger them and providing symptomatic relief for pain, discomfort, and swelling. This may include using a low potency topical corticosteroid, an antimicrobial mouthwash, or a topical analgesic. Most ulcers will heal within two weeks without leaving any scars. However, if a mouth ulcer persists for more than three weeks, it is important to seek urgent referral to a specialist.
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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 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 4
Incorrect
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Which one of the following statements regarding cholesteatomas is accurate?
Your Answer:
Correct Answer: The peak incidence is 10-20 years
Explanation:Understanding Cholesteatoma
Cholesteatoma is a benign growth of squamous epithelium that can cause damage to the skull base. It is most commonly found in individuals between the ages of 10 and 20 years old. Those born with a cleft palate are at a higher risk of developing cholesteatoma, with a 100-fold increase in risk.
The main symptoms of cholesteatoma include a persistent discharge with a foul odor and hearing loss. Other symptoms may occur depending on the extent of the growth, such as vertigo, facial nerve palsy, and cerebellopontine angle syndrome.
During otoscopy, a characteristic attic crust may be seen in the uppermost part of the eardrum.
Management of cholesteatoma involves referral to an ear, nose, and throat specialist for surgical removal. Early detection and treatment are important to prevent further damage to the skull base and surrounding structures.
In summary, cholesteatoma is a non-cancerous growth that can cause significant damage if left untreated. It is important to be aware of the symptoms and seek medical attention promptly if they occur.
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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 10-year-old girl has been discharged from hospital after having her tonsils removed.
Which of the following is typical after a tonsillectomy?Your Answer:
Correct Answer: Halitosis and ear pain temporarily
Explanation:Misconceptions about Tonsillectomy Recovery
Tonsillectomy is a common surgical procedure that involves the removal of the tonsils. However, there are several misconceptions about the recovery process that patients should be aware of.
Firstly, some patients may experience ear pain and halitosis after the surgery. This is due to referred pain from the tonsils and infection of the raw tissue areas, respectively.
Secondly, coughing up small amounts of blood ten days postoperatively is not normal and should be referred to secondary care for possible admission. Secondary bleeds are most common after about 5-10 days, and minor bleeding may be a precursor of a major bleed.
Thirdly, removal of the tonsils doesn’t guarantee a complete cessation of throat infections. Patients may still experience laryngitis or pharyngitis.
Fourthly, a temporary rise in the pitch of the voice is common after tonsillectomy due to swelling in the oropharynx. However, a permanent change in voice is not expected.
Lastly, it is normal to have moderate-to-severe discomfort for up to two weeks after the surgery, including pain while swallowing and pain in the throat. Adequate analgesia is needed, and children may become dehydrated if they do not take in adequate liquids after the surgery.
In conclusion, understanding the misconceptions about tonsillectomy recovery can help patients better prepare for the surgery and manage their expectations during the healing process.
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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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A 65 year-old man comes to you with complaints of nasal blockage on the right side for the past two months. He reports that it is now affecting his sleep. He denies any episodes of bleeding but has been experiencing postnasal drip. Upon examination, you observe a polyp on the right side and inflamed mucosa on both sides. What would be the most suitable course of action?
Your Answer:
Correct Answer: Refer to ENT
Explanation:A unilateral nasal polyp is a concerning symptom that requires immediate attention. While bilateral polyps are typically associated with rhinosinusitis, a unilateral polyp may indicate the presence of malignancy. Therefore, it is crucial to refer the patient to an ENT specialist for further evaluation.
In cases where small bilateral nasal polyps are present, primary care treatment may involve saline nasal douching and intranasal steroids. However, if the polyps are causing significant obstruction, referral to an ENT specialist is necessary.
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 7
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 8
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 9
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 10
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 11
Incorrect
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A 5-year-old girl presents with a six-month history of constant snoring and seems to ‘talk through her nose.’ Her nose seems clear on anterior examination.
What is the most appropriate management intervention?Your Answer:
Correct Answer: A period of watchful waiting
Explanation:Management of Enlarged Adenoids in Children
Explanation:
Enlarged adenoids are a common condition in children, which usually resolve on their own by the age of eight years. In cases where there is no history of sleep apnea or significant impairment of hearing or speech, a period of watchful waiting for six months or longer is appropriate. Nasal corticosteroids are not effective in treating enlarged adenoids as they do not affect the postnasal space. Adenoidectomy may be considered if the problem persists despite the waiting period. Tonsillectomy is not necessary unless there are frequent throat infections. The use of an albuterol inhaler is not recommended as there is no indication of asthma in the child. Overall, careful monitoring and appropriate intervention can effectively manage enlarged adenoids in children. -
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 4-year-old boy is brought to the General Practitioner because of a 4-day history of febrile temperatures and intermittent earache. Examination reveals unilateral otitis media and a bulging drum. The child has no known allergies.
Which of the following is the most appropriate antibiotic for this patient?
Your Answer:
Correct Answer: Amoxicillin
Explanation:Treatment of Acute Otitis Media: Antibiotic Guidelines
Acute otitis media (AOM) is a common childhood infection that often resolves without antibiotic treatment. However, in certain cases, antibiotics may be necessary to prevent serious complications. The following guidelines outline appropriate antibiotic treatment for AOM.
When to Consider Antibiotics:
Antibiotics may be considered after 72 hours if there is no improvement, or earlier if the child is systemically unwell, at high risk of complications, or under two years of age with bilateral otitis media.First-Line Antibiotics:
Amoxicillin is the preferred first-line antibiotic for AOM, as it is effective against the most common bacterial pathogens involved in the infection.Alternative Antibiotics:
Erythromycin or clarithromycin may be used for individuals who cannot take penicillin, but they are less effective against Haemophilus influenza.Second-Line Antibiotics:
Co-amoxiclav and azithromycin should be reserved for individuals who have not responded to first-line antibiotics. However, broad-spectrum antibiotics should be avoided when narrow-spectrum drugs are likely to be effective, as they increase the risk of Clostridioides difficile and methicillin-resistant Staphylococcus aureus.Why Azithromycin is Not Recommended as First-Line:
Azithromycin is not recommended as a first-line antibiotic due to its long half-life, which increases the risk of developing antibiotic resistance.In summary, appropriate antibiotic treatment for AOM depends on the severity of the infection and the individual’s ability to tolerate certain antibiotics. By following these guidelines, healthcare providers can effectively treat AOM while minimizing the risk of complications and antibiotic resistance.
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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 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 14
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 15
Incorrect
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A 50-year-old man presents with classic symptoms of benign paroxysmal positional vertigo (BPPV) and is concerned about the likelihood of recurrence. He reports multiple episodes of the room spinning when he moves his head, lasting 30 seconds to 1 minute. You explain that while symptoms often resolve without treatment over several weeks, the Epley manoeuvre can be offered to alleviate symptoms. The patient, who is a driver, is disabled by his symptoms and would like to know the chances of recurrence over the next 3-5 years.
Your Answer:
Correct Answer: 50%
Explanation:Approximately 50% of individuals diagnosed with BPPV will experience a relapse of symptoms within 3 to 5 years.
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 16
Incorrect
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A 28-year-old man comes in for a routine check-up with his GP. He is a non-smoker and has been feeling generally well. However, he has noticed that his gums have been bleeding when he brushes his teeth. He admits that he has been under a lot of stress lately and has not been brushing his teeth as regularly as he should.
Upon examination, there are no signs of ulceration or leukoplakia. The margins of his gums appear red but are not actively bleeding. There is no evidence of a dental abscess, and he has no fever.
What would be the most appropriate course of action based on his current presentation?Your Answer:
Correct Answer: Advise he should arrange routine dental review
Explanation:Patients who present with gingivitis should be advised to regularly visit a dentist for routine check-ups. Antibiotics are typically not necessary for this condition.
There is no need for urgent dental review, as there are no signs of acute necrotizing ulcerative gingivitis or oral malignancy. Benzydamine mouthwash may provide temporary pain relief, but it is not recommended for gingivitis. Chlorhexidine mouthwash may be used as an adjunct to dental review and antibiotic therapy for necrotizing ulcerative gingivitis.
In cases of simple gingivitis, antibiotics are generally not prescribed.
Understanding Gingivitis and its Management
Gingivitis is a dental condition that is commonly caused by poor oral hygiene. It is characterized by red and swollen gums that bleed easily. In severe cases, it can lead to acute necrotizing ulcerative gingivitis, which is accompanied by painful bleeding gums, bad breath, and ulcers on the gums.
For patients with simple gingivitis, regular dental check-ups are recommended, and antibiotics are usually not necessary. However, for those with acute necrotizing ulcerative gingivitis, it is important to seek immediate dental attention. In the meantime, oral metronidazole or amoxicillin may be prescribed for three days, along with chlorhexidine or hydrogen peroxide mouthwash and simple pain relief medication.
It is crucial to maintain good oral hygiene to prevent gingivitis from developing or worsening. This includes brushing teeth twice a day, flossing daily, and using mouthwash regularly. By understanding the causes and management of gingivitis, individuals can take steps to protect their oral health and prevent complications.
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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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You diagnose a left-sided sudden sensorineural hearing loss (SSNHL) in a normally fit and well 36-year-old woman who has come to see you in your GP clinic. She developed her symptoms over a few hours yesterday and now can not hear at all through her left ear. Her examination shows no obvious external or middle ear causes.
What is your next step?Your Answer:
Correct Answer: Refer her for assessment within 24 hours by an ENT specialist
Explanation:Immediate referral to an ENT specialist or emergency department is necessary for individuals experiencing acute sensorineural hearing loss. This is considered an emergency and requires urgent audiology assessment and a brain MRI. According to NICE CKS guidelines, individuals with sudden onset hearing loss (unilateral or bilateral) within the past 30 days, without any external or middle ear causes, should be referred within 24 hours. Additionally, those with unilateral hearing loss accompanied by focal neurology, head or neck injury, or severe infections such as necrotising otitis externa or Ramsay Hunt syndrome should also be referred urgently. Referral to a specialist other than ENT or non-urgent referral options are incorrect.
When a patient experiences a sudden loss of hearing, it is crucial to conduct a thorough examination to determine whether it is conductive or sensorineural hearing loss. If it is the latter, known as sudden-onset sensorineural hearing loss (SSNHL), it is imperative to refer the patient to an ear, nose, and throat (ENT) specialist immediately. The majority of SSNHL cases have no identifiable cause, making them idiopathic. To rule out the possibility of a vestibular schwannoma, an MRI scan is typically performed. ENT specialists administer high-dose oral corticosteroids to all patients with SSNHL.
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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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You are a primary care physician seeing a 2-year-old girl with her mother. The mother reports that over the past 48 hours, her daughter has had intermittent fevers (up to 37.5ºC) and has been fussy. However, she has been eating and drinking normally.
The mother has also noticed that her daughter has been tugging at her right ear.
Upon examination, the child appears comfortable, and the following vital signs are noted:
Temperature 37.2ºC
Heart rate 105 beats/min
Respiratory rate 22 breaths/min
Upon otoscopy, you observe a small perforation in the right tympanic membrane with a small amount of discharge present in the external ear canal. The left tympanic membrane appears normal.
What is the most appropriate course of action based on the information provided?Your Answer:
Correct Answer: Prescribe a 7 day course of amoxicillin
Explanation:In cases of acute otitis media with perforation, oral antibiotics should be prescribed. The recommended course of treatment is a 7-day course of amoxicillin. While most cases of otitis media resolve on their own with simple analgesia, antibiotics may be necessary in certain situations, such as bilateral infection in children under 2, otorrhoea, perforated tympanic membrane, and symptoms that do not improve after 3 days. In this case, the patient has ongoing and bilateral infection with on and off fevers for 3 days, making a 7-day course of amoxicillin the most appropriate option. Tympanic membrane perforations usually heal within 4-8 weeks, and it is good practice to re-examine them after a few weeks to ensure healing. However, this should be done earlier than 12-16 weeks. Tympanic membrane perforation is a common complication of otitis media and can usually be managed in the community without the need for discussion with ENT. Otomize, which contains aminoglycosides that are ototoxic, should not be used in cases of otitis media with perforation.
Acute otitis media is a common condition in young children, often caused by bacterial infections following viral upper respiratory tract infections. Symptoms include ear pain, fever, and hearing loss, and diagnosis is based on criteria such as the presence of a middle ear effusion and inflammation of the tympanic membrane. Antibiotics may be prescribed in certain cases, and complications can include perforation of the tympanic membrane, hearing loss, and more serious conditions such as meningitis and brain abscess.
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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 parent is concerned about her 9-month-old child’s prominent ears.
Your Answer:
Correct Answer: Delay operation until the age of 8
Explanation:Prominent Ears: Causes, Diagnosis, and Treatment Options
Prominent ears affect a small percentage of the population and are usually inherited. This condition arises due to the lack or malformation of cartilage during ear development in the womb, resulting in abnormal helical folds or lateral growth. While some babies are born with normal-looking ears, the problem may arise within the first three months of life.
Before six months of age, the ear cartilage is soft and can be molded and splinted. However, after this age, surgical correction is the only option. Pinnaplasty or otoplasty can be performed on children from the age of five, but the ideal age for the procedure is around eight years old. This allows enough time to see if the child perceives the condition as a problem, while also avoiding potential teasing or bullying at school.
While some prominent ears may become less visible over time, it is best not to delay corrective procedures. Younger ears tend to produce better results after surgery, and waiting too long may increase the risk of bullying at school. Overall, understanding the causes, diagnosis, and treatment options for prominent ears can help individuals make informed decisions about their care.
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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 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 21
Incorrect
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A 48-year-old factory machine operator is seen with recent onset hearing difficulties. He has had a hearing test done via a private company and has brought the result of his pure tone audiometry in to show you.
Which of the following audiogram findings would most suggest he has early noise-induced hearing loss?Your Answer:
Correct Answer: A notch of hearing loss between 3 and 6 kHz with recovery at higher frequencies
Explanation:Patterns of Hearing Loss Revealed by Pure Tone Audiometry
Pure tone audiometry is a valuable tool for identifying patterns of hearing loss. A normal individual will have hearing thresholds above 20 dBHL across all frequencies. Meniere’s disease typically shows hearing loss at lower frequencies, while presbyacusis often presents with high frequency loss in a ‘ski slope’ pattern.
Early noise-induced hearing loss (NIHL) is usually characterized by a notch between 3 and 6 kHz, with recovery at higher frequencies. If presbyacusis is also present, the notch may be less prominent and appear more like a ‘bulge.’ NIHL is typically bilateral, but it can occur unilaterally in activities such as shooting. As NIHL progresses, the notch seen in early disease may disappear, and there may be increasing hearing loss at all frequencies, most notably at higher frequencies, which can sometimes be difficult to differentiate from presbyacusis.
In summary, pure tone audiometry can reveal various patterns of hearing loss, which can aid in the diagnosis and management of different types of hearing disorders.
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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 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:
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 23
Incorrect
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A 35-year-old man visits the General Practitioner complaining of hearing loss. He served in the military and was exposed to loud noises, which he thinks is the reason for his hearing loss.
What is the accurate statement regarding noise-induced hearing loss?Your Answer:
Correct Answer: It is usually bilateral and symmetrical
Explanation:Understanding Noise-Induced Hearing Loss and Its Unique Characteristics in Shooters
Noise-induced hearing loss is a gradual and symmetrical hearing loss that typically affects both ears. However, in the case of shooters, the loss occurs in the opposite ear to where they hold their gun, as the gun side is shielded. The damage is permanent and greatest at high frequencies. Examination of the tympanic membrane is usually normal, except in cases of glue ear. Prolonged exposure to excessive noise can result in permanent damage, but the loss doesn’t progress once exposure is discontinued. Patients with occupational exposure should be referred for further evaluation, as there may be legal implications. Employers have a duty to protect employees from noise under the Control of Noise at Work Regulations 2005. Compensation may be available under the Armed Forces Compensation Scheme for those affected.
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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 35-year-old sales representative comes in for a routine check-up and reports a 2-week history of a droopy left eyelid with forehead weakness. Upon examination, the symptoms are confirmed and there are no abnormalities found in the eyes or ears.
What is a crucial aspect of the treatment plan?Your Answer:
Correct Answer: Night-time eyelid coverings
Explanation:Proper eye care is crucial in Bell’s palsy, and measures such as using drops, lubricants, and night-time taping should be considered. However, the most important step is to cover the eyelids during the night to prevent dryness and potential corneal damage or infection. antiviral treatment alone is not a recommended treatment for Bell’s palsy, and antibiotics are unnecessary as the condition is caused by a virus, not bacteria. Immediate referral to an ENT specialist is not necessary for a simple case of Bell’s palsy, but may be warranted if symptoms persist beyond 2-3 months.
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 25
Incorrect
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Ramsey Hunt syndrome
Your Answer:
Correct Answer: Refer under 2-week wait to ENT for suspected cancer
Explanation:If an adult presents with unilateral middle ear effusion, it could be a sign of nasopharyngeal cancer. In such cases, the appropriate action would be to refer the patient for an urgent 2-week wait ENT appointment to investigate the possibility of cancer. This is especially important if the patient is of East Asian origin and the effusion is not related to an upper respiratory tract infection. Other options, such as arranging a CT scan of the paranasal sinuses, do not address the urgent need to rule out cancer and should not be done in primary care. Further investigations, such as nasal endoscopy or MRI, may be arranged by the specialist to confirm or rule out the possibility of nasopharyngeal cancer.
Understanding Nasopharyngeal Carcinoma
Nasopharyngeal carcinoma is a type of squamous cell carcinoma that affects the nasopharynx. It is a rare form of cancer that is more common in individuals from Southern China and is associated with Epstein Barr virus infection. The presenting features of nasopharyngeal carcinoma include cervical lymphadenopathy, otalgia, unilateral serous otitis media, nasal obstruction, discharge, and/or epistaxis, and cranial nerve palsies such as III-VI.
To diagnose nasopharyngeal carcinoma, a combined CT and MRI scan is typically used. The first line of treatment for this type of cancer is radiotherapy. It is important to catch nasopharyngeal carcinoma early to increase the chances of successful treatment.
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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 42-year-old man presents with minor bleeding from the gums during tooth brushing, as evidenced by blood on the toothbrush and on spitting out during tooth brushing. There is no pain, lymphadenopathy, fever, or other systemic manifestation of disease. On examination of the teeth and gums, reddened, mild-to-moderately swollen gingivae are observed throughout the mouth.
What is the most probable diagnosis?Your Answer:
Correct Answer: Gingivitis
Explanation:Understanding Gingivitis and Periodontal Disease
Gingivitis is a common condition characterized by inflammation of the gums, often caused by dental plaque. If left untreated, it can progress to periodontitis, which affects the ligaments and bone supporting the teeth. Risk factors include poor oral hygiene, smoking, and diabetes. Treatment involves managing oral hygiene and using antiseptic mouthwashes, but it’s important to see a dentist for proper care.
Necrotising ulcerative gingivitis, also known as Vincent’s disease, is a painful form of gingivitis that can cause ulcers and bleeding. It’s caused by bacteria already present in the mouth and can be treated with antibiotics.
Periodontal disease is a common problem in HIV-infected patients and can present as necrotising ulcerative periodontitis or linear gingival erythema. These conditions can occur even in clean mouths with little plaque or tartar.
Bleeding gums can also be a symptom of leukaemia and platelet disorders. It’s important to seek medical attention if you experience persistent bleeding or other oral health issues.
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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 6-year-old boy is brought to the General Practitioner (GP) by his father. The child recently had an ear infection and his father is concerned that his child may have reduced hearing. There are no signs of inflammation or discharge on examination of the ears, but the GP suspects that the child may have otitis media with effusion (glue ear). His childhood development, including speech and language development, has been normal.
Which of the following management options is most appropriate for this patient?
Your Answer:
Correct Answer: No active treatment
Explanation:Treatment Options for Otitis Media with Effusion in Children
Otitis media with effusion is a common condition in children, but it is usually self-limiting and resolves within 12 months. While there is no proven benefit from medication, there are several treatment options available.
Observation is a viable option, as a period of watchful waiting is unlikely to result in any long-term complications. However, if signs and symptoms persist, referral for a hearing test after 6-12 weeks or to a specialist in ear, nose, and throat (ENT) may be necessary.
Antibiotics are not indicated in cases where there are no symptoms or signs of active infection. Intranasal corticosteroids and oral antihistamines are also not recommended by The National Institute for Health and Care Excellence (NICE) for the treatment of otitis media with effusion in children.
Nasal decongestants, such as pseudoephedrine, may provide temporary relief for stuffy nose and sinus pain/pressure caused by infection or other breathing illnesses, but they are not indicated for children with glue ear.
In summary, the best course of action for otitis media with effusion in children is often observation, with referral to a specialist if necessary. Other treatment options should be carefully considered and discussed with a healthcare provider.
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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 35-year-old woman presents with headache.
Select from the list below the single feature that would suggest frontal sinusitis rather than migraine.Your Answer:
Correct Answer: Green nasal discharge
Explanation:Migraine vs Sinus Headache: Understanding the Difference
Many people who believe they are suffering from a sinus headache may actually be experiencing a migraine. This is because migraines can activate the trigeminal nerves, which are responsible for both the sinus region and the meninges. As a result, it can be difficult to determine the exact source of the pain. In addition, migraines can cause nasal congestion, as well as lacrimation and rhinorrhoea due to autonomic nerve stimulation. Unlike sinusitis, which often presents with thick green nasal discharge, migraines tend to be recurrent and may not have a clear history of sinusitis. Understanding the difference between these two conditions can help with 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 29
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 30
Incorrect
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A 24-year-old-man schedules an appointment due to a nose injury he sustained while playing soccer two days ago. He reports that his nose bled for a few minutes after the injury but has not bled since. He also mentions that his nose did not appear deformed after the incident. He has not sought medical attention before this appointment and is generally healthy with no long-term medications.
During the examination, you notice no signs of nasal bone deviation, but there is significant swelling in the surrounding soft tissue. On anterior rhinoscopy, you observe a bilateral fluctuant swelling of the nasal septum that almost blocks the nostrils.
What is the most suitable course of action?Your Answer:
Correct Answer: Admit directly to the hospital for same day ENT assessment
Explanation:If there is bilateral purple swelling of the nasal septum, it is likely that the patient has a septal haematoma. It is important to examine the nose for this condition, even if the injury seems minor. A septal haematoma can cause permanent damage to the septal cartilage within 24 hours due to obstructed blood flow. If suspected, the patient should be referred to the on-call ENT team for urgent assessment.
If a nasal bone fracture is suspected, the patient should also be referred to the ENT emergency clinic. This type of fracture can be corrected under local anaesthetic within 2-3 weeks of the injury.
Facial bone x-rays are not useful in diagnosing nasal bone fractures.
If the patient has only experienced simple epistaxis without any other nasal injury, Naseptin may be appropriate.
If there is a septal deviation, routine ENT referral may be necessary. However, if there is any uncertainty, it is best to seek advice from an ENT specialist.
Nasal Septal Haematoma: A Complication of Nasal Trauma
Nasal septal haematoma is a serious complication that can occur after even minor nasal trauma. It is characterized by the accumulation of blood between the septal cartilage and the perichondrium. The most common symptom is nasal obstruction, but pain and rhinorrhoea may also be present. On examination, a bilateral, red swelling arising from the nasal septum is typically seen. It is important to differentiate this from a deviated septum, which will be firm upon probing.
Prompt treatment is necessary to prevent irreversible septal necrosis, which can occur within 3-4 days if left untreated. This is caused by pressure-related ischaemia of the cartilage, leading to necrosis and potentially resulting in a ‘saddle-nose’ deformity. Management typically involves surgical drainage and intravenous antibiotics. It is crucial to be aware of this complication and to promptly seek medical attention if nasal trauma occurs.
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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 55-year-old smoker presents with a persistent hoarse voice for the past three to four weeks. He saw a colleague two weeks ago who found nothing focal on examination and advised him to seek review if his hoarseness did not settle after a further week. He has no significant past medical history, is not on any regular medication, and has no known drug allergies. He denies any cough, haemoptysis, swallowing problems, weight loss, or any systemic unwellness. Clinical examination reveals no anaemia, clubbing, lymphadenopathy or neck masses. His chest sounds clear, and an urgent chest x-ray is reported as 'normal'. What is the most appropriate next step in this patient's management?
Your Answer:
Correct Answer: Refer urgently to an ear, nose and throat specialist
Explanation:Recognizing and Referring Suspected Cancer: The Case of a Persisting Hoarse Voice
The NICE guidelines on recognizing and referring suspected cancer do not provide a specific time period for what constitutes persistent symptoms. However, most references suggest that further action should be taken if hoarseness persists for three or more weeks. This could indicate a laryngeal cancer or a lung tumor that has infiltrated the recurrent laryngeal nerve. In such cases, an urgent chest x-ray may help direct referral.
If the chest x-ray is normal, urgent referral to an ENT (or head and neck) specialist is needed to investigate the persisting hoarse voice. However, if the chest x-ray is abnormal and suggestive of lung malignancy, urgent referral to a lung cancer specialist is warranted.
In summary, recognizing and referring suspected cancer is crucial in cases of persisting hoarseness. While the NICE guidelines do not provide a specific time period for what constitutes persistent symptoms, most references suggest that three or more weeks of hoarseness warrants further action. A normal chest x-ray requires urgent referral to an ENT (or head and neck) specialist, while an abnormal chest x-ray warrants urgent referral to a lung cancer 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 32
Incorrect
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A 26-year-old man with sinusitis inquires about the safety of using Sudafed (pseudoephedrine). Is there any medication that would make Sudafed use inappropriate?
Your Answer:
Correct Answer: Monoamine oxidase inhibitor
Explanation:The combination of a monoamine oxidase inhibitor and pseudoephedrine may lead to a dangerous increase in blood pressure known as a hypertensive crisis.
Acute sinusitis is a condition where the mucous membranes of the paranasal sinuses become inflamed. This inflammation is usually caused by infectious agents such as Streptococcus pneumoniae, Haemophilus influenza, and rhinoviruses. Certain factors can predispose individuals to this condition, including nasal obstruction, recent local infections, swimming/diving, and smoking. Symptoms of acute sinusitis include facial pain, nasal discharge, and nasal obstruction. Treatment options include analgesia, intranasal decongestants or nasal saline, and intranasal corticosteroids. Oral antibiotics may be necessary for severe presentations, but they are not typically required. In some cases, an initial viral sinusitis can worsen due to secondary bacterial infection, which is known as double-sickening.
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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 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 34
Incorrect
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A 41-year-old man presents to the surgery for the second time in the past month complaining of a severe sore throat. He has been prescribed a course of co-amoxiclav by your partner for suspected tonsillitis, but tells you this has had no impact on his symptoms. According to his records he has always had large tonsils and has been seen at the surgery for a number of episodes of tonsillitis over the past few years.
On examination his temperature is 37.7°C, pulse is 70 bpm and regular, BP is 122/82 mmHg. There is some cervical lymphadenopathy. There is a large erythematous nodule on the right hand side of the tonsillar bed.
What is the most appropriate next step?Your Answer:
Correct Answer: Non-urgent referral for tonsillectomy
Explanation:Unilateral Tonsillar Enlargement: A Red Flag for Tonsillar Lymphoma
Unilateral tonsillar enlargement is a concerning symptom that may indicate tonsillar lymphoma. Delaying referral to an ENT specialist for biopsy can be detrimental to the patient’s health. Antibiotic therapy may not be effective in treating malignancy, and failure to respond to antibiotics may indicate underlying cancer. Patients with a history of smoking and alcohol consumption are at higher risk of tonsillar cancer, while those with recurrent tonsillitis may be more prone to tonsillar lymphoma.
Other diagnostic options, such as full blood count and viscosity, may not be abnormal in early lymphoma, and non-urgent referral can cause a delay of several weeks before review by an ENT specialist. Therefore, it is crucial to promptly refer patients with unilateral tonsillar enlargement to an ENT specialist for further evaluation.
The British Journal of General Practice (BJGP) published an article in November 2014 that provides a helpful table outlining the differences between acute tonsillitis and oropharyngeal carcinoma. This information can aid in the accurate diagnosis of tonsillar enlargement and prevent misdiagnosis.
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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 20-year-old woman has been experiencing recurrent painful mouth ulceration for several years. The ulcers typically heal in just over a week, and she remains symptom-free until the next recurrence. She denies any associated symptoms or rash, and her father had a similar history as a teenager. She doesn't smoke and denies excessive alcohol use or drug use. Although there is no dental or periodontal disease, she has three discrete, 4-mm-round ulcers with inflammatory haloes on the buccal mucosa.
What is the most likely diagnosis?Your Answer:
Correct Answer: Apthous ulcers
Explanation:There are several types of oral ulcers that can occur. Recurrent aphthous ulcers are the most common, affecting up to 66% of people at some point in their life. These ulcers appear on movable oral tissue and can recur frequently. Treatment options include topical corticosteroids, antimicrobial mouthwash, and topical analgesics. Herpes simplex stomatitis is another type of oral ulcer that mostly affects children and is caused by the herpes simplex virus. Symptoms include fever, malaise, and painful intraoral vesicles that can lead to ulcers. Oral candidiasis, or thrush, presents as white patches on the oral mucosa and tongue that can be wiped off to reveal a raw, erythematous base. Oral hairy leukoplakia is a white patch on the side of the tongue with a hairy appearance that is caused by Epstein-Barr virus and usually occurs in immunocompromised individuals. Oral lichen planus presents as a symmetrical, white, lace-like pattern on the buccal mucosa, tongue, and gums, and may be accompanied by erosions and ulcers.
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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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A 6-year-old boy has a unilateral nasal discharge and a foreign body is seen on that side in the anterior part of the nasal cavity.
Select from the list the management option that is LEAST APPROPRIATE.Your Answer:
Correct Answer: Await spontaneous expulsion
Explanation:Nasal Foreign Bodies: Risks, Complications, and Removal Techniques
Nasal foreign bodies are a common occurrence, but they should not be taken lightly. Bleeding is the most common complication, but inflammation, mucosal damage, extension into adjacent structures, and infection can also occur. In severe cases, a foreign body can accidentally be aspirated, leading to acute respiratory obstruction. Additionally, foreign bodies in the nose can carry causative organisms of infectious diseases. Therefore, spontaneous expulsion should not be anticipated, and urgent ENT referral may be necessary.
Successful removal of a nasal foreign body requires a cooperative patient and a doctor experienced and confident in the removal technique. Several methods are available, including blowing positive pressure through the nose, using forceps or suction, and passing a balloon catheter. The choice of method depends on the type of foreign body and the doctor’s comfort level.
It is important to note that small button batteries should be removed immediately as they can cause local necrosis if they leak. Topical anaesthetic and vasoconstrictor may be helpful in the removal process. In cases where the patient is uncooperative or the foreign body is in a posterior position, urgent ENT referral is appropriate.
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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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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 38
Incorrect
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A 35-year-old man comes to the clinic complaining of vertigo that has been ongoing for 5 days. He reports having a recent viral upper respiratory tract infection. The patient is in good health overall and experiences nausea but no hearing loss or tinnitus. During the examination, the doctor observes fine horizontal nystagmus. What is the probable diagnosis?
Your Answer:
Correct Answer: Vestibular neuronitis
Explanation:If there is no hearing loss, it is more likely that the patient has vestibular neuronitis rather than viral labyrinthitis.
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 39
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 40
Incorrect
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A 28-year-old woman presents with progressive bilateral hearing loss over the last 2-3 years. No other symptoms are reported. She works as a machinist in a factory manufacturing clothing. She has a family history of hearing loss at a young age. She has an 18 month old son who has no hearing difficulties.
Examination of the ears reveals normal tympanic membranes both sides.
She has had a hearing test done privately and the audiogram shows bilateral hearing loss more marked at low frequencies.
What is the most likely underlying diagnosis?Your Answer:
Correct Answer: Otosclerosis
Explanation:Understanding Otosclerosis and Other Hearing Loss Conditions
Otosclerosis is a condition where bone growth occurs in the middle ear, leading to the fixation of the foot plate of the stapes bone and resulting in conductive hearing loss in young adults. This condition is often accelerated during pregnancy and may have a family history. Treatment options include surgery or a hearing aid. Audiometry typically shows hearing loss more marked at low frequencies.
In contrast, presbyacusis is characterized by high frequency loss in a ‘ski slope’ pattern, while noise-induced hearing loss shows a dip at 4 kHz with recovery at higher frequencies. Acoustic neuroma typically shows high frequency loss and is usually unilateral, while Meniere’s disease can produce low frequency hearing loss along with attacks of vertigo, tinnitus, and aural fullness. Understanding the different patterns of hearing loss can help in the diagnosis and management of these conditions.
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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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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 42
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 43
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:
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 44
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 45
Incorrect
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A 23-year-old female presents with severe right-sided ear pain, muffled hearing, and watery discharge for the past 3 days. The patient also reports intense itching in the affected ear. Upon examination, the tympanic membrane is intact, but the external auditory canal is inflamed, red, and swollen with purulent debris and wax. Pulling the pinna causes the patient significant pain. The mastoid process is normal and not tender to palpation. Rinne's and Weber's tests confirm conductive hearing loss. What is the recommended first-line treatment for this patient?
Your Answer:
Correct Answer: Topical antibiotic + a topical steroid for 1-2 weeks
Explanation:Understanding Otitis Externa: Causes, Features, and Management
Otitis externa is a prevalent condition that often prompts primary care visits in the UK. It is characterized by ear pain, itch, and discharge, and can be caused by bacterial or fungal infections, seborrhoeic dermatitis, or contact dermatitis. Swimming is also a common trigger for otitis externa. Upon examination, the ear canal may appear red, swollen, or eczematous.
The recommended initial management for otitis externa is the use of topical antibiotics or a combination of topical antibiotics with a steroid. However, if the tympanic membrane is perforated, aminoglycosides are traditionally not used. If there is canal debris, removal may be necessary, and if the canal is extensively swollen, an ear wick may be inserted. Second-line options include taking a swab inside the ear canal, considering contact dermatitis secondary to neomycin, or using oral antibiotics such as flucloxacillin if the infection is spreading. Empirical use of an antifungal agent may also be considered.
It is important to note that if a patient fails to respond to topical antibiotics, they should be referred to an ENT specialist. Malignant otitis externa is a more severe form of the condition that is more common in elderly diabetics. It involves the extension of infection into the bony ear canal and the soft tissues deep to the bony canal, and may require intravenous antibiotics. While some ENT doctors disagree, concerns about ototoxicity may arise with the use of aminoglycosides in patients with perforated tympanic membranes.
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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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A 65-year-old man visits his GP with concerns about an unusual patch inside his cheek. He noticed a red-white patch while brushing his teeth, but he is unsure how long it has been there. He has a smoking history of 35 pack years and drinks approximately 18 units of alcohol per week. There is no family history of oral cancer. On examination, he appears to be in good health, and no cervical lymphadenopathy is detected. There is a 2cm red and white macule with a velvety texture on the buccal vestibule of the oral cavity, consistent with erythroleukoplakia. What is the most appropriate course of action?
Your Answer:
Correct Answer: Urgent referral (within 2 weeks) for assessment by head and neck team
Explanation:Immediate investigation is necessary for any oral cavity lesion that appears suspicious for erythroplakia or leukoplakia due to the risk of malignancy.
When to Refer Patients with Mouth Lesions for Oral Surgery
Mouth lesions can be a cause for concern, especially if they persist for an extended period of time. In cases where there is unexplained oral ulceration or mass that lasts for more than three weeks, or red and white patches that are painful, swollen, or bleeding, a referral to oral surgery should be made within two weeks. Additionally, if a patient experiences one-sided pain in the head and neck area for more than four weeks, which is associated with earache but doesn’t result in any abnormal findings on otoscopy, or has an unexplained recent neck lump or a previously undiagnosed lump that has changed over a period of three to six weeks, a referral should be made.
Patients who have persistent sore or painful throats or signs and symptoms in the oral cavity that last for more than six weeks and cannot be definitively diagnosed as a benign lesion should also be referred. It is important to note that the level of suspicion should be higher in patients who are over 40, smokers, heavy drinkers, and those who chew tobacco or betel nut (areca nut). By following these guidelines, healthcare professionals can ensure that patients with mouth lesions receive timely and appropriate care. For more information on this topic, please refer to the link provided.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 47
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:
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 48
Incorrect
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A 2-year-old boy is presented by his father with bilateral earache. The child has been experiencing this for the past week despite taking regular paracetamol and neurofen.
During the examination, the child's temperature is recorded at 39.2ºC. His pulse rate is 130 beats per minute and both ears show congested, red, and bulging tympanic membranes.
What is the best course of action for managing this condition?Your Answer:
Correct Answer: Amoxicillin
Explanation:For most cases of acute otitis media, it is recommended to avoid or delay the use of antibiotics. However, a prescription may be necessary for individuals who are systemically unwell, have co-morbidities that put them at high-risk, experience ongoing symptoms for at least 4 days without improvement, children under 2 years old with bilateral otitis media, or those with perforation and/or discharge in the ear canal. Amoxicillin is the preferred first-line drug, while acetic acid spray, otomize spray, and flucloxacillin can be used for otitis externa. Although symptoms should typically be monitored, this patient meets some of the criteria for antibiotic prescription.
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 49
Incorrect
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An 80-year-old man presents for follow up of his hoarse voice, which he first noticed after attending a family gathering a month ago. Initially, a viral infection was suspected and he was given symptomatic advice. However, he reports that there has been no improvement in his symptoms and his voice remains hoarse. He quit smoking over 30 years ago and only drinks occasionally. He denies any cough or recent illness. His weight is stable and he has not experienced any hemoptysis. On examination, his ears, nose, and throat appear normal, as does his chest. What is the most appropriate management plan for this patient?
Your Answer:
Correct Answer: Refer urgently to an ear, nose and throat specialist
Explanation:Management of Persistent Hoarse Voice
A persistent hoarse voice for over three weeks is a ‘red flag’ presentation and should prompt urgent action to investigate for a suspected cancer, such as laryngeal or lung cancer. Risk factors such as smoking history and alcohol history are important to consider but would not alter your management plan.
NICE guidance on this changed slightly with the release of NG12. NICE advises that you should consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with persistent unexplained hoarseness.
It is important to note that a normal basic examination is not sufficient to rule out a sinister underlying cause. Hoarseness can also be caused by pulmonary pathology, and if you have any suspicions that this may be the case, you should arrange an urgent chest x-ray.
In summary, a persistent hoarse voice should be taken seriously and investigated promptly to rule out any potential underlying cancer or pulmonary pathology.
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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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During a routine cranial nerve examination of a different patient, the following results were obtained:
Rinne's test: Air conduction > bone conduction in both ears
Weber's test: Localises to the left side
What do these test results indicate?Your Answer:
Correct Answer: Left sensorineural deafness
Explanation:If there is a sensorineural issue during Weber’s test, the sound will be perceived on the healthy side (right), suggesting a problem on the opposite side (left).
Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness
Rinne’s and Weber’s tests are used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test indicates that BC is better than AC, suggesting conductive deafness.
Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking the patient which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.
The table below summarizes the interpretation of Rinne and Weber tests. A normal result indicates that AC is greater than BC bilaterally and the sound is midline. Conductive hearing loss is indicated by BC being greater than AC in the affected ear and AC being greater than BC in the unaffected ear, with the sound lateralizing to the affected ear. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, with the sound lateralizing to the unaffected ear.
Overall, Rinne’s and Weber’s tests are useful tools for differentiating between conductive and sensorineural deafness, allowing for appropriate management and treatment.
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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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A middle-aged woman of Chinese origin presents to you in surgery to discuss her recurrent nosebleeds. They started 3 months ago and have been occurring unprovoked with increasing frequency. She is not on any anticoagulants, has never had any previous episodes of unexplained or excessive bleeding, and has no family history of any bleeding disorders. On further questioning, the nosebleeds always seem to be from the right nostril which feels a bit blocked. She has tried 2 weeks of Naseptin (chlorhexidine dihydrochloride and neomycin sulfate nasal cream) with no change in her symptoms. She mentions that the previous GP she saw asked about weight loss which she denied at the time, however, she volunteers that she has been tightening her belt more now. Blood tests reveal normal coagulation screen, haemoglobin within the normal range and a thrombocytosis. What condition is it most important to investigate for?
Your Answer:
Correct Answer: Nasopharyngeal cancer
Explanation:The NICE guidelines advise referring patients with recurrent epistaxis and a high risk of underlying disorders to ear, nose and throat for investigation. This patient, who is of Chinese origin and has recurrent nosebleeds, nasal obstruction, and weight loss, is at high risk of nasopharyngeal cancer due to his ethnicity and age. The full blood count results show thrombocytosis, which may indicate malignancy. Hereditary telangiectasia and Von Willebrand’s disease are unlikely due to the absence of a family history and the onset of nosebleeds in later life. Nasal polyps do not typically cause epistaxis, but may present with nasal obstruction, postnasal drip, snoring, or obstructive sleep apnoea. The patient’s age rules out angiofibroma as a possible cause, as this benign tumour typically occurs in pre-pubescent and adolescent males and is rare over the age of 25.
Understanding Nasopharyngeal Carcinoma
Nasopharyngeal carcinoma is a type of squamous cell carcinoma that affects the nasopharynx. It is a rare form of cancer that is more common in individuals from Southern China and is associated with Epstein Barr virus infection. The presenting features of nasopharyngeal carcinoma include cervical lymphadenopathy, otalgia, unilateral serous otitis media, nasal obstruction, discharge, and/or epistaxis, and cranial nerve palsies such as III-VI.
To diagnose nasopharyngeal carcinoma, a combined CT and MRI scan is typically used. The first line of treatment for this type of cancer is radiotherapy. It is important to catch nasopharyngeal carcinoma early to increase the chances of successful treatment.
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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 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 53
Incorrect
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A 12-year-old girl is brought in for an urgent appointment with her mother. She has been experiencing a sore throat, fever, malaise, and headache for the past two days. Yesterday, she complained of pain in her right ear, which has now spread to both ears. She has difficulty eating and drinking due to discomfort.
During the examination, bilateral swelling is observed, which is obstructing the angle of the jaw on both sides. When attempting to open her mouth to examine her throat, she experiences discomfort.
The patient has no significant medical history, and her mother is unsure if she has received all of her scheduled vaccinations.
What is the incubation period for this infection?Your Answer:
Correct Answer: 14-21 days
Explanation:Mumps: Symptoms, Complications, and Incubation Period
Mumps is a viral infection that has an incubation period of 14-21 days. The patient typically experiences a nonspecific prodrome of sore throat, fever, malaise, and headache, which eventually leads to inflammation of the parotid gland. Fortunately, symptomatic treatment is usually sufficient, and the illness resolves within one to two weeks.
However, mumps can lead to serious complications, with meningoencephalitis occurring in 10% of patients with parotitis, and orchitis occurring in 25% of postpubertal males affected by mumps. In about 15% of those affected by orchitis, it is bilateral.
It’s worth noting that the incubation period for mumps may vary slightly depending on the reference source. However, the correct answer should always fall within a reasonable range, so don’t be too concerned if the limits of the reference range differ slightly from what you may have read elsewhere.
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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 60-year-old man comes to the clinic 3 days after being hit on the left side of his head. He reports experiencing muffled hearing on the left side since the incident. Upon examination, there are no visible bruises, but both ears are covered by a thin, translucent layer of wax. Rinne's test reveals that the tuning fork is more audible when placed on the mastoid bone on the left side. On Weber's test, the sound is heard most clearly on the left side. What is the probable diagnosis?
Your Answer:
Correct Answer: Perforated eardrum
Explanation:Differentiating between tympanic membrane perforation and sensorineural hearing loss due to skull trauma is crucial. Rinne’s test can help identify conductive hearing loss in the affected ear, while Weber’s test can rule out sensorineural hearing loss on the right.
Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness
Rinne’s and Weber’s tests are used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test indicates that BC is better than AC, suggesting conductive deafness.
Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking the patient which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.
The table below summarizes the interpretation of Rinne and Weber tests. A normal result indicates that AC is greater than BC bilaterally and the sound is midline. Conductive hearing loss is indicated by BC being greater than AC in the affected ear and AC being greater than BC in the unaffected ear, with the sound lateralizing to the affected ear. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, with the sound lateralizing to the unaffected ear.
Overall, Rinne’s and Weber’s tests are useful tools for differentiating between conductive and sensorineural deafness, allowing for appropriate management and treatment.
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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 9-year-old girl undergoes pinnaplasty.
What is the most significant risk of the surgery that should be discussed with her parents?Your Answer:
Correct Answer: Imperfect result
Explanation:Pinnaplasty: A Solution for Congenitally Prominent Ears
Congenitally prominent ears can have a significant impact on a child’s emotional and behavioral well-being. Pinnaplasty, also known as otoplasty, is a surgical procedure that aims to improve the appearance of the auricle. It is typically performed on children between the ages of 5 and 14, but can be done at any age.
During the procedure, an incision is made behind the ear in the natural fold where the ear meets the head. The necessary amount of cartilage and skin is removed to achieve the desired effect. In some cases, the cartilage may also be trimmed and reshaped before being pinned back with permanent stitches.
While pinnaplasty is generally safe, incomplete correction of prominent ears is the most common undesirable outcome. Other potential complications include postoperative bleeding or fluid accumulation, infection, and scarring.
It’s important to note that pinnaplasty only addresses the external ear and doesn’t involve the middle ear or eardrum. As such, other complications are unlikely to occur. Overall, pinnaplasty can be an effective solution for those seeking to improve the appearance of congenitally prominent ears.
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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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You see a 28-year-old man who complains of painful mouth ulcers. He is in good health otherwise.
During the examination, you notice around 5 small and shallow aphthous ulcers on the inner lining of his mouth.
What is the accurate statement about aphthous mouth ulcers?Your Answer:
Correct Answer: Stopping smoking is a risk factor for aphthous mouth ulcers
Explanation:There are various factors that can contribute to the development of oral ulcers. These include smoking, deficiencies in iron, folic acid, or vitamin B12, and local trauma to the oral mucosa. Additionally, anxiety and exposure to certain foods such as chocolate, coffee, peanuts, and gluten products may also play a role. However, hormonal factors are not typically associated with the development of oral ulcers.
Aphthous mouth ulcers are painful sores that are circular or oval in shape and are found only in the mouth. They are not associated with any systemic disease and often occur repeatedly, usually starting in childhood. These ulcers can be caused by damage to the mouth, such as biting the cheek or brushing too hard, or may be due to a genetic predisposition. Other factors that can trigger these ulcers include stress, certain foods, stopping smoking, and hormonal changes related to the menstrual cycle.
Aphthous ulcers are characterized by their round or oval shape, a clearly defined margin, a yellowish-grey slough on the floor, and a red periphery. They usually appear on non-keratinized mucosal surfaces, such as the inside of the lips, cheeks, floor of the mouth, or undersurface of the tongue. In most cases, investigations are not necessary, but they may be considered if an underlying systemic disease is suspected.
Treatment for aphthous ulcers involves avoiding any factors that may trigger them and providing symptomatic relief for pain, discomfort, and swelling. This may include using a low potency topical corticosteroid, an antimicrobial mouthwash, or a topical analgesic. Most ulcers will heal within two weeks without leaving any scars. However, if a mouth ulcer persists for more than three weeks, it is important to seek urgent referral to a specialist.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 57
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 58
Incorrect
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A 60-year-old man who is a smoker presents with hoarseness of his voice, firm cervical nodes and difficulty in swallowing.
What is the most likely diagnosis?Your Answer:
Correct Answer: Squamous cell carcinoma of the larynx
Explanation:Types of Head and Neck Cancer: Symptoms and Characteristics
Squamous cell carcinoma is the most common type of cancer in the upper airway, with the larynx being the most likely location. Symptoms may include pain radiating to the ear, weight loss, and stridor in advanced cases. Small cell carcinoma of the larynx is rare. Adenocarcinoma of the hypopharynx is relatively rare and usually squamous cell carcinoma. Adenocarcinoma and squamous cell carcinoma are common varieties of oesophageal cancer, with dysphagia, anorexia, weight loss, vomiting, and gastrointestinal bleeding being red flag features. Squamous cell carcinoma is the most common type of tonsillar cancer, with symptoms including a sore throat, ear pain, a foreign body sensation, bleeding, and a neck mass. Tonsillar enlargement may be the only sign if the tumour growth is below the surface, or there may be a fungating mass.
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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 32-year-old man presents with recurrent itchy ears.
Which of the following statements about this condition is correct?Your Answer:
Correct Answer: It may be precipitated by overzealous use of cotton buds
Explanation:Understanding Otitis Externa: Myths and Facts
Otitis externa, commonly known as swimmer’s ear, is a condition that affects the skin of the external ear canal. Here are some common myths and facts about this condition:
Myth: Otitis externa is always bacterial in origin.
Fact: While bacterial pathogens are frequently involved, viral and fungal pathogens may also be seen, particularly after prolonged use of corticosteroid drops.Myth: If adequately treated, otitis externa is unlikely to recur.
Fact: Otitis externa is commonly recurrent, especially in the presence of a predisposing factor, such as a chronic underlying skin disease, immunodeficiency or diabetes.Myth: Systemic complications are common.
Fact: Severe infections may cause local lymphadenitis or cellulitis. Rarely, infection may invade the deeper adjacent structures and progress to necrotising (malignant) otitis externa, a condition that can cause serious morbidity and also mortality. This is mainly seen in immunocompromised individuals, particularly people with diabetes.Myth: The use of aminoglycoside antibiotics is contraindicated.
Fact: In a patient who doesn’t have grommets or a perforated eardrum, aminoglycosides (eg gentamicin) or polymyxin drops are not contraindicated. When the eardrum is not intact, there is concern about ototoxicity. If necessary, they can be used in these circumstances, with caution, by specialists.Debunking Myths About Otitis Externa
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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 42-year-old woman comes to the clinic with a left facial palsy. She reports that the weakness developed gradually over a few days. She is waiting for a referral to the hospital for a nodular swelling in the left parotid salivary gland, suspected to be caused by a stone. Her husband is currently taking oral aciclovir for shingles.
During the examination, a hard nodular mass is found over the tail of the left parotid gland, along with a lower motor neurone seventh nerve palsy.
What is the most appropriate next step?Your Answer:
Correct Answer: Urgent surgical referral
Explanation:Parotid Tumour with Facial Palsy
The presence of a hard, nodular mass over the tail of the parotid gland and facial palsy strongly suggest a parotid tumour with nerve infiltration. Urgent referral to a hospital for surgical review and possible biopsy under ultrasound guidance is necessary. Unfortunately, facial nerve function recovery is unlikely.
There is no indication of zoster infection or underlying inflammation, so aciclovir and prednisolone are not appropriate treatments. Sialography is useful for investigating salivary gland ducts and stones, but not for neoplastic disease.
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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 50-year-old woman has a slowly enlarging, unilateral, smooth, painless lump below her left ear.
What is the most likely diagnosis?Your Answer:
Correct Answer: Pleomorphic adenoma
Explanation:Salivary Gland Neoplasms: Common Benign Tumors and Signs of Malignancy
Salivary gland neoplasms are mostly benign, with pleomorphic adenoma being the most common. Pain may occur, and a persistent and unexplained neck lump warrants urgent referral. Mumps is not a likely cause as it typically affects both parotid glands. Lymphoma usually causes enlargement of multiple lymph nodes, while parotid carcinoma is much less common than pleomorphic adenoma. Malignant tumors may present with rapid growth, hardness, fixation, tenderness, lymph node involvement, and metastatic disease. Infiltration may affect local sensory nerves and the facial nerve. Reactive lymphadenopathy usually involves multiple lymph nodes and is transient.
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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 45-year-old man presents with complaints of dizziness that have developed over the past two weeks. He experiences episodes of vertigo when he turns his head, particularly when he turns over in bed. He denies any recent illness or injury. The vertigo lasts for several seconds at a time and he reports no hearing loss, ear pain, fullness, or ringing. On examination, there are no abnormalities in cranial nerve function, cerebellar signs, or Romberg's test. Dix-Hallpike testing is positive for rotatory vertigo and nystagmus.
What is the most appropriate pharmacological approach for this patient?Your Answer:
Correct Answer: Promethazine 25 mg nocte
Explanation:Management of Benign Paroxysmal Positional Vertigo
This patient is exhibiting typical signs and symptoms of benign paroxysmal positional vertigo (BPPV). It is important to note that vestibular sedatives are not effective in managing BPPV. However, the Epley manoeuvre can be performed and taught to the patient, which has been shown to effectively reduce or eliminate symptoms.
It is also important to remember that no treatment needed is a valid management option for BPPV. This concept is particularly relevant for the MRCGP AKT exam, which tests primary care management skills. As a primary care physician, it is important to recognize when doing nothing is the most appropriate course of action for a patient. Don’t hesitate to select this option if it is the best choice for the patient’s condition.
Overall, the management of BPPV involves a combination of patient education, reassurance, and appropriate interventions such as the Epley manoeuvre.
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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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A 36-year-old woman has been receiving treatment for the past three weeks for otitis externa with flumetasone/clioquinol 0.02%/1%, followed by gentamicin 0.3% w/v and hydrocortisone acetate 1% ear drops. She acquired the condition while on vacation in Spain. She is now experiencing increasing itchiness in her ears. During examination, her ears have abundant discharge with black spots on a white background. What is the most appropriate next step in managing this patient?
Your Answer:
Correct Answer: Clotrimazole solution
Explanation:Treatment Options for Fungal Otitis Externa
Fungal otitis externa is a common ear infection that can be difficult to diagnose and treat. Patients who have had prolonged courses of steroid and antibiotic drops are particularly susceptible to this type of infection. Symptoms include pruritus and discharge, which may not respond to antibiotics. The most common fungal agents are Aspergillus and Candida, which can be treated with topical clotrimazole. Topical ciprofloxacin is not effective against fungal infections, and co-amoxiclav tablets should not be used. Sofradex® ear drops, which contain steroids, may exacerbate symptoms. If initial treatment with antifungal medication is unsuccessful, referral to an Ear, Nose and Throat specialist may be necessary for further evaluation and treatment.
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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 50-year-old woman comes to her General Practitioner with concerns about a lump in her throat that she has been feeling for the past six months. She reports feeling the lump even when she is not swallowing. Upon examination, her oropharynx, ears, nose, and neck appear normal. She is also a non-smoker.
What would be a significant cause for worry in a patient with these symptoms who is 50 years old?Your Answer:
Correct Answer: Left-sided ear pain
Explanation:Understanding Unilateral Ear Pain and Globus Sensation
Unilateral ear pain in adults with normal otoscopy findings may indicate cancer of the base of the tongue, especially if accompanied by persistent hoarseness, dysphagia, weight loss, or a swelling in the neck. Risk factors for head and neck cancers include smoking and alcohol consumption. However, if the pain is worse between meals and eating or drinking alleviates the symptoms, it is more likely to be globus sensation, which is the feeling of a lump in the throat that doesn’t affect swallowing function. If the symptom persists for six months without affecting swallowing, it is less likely to be a worrying cause such as laryngeal or esophageal cancer. Intermittent symptoms are also less likely to indicate a malignant cause, as they are typical for globus and often exacerbated by stress.
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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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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 66
Incorrect
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A child presents with an inability to swallow, a ‘hot potato’ voice and an asymmetrical tonsillitis.
What is the most effective treatment?Your Answer:
Correct Answer: Drainage of abscess
Explanation:Treatment for Quinsy: Drainage, Antibiotics, and Corticosteroids
Quinsy, also known as peritonsillar abscess, is a serious complication of tonsillitis that requires urgent treatment. Symptoms include a displaced uvula, enlarged oropharynx, and a hot potato voice. The recommended treatment involves drainage of the abscess via needle and scalpel incision, followed by antibiotics such as penicillin, cephalosporins, co-amoxiclav, or clindamycin. In some cases, intravenous corticosteroids may also be beneficial. Watchful waiting is not recommended, as the infection can spread and lead to serious complications. Prompt treatment is necessary to prevent aspiration, airway obstruction, and other life-threatening 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 67
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 68
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 69
Incorrect
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Which of the following characteristics is the least indicative of otosclerosis diagnosis?
Your Answer:
Correct Answer: Onset after the age of 50 years
Explanation: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 70
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:
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 71
Incorrect
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A 30 year old man comes to the clinic complaining of anorexia, feverishness, and vertigo that have been going on for four days. He reports having difficulty balancing and staying upright when walking, as well as experiencing mild vertigo episodes lasting 10-20 minutes at a time. His hearing is unaffected. During the examination, some cervical lymphadenopathy is observed, but otherwise, there are no notable findings. What is the probable diagnosis?
Your Answer:
Correct Answer: Vestibular neuronitis
Explanation:A typical case of vestibular neuritis involves a patient who has recently recovered from an upper respiratory tract infection and experiences recurrent episodes of vertigo accompanied by nausea and vomiting. There is usually no hearing loss or tinnitus present. Prior to the onset of symptoms, the patient may have experienced viral symptoms. Unlike labyrinthitis, vestibular neuritis doesn’t cause hearing loss or tinnitus. If a patient experiences any neurological symptoms or signs, acute deafness, new types of headaches, or vertical nystagmus, urgent referral should be considered.
Vertigo is a condition characterized by a false sensation of movement in the body or environment. There are various causes of vertigo, each with its own unique characteristics. Viral labyrinthitis, for example, is typically associated with a recent viral infection, sudden onset, nausea and vomiting, and possible hearing loss. Vestibular neuronitis, on the other hand, is characterized by recurrent vertigo attacks lasting hours or days, but with no hearing loss. Benign paroxysmal positional vertigo is triggered by changes in head position and lasts for only a few seconds. Meniere’s disease, meanwhile, is associated with hearing loss, tinnitus, and a feeling of fullness or pressure in the ears. Elderly patients with vertigo may be experiencing vertebrobasilar ischaemia, which is accompanied by dizziness upon neck extension. Acoustic neuroma, which is associated with hearing loss, vertigo, and tinnitus, is also a possible cause of vertigo. Other causes include posterior circulation stroke, trauma, multiple sclerosis, and ototoxicity from medications like gentamicin.
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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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A 43-year-old man presents to you with complaints of tinnitus and hearing loss for the past few weeks. He has a history of chronic obstructive pulmonary disease and is currently on medications including salbutamol inhaler, azithromycin, beclomethasone-formoterol (Fostair) inhaler, tiotropium inhaler, and glycopyrronium bromide.
Upon examination, you note a positive Rinne test bilaterally with reduced hearing on both sides, worse on the left. The Weber test lateralizes to the right, and otoscopy is normal. You suspect a sensorineural hearing loss and urgently refer the patient to an ENT specialist.
Which medication from his current regimen may be contributing to his symptoms and should be discontinued?Your Answer:
Correct Answer: Azithromycin
Explanation:Azithromycin has been found to have a negative impact on hearing, causing tinnitus and sensorineural hearing loss. Patients should discontinue use of the medication immediately if these symptoms occur to prevent irreversible hearing damage. While most cases of hearing loss will improve, caution should be exercised when taking this medication.
Salbutamol and beclomethasone-formoterol are associated with common side effects such as arrhythmias, headaches, dizziness, nausea, palpitations, tremor, and hypokalaemia (with high doses). Tiotropium and glycopyrronium are also associated with side effects such as arrhythmias, cough, headaches, dry mouth, and nausea.
Macrolides are a class of antibiotics that include erythromycin, clarithromycin, and azithromycin. They work by blocking translocation during bacterial protein synthesis, ultimately inhibiting bacterial growth. While they are generally considered bacteriostatic, their effectiveness can vary depending on the dose and type of organism being treated. Resistance to macrolides can occur through post-transcriptional methylation of the 23S bacterial ribosomal RNA.
However, macrolides can also have adverse effects. They may cause prolongation of the QT interval and gastrointestinal side-effects, such as nausea. Cholestatic jaundice is a potential risk, but using erythromycin stearate may reduce this risk. Additionally, macrolides are known to inhibit the cytochrome P450 isoenzyme CYP3A4, which metabolizes statins. Therefore, it is important to stop taking statins while on a course of macrolides to avoid the risk of myopathy and rhabdomyolysis. Azithromycin is also associated with hearing loss and tinnitus.
Overall, while macrolides can be effective antibiotics, they do come with potential risks and side-effects. It is important to weigh the benefits and risks before starting a course of treatment with these antibiotics.
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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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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 74
Incorrect
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A 55-year-old smoker requests more antibiotics for a left-sided earache. He had seen a locum for tonsillitis three weeks ago, which was mainly on the left side, and was prescribed penicillin V. On examination, his ears appear normal.
What is the most appropriate course of action?Your Answer:
Correct Answer: Examine the pharynx
Explanation:Treatment Options for Different Ear Conditions
Examination of the Pharynx for Unilateral Ear Pain
If a patient presents with unilateral ear pain and a normal appearance of the ear, it is important to examine the pharynx and tonsils. Tonsillar carcinoma may cause referred pain and present with unilateral tonsillar enlargement. Prognosis is poor, but surgery and radiotherapy may be helpful.
No Antibiotics Needed for Unresolved Symptoms
If a patient’s symptoms have not improved despite initial treatment, a delayed prescription for antibiotics will not help and may delay diagnosis. Further investigation should be considered.
Exercises for Eustachian Tube Dysfunction
Eustachian tube dysfunction may cause muffled sounds or a popping/clicking sensation. Treatment may include exercises such as swallowing, yawning, or chewing gum to help open the Eustachian tube.
Topical Antibiotics for Otitis Externa
Otitis externa may cause a swollen and erythematous ear canal with discharge or debris. Topical antibiotics such as neomycin or ciprofloxacin may be prescribed to treat this condition. However, the appearance of a normal ear canal and tympanic membrane doesn’t indicate a need for topical antibiotics.
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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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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 76
Incorrect
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A 25-year-old man presents to the General Practitioner with a swollen ear. He plays amateur rugby and was punched during a match the previous day. The upper pinna is fluctuant and mildly erythematous, but there are no other injuries. What is the most suitable management option?
Your Answer:
Correct Answer: Early drainage and compression
Explanation:Auricular Haematoma: Causes, Symptoms, and Treatment
Auricular haematoma is a common facial injury that results from direct trauma to the anterior auricle. It is often seen in athletes such as wrestlers, rugby players, and footballers. The condition occurs when shearing forces cause separation of the perichondrium from the underlying cartilage, leading to tearing of the perichondrial blood vessels and hematoma formation.
If left untreated, the haematoma can lead to avascular necrosis of the auricular cartilage, resulting in a ‘cauliflower ear’ deformity. To prevent this, evacuation of the haematoma is necessary. This can be done through aspiration with a 10 ml syringe attached to a wide needle or by incision and drainage. Compression is also necessary to prevent reoccurrence.
However, infection may be a complication, and if it worsens, patients may need to be admitted to the hospital for intravenous antibiotics and surgical exploration. Patients with recurrent haematomas or haematomas more than seven days old may also need surgical debridement.
In conclusion, auricular haematoma is a serious condition that requires prompt treatment to prevent complications. Athletes and individuals who engage in activities that put them at risk of this injury should take precautions to avoid it.
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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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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 78
Incorrect
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A 2-year-old boy has cerebral palsy. He presents with profuse rhinorrhoea, pyrexia and noisy respiration. The noise is a heavy-snoring inspiratory sound. His tonsils are enlarged and inflamed.
Which of the following describes the sound that this child is making?
Your Answer:
Correct Answer: Stertorous
Explanation:Stertorous refers to a noisy and laboured breathing sound, often heard during deep sleep or coma, caused by obstruction in the upper airways. Hypernasal speech is an abnormal voice resonance due to increased airflow through the nose during speech, caused by an incomplete closure of the soft palate and/or velopharyngeal sphincter. Rales, also known as crackles or crepitations, are clicking or crackling noises heard during auscultation, caused by the popping open of small airways and alveoli collapsed by fluid or exudate during expiration. Stridor is a high-pitched sound occurring during inhalation or exhalation, indicating respiratory obstruction, commonly caused by croup, foreign bodies, or allergic reactions. Wheezing is a high-pitched whistling sound made while breathing, caused by narrowed airways, typically in asthma.
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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 47-year-old man visits his primary care physician with concerns about a persistent ulcer on his tongue that has been growing for a few weeks. He is a heavy smoker, consuming 30 cigarettes a day, and drinks alcohol regularly. Upon examination, the physician notes bilateral submandibular lymphadenopathy, multiple dental caries, and a 1-cm ulcer on the lateral border of his tongue. What is the most suitable course of action for managing this patient?
Your Answer:
Correct Answer: Refer under 2-week rule
Explanation:Diagnosis and Management of Tongue Cancer
Tongue cancer is a common type of oral cancer, with about 75% of cases occurring on the mobile tongue. It typically presents as a persistent growing lesion, which may be painless or painful. Carcinoma of the tongue base is often clinically silent until it infiltrates the musculature. Risk factors for tongue cancer include poor dental hygiene, smoking, drinking, and betel and pan consumption in ethnic minorities.
All suspicious tongue lesions should be referred urgently under the 2-week rule for exclusion of malignancy. Treatment options for tongue cancer include surgery and radiotherapy. The overall 5-year survival rates are 60% for women and 40% for men.
It is important to note that prescribing Tri Adcortyl® ointment or antibiotics would not be appropriate for the management of tongue cancer. Instead, urgent referral for further evaluation and treatment is necessary.
In some cases, a chancre caused by syphilis may present as a solitary, painless, indurated, reddish ulcer on the oral mucosa. Therefore, testing for syphilis and treating if positive may be necessary in some cases. However, it is important to differentiate between syphilis and tongue cancer, as the management and prognosis differ significantly.
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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 67-year-old male comes to the GP with a history of hearing loss for 6 months due to ototoxicity from furosemide. Upon examination, he has severe bilateral sensorineural hearing loss and can only hear spoken words if they are within 10 cm of him. He has been using hearing aids for 4 months, but they are not very effective. What aspect of his history indicates that cochlear implantation may be necessary?
Your Answer:
Correct Answer: Duration of hearing aid use
Explanation:Before considering a cochlear implant as a management strategy for hearing loss in adults, a failed trial of hearing aids for at least 3 months is generally required, regardless of the cause, age at the time of hearing loss, duration, or severity of the condition. In the case of this patient, the duration of his hearing aid use is the most significant factor suggesting the appropriateness of a cochlear implant.
A cochlear implant is an electronic device that can be given to individuals with severe-to-profound hearing loss. The suitability for a cochlear implant is determined by audiological assessment and/or difficulty developing basic auditory skills in children, and a trial of appropriate hearing aids for at least 3 months in adults. The causes of severe-to-profound hearing loss can be genetic, congenital, idiopathic, infectious, viral-induced sudden hearing loss, ototoxicity, otosclerosis, Ménière disease, or trauma. Prior to an assessment for the cochlear implant, patients should have exhausted all medical therapies aimed at targeting any underlying pathological process contributing to the loss of hearing.
Surgical implantation may be complicated by infection, facial paralysis due to nerve injury intra-operatively, cerebrospinal fluid (CSF) leakage, and meningitis. Patients are discharged for the postoperative physical recovery of the implantation site and generally return to outpatient clinic 3-5 weeks post-op for device stimulation. Contraindications to consideration for cochlear implant include lesions of cranial nerve VIII or in the brain stem causing deafness, chronic infective otitis media, mastoid cavity or tympanic membrane perforation, and cochlear aplasia.
The device has both internal and external components. Externally, the microphone recognises the environmental sound and sends it to the sound processor. This, in turn, transforms the impulses received into a digital signal that which is then transferred to the transmitter coil. The transmitter coil conveys the signal to the internal components. Internally, a receiver, which magnetically connected to, and sits directly above the transmitter coil, and receives the impulses from the external apparatus which are then processed by a set of electrodes. The electrodes do the work that would be performed by the inner ear hair cells in a ‘normal’ ear. The brain can then process these signals to comprehend sound.
Rechargeable batteries can be used to power the apparatus and life span depends upon usage and the individual device. Hearing link describes cochlear implants as ‘…the world’s most successful medical prostheses in that less than 0.2% of recipients reject it or do not use it and the failure rate needing reimplantation is around 0.5%.’ It is important for patients to demonstrate an understanding of what to expect from cochlear implantation, including comprehension of the likely limitations of the device. Patients should also demonstrate an interest in using the
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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 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 82
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 83
Incorrect
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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:
Correct Answer: Otosclerosis
Explanation:Otosclerosis, which is an inherited condition, can cause hearing loss in young adults. The symptoms of slowly progressing bilateral conductive hearing loss and a positive family history are typical of otosclerosis.
Presbyacusis, on the other hand, is a type of hearing loss that occurs with aging and is unlikely to affect a young woman. Sensorineural hearing loss is caused by acoustic neuroma, while Meniere’s disease is characterized by episodes of vertigo.
Understanding Otosclerosis: A Progressive Conductive Deafness
Otosclerosis is a medical condition that occurs when normal bone is replaced by vascular spongy bone. This condition leads to a progressive conductive deafness due to the fixation of the stapes at the oval window. It is an autosomal dominant condition that typically affects young adults, with onset usually occurring between the ages of 20-40 years.
The main features of otosclerosis include conductive deafness, tinnitus, a normal tympanic membrane, and a positive family history. In some cases, patients may also experience a flamingo tinge, which is caused by hyperemia and affects around 10% of patients.
Management of otosclerosis typically involves the use of a hearing aid or stapedectomy. A hearing aid can help to improve hearing, while a stapedectomy involves the surgical removal of the stapes bone and replacement with a prosthesis.
Overall, understanding otosclerosis is important for individuals who may be at risk of developing this condition. Early diagnosis and management can help to improve hearing and prevent further complications.
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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 63-year-old woman comes in with bilateral tinnitus. She denies any changes in her hearing or other ear-related symptoms. Upon examination, there are no abnormalities found in her ears or cranial nerves. Which medication is she likely to have started taking recently?
Your Answer:
Correct Answer: Quinine
Explanation: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 85
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 86
Incorrect
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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:
Correct 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 87
Incorrect
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A 67-year-old man comes to the clinic complaining of vertigo that has been present for the past 5 weeks after a recent respiratory tract infection. He reports feeling nauseous and unsteady on his feet, especially when turning over in bed. He denies any hearing loss or ringing in his ears. A cerebellar stroke was ruled out when he was initially evaluated at the hospital.
During the examination, you observe fine-horizontal nystagmus. However, the neurological examination is otherwise unremarkable, and his hearing and otoscopy results are normal. You suspect that he may be suffering from vestibular neuronitis.
What would be the most appropriate next step in managing this patient's condition?Your Answer:
Correct Answer: Refer the patient to a balance specialist for consideration of vestibular rehabilitation exercises
Explanation:Vestibular rehabilitation exercises are the recommended treatment for chronic symptoms of vestibular neuronitis. While short-term use of oral prochlorperazine or antihistamines can provide relief, they should not be used for more than three days as they may hinder the body’s compensatory mechanisms and delay recovery.
NICE CKS guidance advises against the use of corticosteroids, benzodiazepines, or antiviral medication as there is no evidence of their effectiveness.
If symptoms persist for six weeks or more, patients should be referred to a specialist for further investigation and vestibular rehabilitation exercises. It is crucial to note that urgent referral is necessary if symptoms do not improve within one week of initial treatment to rule out other potential causes.
Understanding Vestibular Neuronitis
Vestibular neuronitis is a type of vertigo that typically occurs after a viral infection. It is characterized by recurrent episodes of vertigo that can last for hours or days, accompanied by nausea and vomiting. Horizontal nystagmus is also a common symptom, but there is no hearing loss or tinnitus.
It is important to differentiate vestibular neuronitis from other conditions such as viral labyrinthitis and posterior circulation stroke. The HiNTs exam can be used to distinguish between these conditions.
Treatment for vestibular neuronitis typically involves medication to alleviate symptoms, such as buccal or intramuscular prochlorperazine for severe cases, or a short course of oral medication for less severe cases. Vestibular rehabilitation exercises are also recommended for patients who experience chronic symptoms.
Understanding the symptoms and treatment options for vestibular neuronitis can help individuals manage this condition and improve their quality of life.
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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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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 89
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 90
Incorrect
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A 16-year-old female presents with a sore throat. Upon examination, she has enlarged tonsils on both sides and tender cervical lymphadenopathy. Her medical history shows that she has had six episodes of tonsillitis in the past year and has missed several days of school due to her sore throat. With a Centor score of 3/4, you decide to prescribe penicillin V. What other treatment options should be considered?
Your Answer:
Correct Answer: Refer to ENT for consideration of a tonsillectomy
Explanation:The frequency of tonsillectomies has significantly decreased in recent years due to increased recognition of the possible risks and limited advantages. Nevertheless, the patient meets the referral standards outlined by NICE.
Tonsillitis and Tonsillectomy: Complications and Indications
Tonsillitis is a condition that can lead to various complications, including otitis media, peritonsillar abscess, and, in rare cases, rheumatic fever and glomerulonephritis. Tonsillectomy, the surgical removal of the tonsils, is a controversial procedure that should only be considered if the person meets specific criteria. According to NICE, surgery should only be considered if the person experiences sore throats due to tonsillitis, has five or more episodes of sore throat per year, has been experiencing symptoms for at least a year, and the episodes of sore throat are disabling and prevent normal functioning. Other established indications for a tonsillectomy include recurrent febrile convulsions, obstructive sleep apnoea, stridor, dysphagia, and peritonsillar abscess if unresponsive to standard treatment.
Despite the benefits of tonsillectomy, the procedure also carries some risks. Primary complications, which occur within 24 hours of the surgery, include haemorrhage and pain. Secondary complications, which occur between 24 hours to 10 days after the surgery, include haemorrhage (most commonly due to infection) and pain. Therefore, it is essential to weigh the benefits and risks of tonsillectomy before deciding to undergo 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 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 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 93
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 94
Incorrect
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A 70-year-old man visits the GP clinic after waking up unable to move the left side of his face. His wife observed slight drooling from the left side and difficulty fully closing his left eyelid. He has no significant medical history. Which symptom is most consistent with Bell's palsy?
Your Answer:
Correct Answer: Paralysis of whole face of the affected side
Explanation:Bell’s palsy results in complete paralysis on one side of the face as it affects the lower motor neurones. In contrast, upper motor neurone-related conditions like stroke spare the forehead, which exhibits some wrinkling due to the bilateral nerve innervation of the forehead by upper motor neurones.
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 95
Incorrect
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A 32-year-old woman presents to the General Practitioner with sudden onset of unilateral sensorineural deafness. She has no prior history of ear issues and is not currently taking any medications.
What is the most probable diagnosis?Your Answer:
Correct Answer: Idiopathic
Explanation:Idiopathic Unilateral Sudden Sensorineural Hearing Loss: Causes, Symptoms, and Treatment Options
Idiopathic unilateral sudden sensorineural hearing loss (ISSHL) is a rare condition characterized by a sudden loss of hearing in one ear, often accompanied by tinnitus, vertigo, and aural fullness. The exact cause of ISSHL is not well understood, but it may be linked to viral infections, vascular issues, or immune-mediated inner ear disease.
Patients with ISSHL should be referred for urgent treatment, typically involving corticosteroids. Other treatment options include low molecular weight dextran, carbogen, hyperbaric oxygen, low-density lipid apheresis, aciclovir, and stellate ganglion block. However, there is limited evidence to support the effectiveness of any one treatment.
Many patients with ISSHL are admitted to the hospital, but fortunately, spontaneous recovery rates are generally good. Studies have reported recovery rates ranging from 47-63%, although different criteria for recovery were used in each study.
In summary, ISSHL is a rare but serious condition that requires prompt medical attention. While treatment options exist, the evidence for their effectiveness is limited, and many patients may recover spontaneously.
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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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A 50-year-old woman presents with a large thyroid swelling, difficulty breathing on lying flat and slight dysphagia. What is the most appropriate investigation to delineate the size and extent of the goitre?
Your Answer:
Correct Answer: Computed tomography (CT) scan
Explanation:Diagnostic Imaging Techniques for Thyroid Evaluation
Thyroid evaluation involves the use of various diagnostic imaging techniques to determine the size, extent, and function of the thyroid gland. Computed tomography (CT) scanning is a precise method that provides a better assessment of the effect of the thyroid gland on nearby structures. Barium swallow is useful in assessing oesophageal obstruction, while chest X-ray can determine the extent of goitre and the presence of calcification. Ultrasound is commonly used to guide biopsy of the thyroid and detect and characterise thyroid nodules. Radionuclide uptake and scanning using technetium isotope are used to evaluate thyroid function and anatomy in hyperthyroidism, including the assessment of thyroid nodules. These diagnostic imaging techniques play a crucial role in the accurate diagnosis and management of thyroid disorders.
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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 19-year-old female presents to you with complaints of a sore throat. She reports feeling sick for the past three days with a high fever and painful throat. She has been self-medicating with an over-the-counter flu remedy containing paracetamol. Upon examination, she has a temperature of 37.1°C, tender anterior cervical lymphadenopathy, visible tonsillar exudate, and a dry cough. What is this patient's Centor score?
Your Answer:
Correct Answer: 3
Explanation:Understanding the Centor Score for Tonsillitis
The Centor score is a tool used by clinicians to differentiate between viral and bacterial tonsillitis, which helps guide the use of antibiotics. It consists of four criteria: the presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, a history of fever, and absence of cough. If at least three out of the four criteria are met, it suggests a bacterial infection and antibiotics may be beneficial. Conversely, if less than three criteria are met, antibiotics are unlikely to be needed. It’s important to note that the Centor score is based on a history of fever, not necessarily a fever at the time of being seen. The McIsaac modification adds a point for patients under 15 years old and deducts a point for those over 45 years old. The Centor score is a helpful tool, but it should not replace clinical judgement.
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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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What is a true statement about tuning fork tests used for hearing?
Your Answer:
Correct Answer: A false negative Rinne occurs in conductive deafness
Explanation:Tuning Forks for Hearing and Vibration Testing
A tuning fork is a useful tool for testing both hearing and vibration. However, not all tuning forks are created equal. A 128 tuning fork is suitable for testing vibration, but it is not reliable for hearing. For hearing tests, the 512 cps fork is the best option, although a compromise frequency of 256 can also be used. It’s important to note that compromise frequencies are less effective for both hearing and vibration.
When conducting lateralizing tests, the Weber test is commonly used. However, it is less reliable than the Rinne test. False negative Rinne results can occur in cases of sensorineural deafness. Therefore, it’s important to choose the appropriate tuning fork for the specific test being conducted.
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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 45-year-old man presents with decreased hearing in his right ear. Upon examination, you observe that his right ear canal is obstructed with wax, while the left ear is unobstructed. What results would you anticipate when conducting Rinne and Weber tests?
Your Answer:
Correct Answer: Weber: sound localises to the right; Rinne: BC > AC on the right and AC > BC on the left
Explanation:The Rinne and Weber tests are utilized to differentiate between conductive and sensorineural hearing loss.
In the case of this individual, there is an obstruction of wax in the right ear canal, which would result in a conductive hearing loss on the right side.
During the Weber test, the patient should be able to locate the sound to the side of a conductive hearing loss, as bone conduction is enhanced. The sound will be located away from a sensorineural hearing loss.
If there is a conductive hearing loss, the Rinne test will be negative, as bone conduction is better than air conduction. It will be positive if air conduction is better than bone conduction, which may be the case for mild-moderate sensorineural hearing loss or if there is normal hearing.
In this instance, the wax blockage causes a conductive hearing loss on the right side. Therefore, during the Weber test, the sound should be localized to the right, and Rinne should be negative on the right side and positive on the left.
Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness
Rinne’s and Weber’s tests are used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test indicates that BC is better than AC, suggesting conductive deafness.
Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking the patient which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.
The table below summarizes the interpretation of Rinne and Weber tests. A normal result indicates that AC is greater than BC bilaterally and the sound is midline. Conductive hearing loss is indicated by BC being greater than AC in the affected ear and AC being greater than BC in the unaffected ear, with the sound lateralizing to the affected ear. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, with the sound lateralizing to the unaffected ear.
Overall, Rinne’s and Weber’s tests are useful tools for differentiating between conductive and sensorineural deafness, allowing for appropriate management and treatment.
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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 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 101
Incorrect
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Which of the following patients is most likely to develop nasal polyps?
Your Answer:
Correct Answer: A 40-year-old man
Explanation:Male adults are the most commonly affected by nasal polyps.
Understanding Nasal Polyps
Nasal polyps are a relatively uncommon condition affecting around 1% of adults in the UK. They are more commonly seen in men and are not typically found in children or the elderly. There are several associations with nasal polyps, including asthma (particularly late-onset asthma), aspirin sensitivity, infective sinusitis, cystic fibrosis, Kartagener’s syndrome, and Churg-Strauss syndrome. When asthma, aspirin sensitivity, and nasal polyposis occur together, it is known as Samter’s triad.
The most common features of nasal polyps include nasal obstruction, rhinorrhoea, sneezing, and a poor sense of taste and smell. However, if a patient experiences unilateral symptoms or bleeding, further investigation is always necessary.
If a patient is suspected of having nasal polyps, they should be referred to an ear, nose, and throat (ENT) specialist for a full examination. Treatment typically involves the use of topical corticosteroids, which can shrink polyp size in around 80% of patients. With proper management, most patients with nasal polyps can experience relief from their symptoms.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 102
Incorrect
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A 78-year-old woman comes to the clinic with a sudden cough that has lasted for four days and a dry throat. She feels sick but has no fever. Her lung examination is normal. Which of the following is not a reason to prescribe antibiotics immediately?
Your Answer:
Correct Answer: Hoarseness and/or laryngitis accompanying the cough
Explanation:Factors to Consider When Prescribing Antibiotics for Respiratory Infections
When considering prescribing antibiotics for respiratory infections, it is important to take into account various risk factors that may increase the likelihood of complications. While antibiotics may be necessary in some cases, their use should be weighed against potential adverse effects and the development of antibiotic-resistance patterns.
One factor to consider is hoarseness and/or laryngitis accompanying the cough. In most cases, laryngitis is mild and self-limiting, and antibiotics may not be necessary. However, they may be considered in patients with persistent symptoms.
Another factor to consider is a history of congestive cardiac failure. For patients between 65 and 79 years, two risk factors should be present before prescribing antibiotics.
Current use of oral glucocorticoids is also a risk factor, as these patients are immunosuppressed and may be more susceptible to complications from respiratory infections.
Diabetes and hospitalization in the previous year are also risk factors for complications and should be taken into account when considering antibiotic prescriptions.
Overall, it is important to carefully evaluate each patient’s individual risk factors before deciding whether antibiotics are necessary for the treatment of respiratory infections.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 103
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 104
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 105
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 106
Incorrect
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A 30-year-old female patient complains of recurrent episodes of 'dizziness'. These episodes usually last for 30-60 minutes and happen every few days. The patient experiences a sensation of the room spinning and often feels nauseous during these attacks. Additionally, there is a 'roaring' sensation in the left ear. Otoscopy shows no abnormalities, but Weber's test indicates localization to the right ear. What is the probable diagnosis?
Your Answer:
Correct Answer: Meniere's disease
Explanation:The Weber’s test in sensorineural hearing loss indicates that the sound is perceived more strongly in the ear opposite to the affected ear.
Meniere’s disease is a condition that affects the inner ear and its cause is unknown. It is more commonly seen in middle-aged adults but can occur at any age and affects both men and women equally. The condition is characterized by the excessive pressure and progressive dilation of the endolymphatic system. The main symptoms of Meniere’s disease are recurrent episodes of vertigo, tinnitus, and sensorineural hearing loss. Vertigo is usually the most prominent symptom, but patients may also experience a sensation of aural fullness or pressure, nystagmus, and a positive Romberg test. These episodes can last from minutes to hours and are typically unilateral, but bilateral symptoms may develop over time.
The natural history of Meniere’s disease is that symptoms usually resolve in the majority of patients after 5-10 years. However, most patients will be left with some degree of hearing loss, and psychological distress is common. ENT assessment is required to confirm the diagnosis, and patients should inform the DVLA as the current advice is to cease driving until satisfactory control of symptoms is achieved. Acute attacks can be managed with buccal or intramuscular prochlorperazine, and admission to the hospital may be required. Prevention strategies include the use of betahistine and vestibular rehabilitation exercises, which may be beneficial.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 107
Incorrect
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A 23-year-old male presents with hearing difficulties. You conduct an assessment of his auditory system, which includes Rinne's and Weber's tests:
Rinne's test: Left ear - bone conduction > air conduction; Right ear - air conduction > bone conduction
Weber's test: Lateralizes to the left side
What is the significance of these
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