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Question 1
Correct
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A 55-year-old man presents with unilateral nasal obstruction caused by soft tissue swelling and bleeding from the same side of the nose. What is the most suitable next step?
Your Answer: Direct specialist visualisation of the nasal passages
Explanation:Unilateral Nasal Obstruction: Possible Causes and Management
Unilateral nasal obstruction can be caused by various factors, including nasal polyps, infection, and neoplastic processes. If the obstruction is accompanied by soft tissue blockage and unilateral epistaxis, the possibility of a neoplastic process should be considered, and direct visualisation of the area in an ear, nose, and throat clinic is necessary. Nasopharyngeal carcinoma is a rare but possible cause of unilateral nasal obstruction.
Aside from neoplastic processes, other nasal tumors that may cause unilateral nasal obstruction include inverted papilloma, sarcoma, lymphoma, olfactory neuroblastoma, and juvenile nasopharyngeal angiofibroma.
Using nasal decongestants for prolonged periods is not recommended as it may cause rebound congestion of the nasal mucosa. Antibiotics are not normally indicated for nasal blockage caused by the common cold, influenza virus, or rhinosinusitis. Topical corticosteroids may be beneficial in allergic rhinitis and some cases of vasomotor rhinitis, while corticosteroid drops are used in the medical management of nasal polyps. Oral steroids are not typically used in the management of any form of nasal obstruction.
In summary, the management of unilateral nasal obstruction depends on the underlying cause, and direct specialist visualisation of the nasal passages is necessary for proper diagnosis and treatment.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 2
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 3
Incorrect
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A 48-year-old man comes to the clinic with an enlarged and discoloured filiform papillae on his tongue. The upper surface of his tongue appears black in colour, with the tip and sides being spared. Although he has no symptoms, he is worried about the appearance. The patient has no significant medical history, takes no medication, and is in good health. There are no oral cavity or tongue-related focal lesions. What is the best initial management strategy?
Your Answer:
Correct Answer: Provide advice on good oral hygiene
Explanation:Black hairy tongue is a harmless condition that causes enlargement and discoloration of the filiform papillae of the tongue, resulting in a hairy appearance. Also known as lingua villosa nigra, this condition can be caused by certain medications, poor oral hygiene, tobacco and alcohol use, colored drinks, dehydration, and hyposalivation. The use of chlorhexidine or peroxidase-containing mouthwashes can also aggravate the condition. However, hairy tongue is typically self-limiting and can be managed by advising good oral hygiene practices such as regular brushing, gentle tongue scraping, and avoiding smoking and excessive alcohol consumption.
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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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A 25-year-old female complains of painful chewing and clicking in her jaw accompanied by a squeezing headache. She denies any joint pains and appears to be in good health. During the examination, she was able to open her mouth normally but experienced pain when opening wider. Mild pain was observed upon palpation of the area, and her temperature was 36.4ºC. What is the best course of action?
Your Answer:
Correct Answer: Mild analgesia, heat packs, avoid exacerbating foods
Explanation:Patients with suspected temporomandibular joint dysfunction should be encouraged to practice early self-management techniques to control their symptoms and limit functional impairment. These techniques include using simple analgesics like paracetamol or ibuprofen, applying heat packs to the affected area, and avoiding hard or crunchy foods that can exacerbate the pain. With proper self-management, patients can expect to recover within 2-3 months.
If temporal arteritis is suspected, investigations such as ESR and temporal biopsy may be necessary. This condition presents with a throbbing headache, an obvious temporal artery, and claudication when chewing, and requires immediate treatment with corticosteroids to prevent vision loss.
While referral to a dentist may be necessary if self-management techniques are ineffective, an x-ray of the mandible is not required for diagnosis. Strong analgesia and opioids should be avoided, as simple analgesia is just as effective and carries fewer risks. X-rays are also unnecessary, as TMJ dysfunction is a clinical diagnosis that doesn’t require imaging to manage.
Understanding Temporomandibular Joint Dysfunction
Temporomandibular joint dysfunction (TMJ) is a condition that affects the jaw joint and the muscles that control its movement. It is characterized by pain in the TMJ area, which may radiate to the head, neck, or ear. Patients may also experience restricted jaw motion, making it painful to chew or speak. Additionally, they may notice clicking or other noises when moving their jaw.
To manage TMJ, healthcare professionals may recommend soft foods to reduce the strain on the jaw. Simple analgesia, such as paracetamol and NSAIDs, can also help alleviate pain. Short courses of benzodiazepines may be prescribed to help relax the muscles and reduce anxiety. It is also important to seek a review by a dentist to rule out any dental issues that may be contributing to the condition.
In summary, TMJ is a painful condition that affects the jaw joint and muscles. It can be managed through a combination of lifestyle changes, medication, and dental care. By understanding the symptoms and seeking appropriate treatment, patients can improve their quality of life and reduce the impact of TMJ on their 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 5
Incorrect
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A 45-year-old woman comes to your GP clinic complaining of recurrent episodes of dizziness, which she describes as a sensation of the room spinning. She has experienced five such episodes in the past month, each lasting for one or two days and accompanied by nausea, which has prevented her from going to work. She reports no symptoms between episodes and has a history of migraines in her 20s but is otherwise healthy. During these episodes, she is sensitive to loud noises but denies any hearing loss or tinnitus. Neurological examination, Dix-Hallpike, and examination of both ear canals are unremarkable. What is the most likely diagnosis?
Your Answer:
Correct Answer: Vestibular migraine
Explanation:Consider vestibular migraine as a possible cause of episodic vertigo in patients with a history of migraines. The timing and duration of vertigo symptoms can help differentiate between different causes. Benign paroxysmal positional vertigo typically causes brief episodes of vertigo, while Meniere’s disease causes longer episodes with accompanying hearing loss, tinnitus, or ear fullness. Labyrinthitis and vestibular neuronitis can cause sudden onset of constant vertigo, but not the episodic nature described in this case. Given the duration, episodic nature, phonophobia, and history of migraines, vestibular migraine is the most likely diagnosis. The International Classification of Headache Disorders provides diagnostic criteria for vestibular migraine, including a history of migraines and moderate to severe vestibular symptoms lasting between 5 minutes and 72 hours, with at least half of the episodes associated with migrainous features such as headache, photophobia, phonophobia, or visual aura. Other potential causes should be ruled out.
Vertigo is a condition characterized by a false sensation of movement in the body or environment. There are various causes of vertigo, each with its own unique characteristics. Viral labyrinthitis, for example, is typically associated with a recent viral infection, sudden onset, nausea and vomiting, and possible hearing loss. Vestibular neuronitis, on the other hand, is characterized by recurrent vertigo attacks lasting hours or days, but with no hearing loss. Benign paroxysmal positional vertigo is triggered by changes in head position and lasts for only a few seconds. Meniere’s disease, meanwhile, is associated with hearing loss, tinnitus, and a feeling of fullness or pressure in the ears. Elderly patients with vertigo may be experiencing vertebrobasilar ischaemia, which is accompanied by dizziness upon neck extension. Acoustic neuroma, which is associated with hearing loss, vertigo, and tinnitus, is also a possible cause of vertigo. Other causes include posterior circulation stroke, trauma, multiple sclerosis, and ototoxicity from medications like gentamicin.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 6
Incorrect
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You diagnose a middle-aged man with a left-sided sudden-onset sensorineural hearing loss that started 12 hours ago during your joint clinic with a medical student and refer directly to ENT who diagnose an idiopathic sudden-onset sensorineural hearing loss and begin treatment. Your medical student asks what will happen next for the patient.
What is the most suitable medication for treatment?Your Answer:
Correct Answer: Oral prednisolone for 7 days
Explanation:Patients with sudden-onset sensorineural hearing loss who are referred to ENT are typically prescribed high-dose oral corticosteroids as treatment. The recommended dosage, according to ENT UK’s guideline, is oral prednisolone at a maximum of 60mg/day or 1 mg/kg/day for 7 days, followed by a tapering off period over the next week. Dexamethasone, another type of corticosteroid, doesn’t require intravenous or intramuscular administration. Intravenous immunoglobulin is not a recommended treatment for idiopathic sudden-onset sensorineural hearing loss. While oral acyclovir has been considered for treating Bell’s palsy, the evidence supporting its effectiveness is weak.
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 7
Incorrect
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A 26-year-old male presents with benign paroxysmal positional vertigo that has persisted for 3 weeks after a recent upper respiratory tract infection. He requests the Epley manoeuvre to alleviate his symptoms as he is currently unable to operate a vehicle. What is the success rate of the Epley manoeuvre in patients with this condition?
Your Answer:
Correct Answer: 80%
Explanation:Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo that occurs suddenly when there is a change in head position. It is more prevalent in individuals over the age of 55 and is less common in younger patients. Symptoms of BPPV include dizziness and vertigo, which can be accompanied by nausea. Each episode typically lasts for 10-20 seconds and can be triggered by rolling over in bed or looking upwards. A positive Dix-Hallpike manoeuvre, which is indicated by vertigo and rotatory nystagmus, can confirm the diagnosis of BPPV.
Fortunately, BPPV has a good prognosis and usually resolves on its own within a few weeks to months. Treatment options include the Epley manoeuvre, which is successful in around 80% of cases, and vestibular rehabilitation exercises such as the Brandt-Daroff exercises. While medication such as Betahistine may be prescribed, it tends to have limited effectiveness. However, it is important to note that around half of individuals with BPPV may experience a recurrence of symptoms 3-5 years after their initial diagnosis.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 8
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 9
Incorrect
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The wife of a 65-year-old man contacts you urgently for a home visit. The patient has a medical history of hypertension, hypercholesterolemia, and type 2 diabetes. According to his wife, he is experiencing severe dizziness due to labyrinthitis and is unable to leave his bed.
Upon arrival, you find the patient in bed, complaining of intense dizziness that makes him feel like the room is spinning. He has vomited multiple times and cannot stand up. He has never experienced this before.
During the assessment, the patient's vital signs are normal. Otoscopy reveals no abnormalities. Neurological examination of the limbs shows normal power, tone, reflexes, and coordination. However, he cannot walk for a gait examination. Eye examination shows bidirectional nystagmus on lateral gaze bilaterally. A head impulse test is normal with no catch-up saccades seen. All other cranial nerves are normal.
What is the most appropriate course of action?Your Answer:
Correct Answer: Call ambulance and refer to on-call stroke team
Explanation:The HiNTs exam is a helpful tool for differentiating between vestibular neuronitis and posterior circulation stroke in cases of acute vertigo. It consists of three steps, with a fourth step recently suggested for detecting AICA infarcts. The exam assesses for nystagmus, skew deviation, head impulse test, and new unilateral hearing loss. A normal head impulse test is concerning and warrants referral to the acute stroke team. While prochlorperazine may be useful for acute peripheral vestibular neuropathy, betahistine is only licensed for Meniere’s disease. As this patient’s symptoms are ongoing, a TIA clinic would not be appropriate, and urgent neuroimaging should be performed before considering high dose aspirin. If there is any diagnostic uncertainty, referral for same-day assessment is necessary.
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 10
Incorrect
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A 62-year-old Chinese man who is a smoker visits his doctor with complaints of a constantly congested nose and bloody discharge from the nose. What type of cancer is he most susceptible to?
Your Answer:
Correct Answer: Nasopharyngeal
Explanation:Differentiating Head and Neck Cancers: Understanding Risk Factors and Symptoms
Head and neck cancers can present with a variety of symptoms, making it important to understand the risk factors associated with each type of cancer. Nasopharyngeal carcinoma, for example, is more commonly found in Southeast Asia and is thought to be caused by both genetic susceptibility and environmental factors such as heavy alcohol intake and infection with Epstein-Barr virus. Symptoms include nasal obstruction, bloodstained sputum or nasal discharge, tinnitus, headache, ear fullness, and unilateral conductive hearing loss.
Oral cancers, on the other hand, tend to present with a persistent lump in the mouth or with the patient possibly complaining of ear pain or pain on chewing. Smoking, chewing tobacco, and drinking alcohol are risk factors. Laryngeal cancers are also associated with smoking, but are more common in patients of black and white ethnicities.
Malignant parotid tumors are rare, and there is no higher prevalence in patients of South Asian descent. Thyroid cancers, which are relatively common, tend to present with an unexplained lump or swelling in the front of the neck and a hoarse voice. Risk factors include exposure to ionizing radiation, thyroiditis and other thyroid diseases, as well as genetic predisposition.
Understanding the different risk factors and symptoms associated with each type of head and neck cancer can help healthcare professionals make an accurate diagnosis and provide appropriate treatment.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 11
Incorrect
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A 40-year-old female patient presents with vestibular neuronitis after a recent viral respiratory infection. She reports experiencing vertigo, nausea, and vomiting. What is the initial treatment recommended for her symptoms?
Your Answer:
Correct Answer: Prochlorperazine for 7 days
Explanation:To relieve vertigo, nausea, and vomiting caused by vestibular neuronitis, it is advised to use Prochlorperazine. It should be taken for three days on a regular basis and then as needed for a maximum of seven days. However, caution should be exercised as it may cause dystonic reactions, particularly in young women. Other treatment options are not recommended for individuals with vestibular neuronitis.
Understanding Vestibular Neuronitis
Vestibular neuronitis is a type of vertigo that typically occurs after a viral infection. It is characterized by recurrent episodes of vertigo that can last for hours or days, accompanied by nausea and vomiting. Horizontal nystagmus is also a common symptom, but there is no hearing loss or tinnitus.
It is important to differentiate vestibular neuronitis from other conditions such as viral labyrinthitis and posterior circulation stroke. The HiNTs exam can be used to distinguish between these conditions.
Treatment for vestibular neuronitis typically involves medication to alleviate symptoms, such as buccal or intramuscular prochlorperazine for severe cases, or a short course of oral medication for less severe cases. Vestibular rehabilitation exercises are also recommended for patients who experience chronic symptoms.
Understanding the symptoms and treatment options for vestibular neuronitis can help individuals manage this condition and improve their quality of life.
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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 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 13
Incorrect
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A 40-year-old man presents to the GP with episodes of dizziness that began two weeks ago. These episodes occur randomly but are worsened when he changes the position of his head. His most recent episode lasted longer than a day and was particularly uncomfortable, accompanied by nausea and vomiting. During a cranial nerve examination, the GP observes horizontal nystagmus. The patient denies experiencing any aural symptoms like tinnitus. When asked about his overall health, the patient reports having had a viral upper respiratory tract infection the previous week.
What is the diagnosis?Your Answer:
Correct Answer: Vestibular neuronitis
Explanation:Horizontal nystagmus is a common symptom of vestibular neuronitis, which is caused by inflammation of the vestibular nerve. This condition typically presents with vertigo, nausea, vomiting, and balance problems, but doesn’t cause hearing loss as the cochlear nerve is not affected. The presence of horizontal nystagmus helps to rule out a central cause of vertigo, such as a stroke.
Acoustic neuroma, on the other hand, is characterized by a tumor that compresses the eighth cranial nerve, leading to symptoms such as vertigo, hearing loss, tinnitus, and an absent corneal reflex. Meniere’s disease is another condition that causes sudden episodes of vertigo, hearing loss, and tinnitus, but also involves a sensation of fullness in the ears due to an abnormal amount of endolymph in the inner ear. However, the absence of tinnitus in the patient in the vignette makes these diagnoses less likely.
A posterior circulation stroke can also cause nystagmus, vertigo, and nausea, but these symptoms typically come on suddenly and are accompanied by ataxia, unilateral limb weakness, and an altered mental state. In addition, a central cause of vertigo would result in vertical nystagmus rather than horizontal nystagmus.
Viral labyrinthitis is similar to vestibular neuronitis, but is more likely to cause hearing loss and tinnitus. In vestibular neuronitis, only the vestibular nerve is affected, while hearing is spared.
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 14
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 15
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 16
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 17
Incorrect
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A 42-year-old man presents with a 'neck lump' that he has noticed over the past two months. On examination, you palpate a diffuse midline swelling which moves with swallowing but not with tongue protrusion. There are no other neck lumps or focal nodules, and the patient's voice is normal with no hoarseness. There is no cervical lymphadenopathy or stridor. The patient has no significant past medical history or family history.
He reports feeling slightly more fatigued and has gained some weight over the past few months but otherwise feels well. He notes that the swelling in his neck has not changed in size since he first noticed it.
Thyroid function tests reveal hypothyroidism. What is the most appropriate management plan?Your Answer:
Correct Answer: Repeat the thyroid function test in four to six weeks
Explanation:Thyroid Swelling: Recognizing and Referring Suspected Cancer
Note that it is important to clarify descriptions and findings during a patient’s history and examination. For instance, a patient may describe a lump when it is actually a diffuse swelling. According to NICE guidelines, an unexplained thyroid lump warrants a suspected cancer pathway referral within two weeks. However, other factors to consider during the assessment include a solitary nodule increasing in size, a history of neck irradiation, family history of an endocrine tumor, unexplained hoarseness or voice changes, cervical lymphadenopathy, very young or elderly patients. Patients with symptoms of tracheal compression should be admitted immediately to the hospital.
In cases where a thyroid swelling doesn’t meet any of the urgent or immediate referral criteria, a thyroid function blood test should be conducted. If the test reveals hypothyroidism, it may explain the patient’s weight gain and tiredness. Patients with abnormal thyroid function and a goitre are unlikely to have thyroid cancer and can be managed in primary care. Those with a goitre and normal thyroid function tests can be referred non-urgently to a thyroid surgeon.
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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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Sarah is an 80-year-old woman who visits your clinic with complaints of hearing difficulty. During the examination, you observe that she has impacted earwax in both ear canals. You suggest using olive oil ear drops, but she informs you that she has previously tried them without success.
What would be your next course of action in managing the earwax?Your Answer:
Correct Answer: Sodium bicarbonate ear drops
Explanation:If using olive oil drops to remove impacted earwax is unsuccessful, an alternative option is to use sodium bicarbonate drops to soften the wax.
It is important to note that Otomize ear spray contains neomycin, an antibiotic that can be harmful to patients with a perforated eardrum. Therefore, caution should be exercised when using these drops.
While ear syringing is a possibility, it is recommended to soften the wax with drops for at least two weeks prior to attempting the procedure.
Since the patient’s hearing is affected by the wax, a wait-and-see approach is not advisable. Referral to audiology is also unnecessary as the cause of the hearing loss is already known, and delaying treatment may worsen the condition.
Understanding earwax and Its Impacts
earwax is a natural substance produced by the body to protect the ear canal. However, it is not uncommon for earwax to become impacted, leading to a range of symptoms such as pain, hearing loss, tinnitus, and vertigo. In such cases, treatment is necessary to alleviate the discomfort caused by the impacted earwax. Primary care options for treatment include ear drops or irrigation, also known as ‘ear syringing’. It is important to note that treatment should not be administered if there is a suspected perforation or if the patient has grommets. Ear drops such as olive oil, sodium bicarbonate 5%, and almond oil can be used to help alleviate the symptoms of impacted earwax.
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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 50-year-old male construction worker had recently noticed a decline in his hearing ability in both ears. As a child, he had experienced several ear infections, including a severe one during a bout of measles that impacted his education. There was no history of deafness in his family. During examination, his tympanic membranes appeared intact, but there were calcified scars anterior to the handle of the malleus in both ears. The Rinne test was positive in both ears, and the Weber test was central in both anterior and posterior positions. Striking the 256 cps tuning fork firmly was necessary to achieve the desired volume. What is the probable diagnosis?
Your Answer:
Correct Answer: Chronic acoustic trauma
Explanation:Possible Causes of Deafness in Middle Age
The patient’s medical history indicates a likelihood of tubotympanic problems associated with serous otitis during childhood, as evidenced by scarred tympanic membranes. However, it is unlikely that these issues would cause recent deafness in middle age. The results of the Rinne and Weber tests, using a more accurate tuning frequency of 512, suggest bilateral sensorineural deafness. With no family history, idiopathic premature deafness is less likely.
Ossicular chain disruption is typically a result of direct trauma and is more likely to be unilateral. Given that building workers are often unregulated when it comes to hearing protection, the probable diagnosis is chronic acoustic trauma.
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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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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 21
Incorrect
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You come across a 16-year-old student who has been experiencing vertigo for the past 2 days. She complains of feeling like the room is spinning and experiencing nausea. She has been suffering from a severe cold for the last 10 days but denies any other symptoms. Upon examination and hearing tests, you suspect that she has vestibular neuronitis.
What is a correct statement about vestibular neuronitis?Your Answer:
Correct Answer: Hearing is normal in vestibular neuronitis
Explanation:Understanding Vestibular Neuronitis
Vestibular neuronitis is a type of vertigo that typically occurs after a viral infection. It is characterized by recurrent episodes of vertigo that can last for hours or days, accompanied by nausea and vomiting. Horizontal nystagmus is also a common symptom, but there is no hearing loss or tinnitus.
It is important to differentiate vestibular neuronitis from other conditions such as viral labyrinthitis and posterior circulation stroke. The HiNTs exam can be used to distinguish between these conditions.
Treatment for vestibular neuronitis typically involves medication to alleviate symptoms, such as buccal or intramuscular prochlorperazine for severe cases, or a short course of oral medication for less severe cases. Vestibular rehabilitation exercises are also recommended for patients who experience chronic symptoms.
Understanding the symptoms and treatment options for vestibular neuronitis can help individuals manage this condition and improve their quality of life.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 22
Incorrect
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A 55-year-old man who gave up smoking ten years ago presents at surgery with hoarseness.
It has been present for four weeks and is not improving. He has no systemic illness to explain it and the only thing of note is that he is a heavy whisky drinker.
You suspect he may have laryngeal cancer.
Which of the following symptoms would augment that suspicion?Your Answer:
Correct Answer: Odynophagia
Explanation:Symptoms of Laryngeal and Lung Cancer
Laryngeal cancer can present with two main symptoms: dysphagia and odynophagia, which are difficulty and painful swallowing, respectively. On the other hand, lung cancer may cause bovine cough, a distinct coughing sound, and recurrent laryngeal palsy. Hoarseness is a common symptom of both types of cancer, but submandibular swelling may indicate other head and neck cancers. It is important to note that vomiting is not typically a symptom of these cancers, except in advanced stages. Early detection and treatment are crucial for improving outcomes in cancer 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 23
Incorrect
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A 6-year-old girl has been unwell with earache and a fever. The earache has improved since her ear started discharging. The eardrum is not visible because of the amount of discharge. She is prescribed an antibiotic and given advice about symptom control.
Select from the list the single most appropriate further management option.Your Answer:
Correct Answer: Further review is only necessary if the parents are not happy with progress
Explanation:Complications and Management of Acute Otitis Media in Children
Acute otitis media is a common childhood infection that can cause severe pain and discomfort. One well-recognized complication is the bursting of the eardrum, which can provide relief from the pressure and pain. While most cases of acute otitis media resolve on their own, some children may develop chronic suppurative otitis media.
Treatment options include myringotomy, but follow-up is only necessary if symptoms persist or recur despite antibiotic treatment. Parents may return early due to safety netting or anxiety, but checking for resolution at 48 hours is too soon. At three weeks, there may still be a perforation and/or evidence of hearing loss.
Fortunately, most perforations spontaneously close within a month, although there may be evidence of middle ear effusion for some time afterward. If a child has ongoing hearing problems, they should be referred for formal assessment with audiometry.
In summary, acute otitis media can be managed effectively with appropriate treatment and monitoring. Parents should be aware of potential complications and seek medical attention if symptoms persist or worsen.
Managing Acute Otitis Media in Children: Complications and Follow-Up
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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 4-year-old girl is brought to her General Practitioner by her parents because of concerns regarding her hearing. They have noticed she often doesn't respond when spoken to and seems to have difficulty following instructions. Three months ago, she presented with pain and discharge from her right ear and was treated with a course of amoxicillin.
On examination, she is well. Both tympanic membranes are intact and have a grey appearance, with absent light reflexes.
What is the single most likely diagnosis?Your Answer:
Correct Answer: Otitis media with effusion
Explanation:Differential diagnosis of hearing impairment in a child with grey eardrum and absent light reflexes
Otitis media with effusion and other possible causes of conductive hearing loss
The patient is a child who had received treatment for acute otitis media three months ago. The current presentation includes hearing impairment and a grey eardrum with absent light reflexes. Based on these findings, the most likely diagnosis is otitis media with effusion, which is a common sequelae of acute otitis media and a leading cause of hearing impairment in childhood. Other possible causes of conductive hearing loss include otosclerosis, cholesteatoma, and ossicular discontinuity.
Otosclerosis is unlikely in this case because it typically presents in the early twenties and involves the fusion of the stapes with the cochlea, which is not evident on otoscopy. Cholesteatoma, on the other hand, would be visible as a perforation or retraction pocket of the tympanic membrane and requires referral to ENT specialists. Ossicular discontinuity is usually caused by trauma, which is not reported by the patient.
Sensorineural hearing loss is another type of hearing impairment that results from damage to the hair cells in the cochlea or the vestibulocochlear nerve. However, this diagnosis is less likely in this case because the appearance of the eardrum is abnormal, indicating a conductive rather than a sensorineural problem.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 25
Incorrect
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You review a patient who you diagnosed with Meniere's disease last week. Her vertigo has settled but she still has hearing loss and tinnitus on the right side. She is still waiting to be seen by the ENT department but has a few questions about Meniere's disease.
Which statement below regarding Meniere's disease is correct?Your Answer:
Correct Answer: Around half of people with Meniere's disease have bilateral involvement after 5 years if not treated
Explanation:Meniere’s disease is a condition that affects the inner ear and its cause is unknown. It is more commonly seen in middle-aged adults but can occur at any age and affects both men and women equally. The condition is characterized by the excessive pressure and progressive dilation of the endolymphatic system. The main symptoms of Meniere’s disease are recurrent episodes of vertigo, tinnitus, and sensorineural hearing loss. Vertigo is usually the most prominent symptom, but patients may also experience a sensation of aural fullness or pressure, nystagmus, and a positive Romberg test. These episodes can last from minutes to hours and are typically unilateral, but bilateral symptoms may develop over time.
The natural history of Meniere’s disease is that symptoms usually resolve in the majority of patients after 5-10 years. However, most patients will be left with some degree of hearing loss, and psychological distress is common. ENT assessment is required to confirm the diagnosis, and patients should inform the DVLA as the current advice is to cease driving until satisfactory control of symptoms is achieved. Acute attacks can be managed with buccal or intramuscular prochlorperazine, and admission to the hospital may be required. Prevention strategies include the use of betahistine and vestibular rehabilitation exercises, which may be beneficial.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 26
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 27
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 28
Incorrect
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A 56-year-old woman with a history of hypertension visits the surgery with a complaint of hoarseness that has been present for 3 weeks. The hoarseness started after she had an upper respiratory tract infection 7 weeks ago. She is in good health and doesn't smoke. What is the best course of action for management?
Your Answer:
Correct Answer: Urgent referral to ear, nose and throat
Explanation:Hoarseness can be caused by various factors such as overusing the voice, smoking, viral infections, hypothyroidism, gastro-oesophageal reflux, laryngeal cancer, and lung cancer. It is important to investigate the underlying cause of hoarseness, and a chest x-ray may be necessary to rule out any apical lung lesions.
If laryngeal cancer is suspected, it is recommended to refer the patient to an ENT specialist through a suspected cancer pathway. This referral should be considered for individuals who are 45 years old and above and have persistent unexplained hoarseness or an unexplained lump in the neck. Early detection and treatment of laryngeal cancer can significantly improve the patient’s prognosis.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 29
Incorrect
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What is a true statement about mumps infection?
Your Answer:
Correct Answer: Sterility commonly follows orchitis
Explanation:Mumps: Symptoms and Complications
Mumps is a viral infection that has an incubation period of 14-21 days. It can affect any of the salivary glands, but sometimes only one gland is affected. In rare cases, mumps can cause meningoencephalitis, which is inflammation of the brain and its surrounding tissues.
One of the common complications of mumps is orchitis, which is inflammation of the testicles. This occurs in around 25% of cases and can cause pain, swelling, and fever. However, sterility is a relatively uncommon complication following orchitis.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 30
Incorrect
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A 38-year-old man visits his primary care physician complaining of persistent blockage of his right nostril, accompanied by sneezing and rhinorrhea, six weeks after recovering from a cold. Upon examination, a large polyp is observed in the right nostril, while the left nostril appears normal. What is the most suitable course of action for managing this condition?
Your Answer:
Correct Answer: Urgent referral to ENT
Explanation:Understanding Nasal Polyps
Nasal polyps are a relatively uncommon condition affecting around 1% of adults in the UK. They are more commonly seen in men and are not typically found in children or the elderly. There are several associations with nasal polyps, including asthma (particularly late-onset asthma), aspirin sensitivity, infective sinusitis, cystic fibrosis, Kartagener’s syndrome, and Churg-Strauss syndrome. When asthma, aspirin sensitivity, and nasal polyposis occur together, it is known as Samter’s triad.
The most common features of nasal polyps include nasal obstruction, rhinorrhoea, sneezing, and a poor sense of taste and smell. However, if a patient experiences unilateral symptoms or bleeding, further investigation is always necessary.
If a patient is suspected of having nasal polyps, they should be referred to an ear, nose, and throat (ENT) specialist for a full examination. Treatment typically involves the use of topical corticosteroids, which can shrink polyp size in around 80% of patients. With proper management, most patients with nasal polyps can experience relief from their symptoms.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 31
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 32
Incorrect
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A 5-year-old girl is brought to the GP clinic by her mother. She is on day 7 post-tonsillectomy and was recovering well until this morning when her mother noticed a small amount of blood on her pillow and fresh red blood in her mouth. Upon examination, the girl appears to be in good health, but there is a blood clot in her right tonsillar fossa with no active bleeding. Her vital signs are as follows:
Systolic blood pressure: 100 mmHg (normal range: 75-110)
Pulse: 96 bpm (normal range: 80-150)
Temperature: 36.8ºC (normal range: 35.5-37.5)
Respiratory rate: 24/min (normal range: 17-30)
What is the appropriate course of action?Your Answer:
Correct Answer: Immediate referral to ENT
Explanation:ENT assessment is necessary for all cases of post-tonsillectomy haemorrhage.
Any haemorrhage occurring more than 24 hours after a tonsillectomy is considered a secondary haemorrhage and can be life-threatening. Therefore, it is crucial that all patients are managed by ENT in a hospital setting. Children may have difficulty quantifying blood loss as they may swallow the blood, making bleeding less noticeable.
It is incorrect to review the patient in 24 hours as this is an emergency situation. Similarly, reassuring the patient or referring them to paediatrics is not appropriate. Although tranexamic acid may be helpful, hospital admission is necessary for this surgical emergency and should be managed by ENT.
Complications after Tonsillectomy
Tonsillectomy is a common surgical procedure that involves the removal of the tonsils. However, like any surgery, it carries some risks and potential complications. One of the most common complications is pain, which can last for up to six days after the procedure.
Another complication that can occur after tonsillectomy is haemorrhage, or bleeding. There are two types of haemorrhage that can occur: primary and secondary. Primary haemorrhage is the most common and occurs within the first 6-8 hours after surgery. It requires immediate medical attention and may require a return to the operating room.
Secondary haemorrhage, on the other hand, occurs between 5 and 10 days after surgery and is often associated with a wound infection. It is less common than primary haemorrhage, occurring in only 1-2% of all tonsillectomies. Treatment for secondary haemorrhage usually involves admission to the hospital and antibiotics, but severe bleeding may require surgery.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 33
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 34
Incorrect
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Samantha is a 50-year-old factory worker whose hearing has been gradually declining over the past 4 years. She has been exposed to loud noises in her workplace for many years.
Samantha finally decided to visit her doctor 3 months ago, as she was hesitant to seek help, and her hearing has now severely deteriorated. After undergoing audiology testing, she was diagnosed with bilateral sensorineural hearing loss.
What would be the most suitable course of action for managing Samantha's condition?Your Answer:
Correct Answer: Trial of hearing aids
Explanation:Before considering a cochlear implant, both children and adults must undergo an assessment by a multidisciplinary team. As part of this assessment, they should have tried using an acoustic hearing aid for at least three months. Cochlear implantation is recommended for individuals with severe to profound deafness who do not receive sufficient benefit from hearing aids.
Mark should try to avoid noisy environments, including his current workplace, to prevent further damage to his hearing. However, it is not advisable for him to immediately stop working. Instead, he should discuss his situation with his occupational health team to explore options for working in a quieter environment.
While education on sign language and lip reading may be helpful, it is important to note that adults who become deaf are unlikely to become proficient in sign language.
It is incorrect to tell Mark that nothing more can be done. He may be eligible for a trial of hearing aids and referral for a cochlear implant if necessary.
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 35
Incorrect
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A 63-year-old woman comes to your clinic complaining of a painless, foul-smelling discharge from her left ear that has been going on for four months. She had seen another doctor a month ago who prescribed gentamicin/hydrocortisone ear drops, but they did not help alleviate her symptoms.
Upon examination, there is some wax buildup in the attic of her left ear, but otherwise, everything appears normal. Her cranial nerve examination is also unremarkable.
What would be the best course of action to take?Your Answer:
Correct Answer: Refer to ENT outpatient clinic
Explanation:If a patient has persistent unilateral ear discharge that doesn’t respond to antibiotics, it is important to consider the possibility of cholesteatoma, according to NICE guidelines. A cholesteatoma can be concealed behind wax in the attic, so a referral to an ENT clinic for microsuction and direct inspection is necessary. The urgency of the referral depends on the severity of the patient’s symptoms. In this case, a semi-urgent referral is appropriate, but if the patient experiences more advanced symptoms such as vertigo or facial nerve palsy, an urgent discussion with an on-call ENT specialist is necessary.
While olive oil may be helpful for wax buildup, it is not the main issue in this case, as the patient is experiencing discharge. Oral antibiotics are not recommended as there is no evidence of infection. An MRI of the IAMs may be necessary, but it is best to arrange this as part of an assessment by the ENT service. Ear syringing may be useful for wax buildup, but it is not advisable in this situation.
Understanding Cholesteatoma
Cholesteatoma is a benign growth of squamous epithelium that can cause damage to the skull base. It is most commonly found in individuals between the ages of 10 and 20 years old. Those born with a cleft palate are at a higher risk of developing cholesteatoma, with a 100-fold increase in risk.
The main symptoms of cholesteatoma include a persistent discharge with a foul odor and hearing loss. Other symptoms may occur depending on the extent of the growth, such as vertigo, facial nerve palsy, and cerebellopontine angle syndrome.
During otoscopy, a characteristic attic crust may be seen in the uppermost part of the eardrum.
Management of cholesteatoma involves referral to an ear, nose, and throat specialist for surgical removal. Early detection and treatment are important to prevent further damage to the skull base and surrounding structures.
In summary, cholesteatoma is a non-cancerous growth that can cause significant damage if left untreated. It is important to be aware of the symptoms and seek medical attention promptly if they occur.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 36
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 37
Incorrect
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A mother brings her 6-year-old daughter to see the GP because of a painful ulcer on her lower lip. It has been present for 5-6 days. On examination, it is erythematous with indurated papules about 4mm in diameter. The GP takes a look and diagnoses an aphthous ulcer.
Within what timescale would most minor aphous ulcers (2-10mm) take to heal?Your Answer:
Correct Answer: 7-14 days
Explanation:Aphthous Ulcers: Painful Lesions on Oral Mucosa
Aphthous ulcers are painful ulcerations that can occur on the labial, buccal, or lingual mucosa. These lesions can present as erythematous indurated papules and can be solitary or multiple. Minor ulcers, which are between 2-10mm in diameter, typically heal on their own within 7-10 days, although some may take up to 14 days. Major ulcers, which are over 10mm in diameter and are rare, can take 10-30 days to heal. Treatment for aphthous ulcers is palliative, with pain relief and local topical anaesthetics being the primary methods used. To learn more about aphthous ulcers, visit the NICE CKS or UCLH websites.
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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 48-year-old woman presents to the clinic for follow-up. She reports feeling increasingly fatigued and overwhelmed with caring for her grandchild. Additionally, she has noticed a hoarse voice and persistent tiredness. She has no significant medical history and has never smoked. She has also been experiencing constipation and has started taking daily senna. On examination, her blood pressure is 115/75 mmHg, pulse is 55 and regular, and BMI is 29 kg/m2. She has a smooth, non-tender goiter. Laboratory results show Hb 118 g/L (115-165), WCC 8.0 ×109/L (4.5-10), PLT 180 ×109/L (150-450), Na 131 mmol/L (135-145), K 4.3 mmol/L (3.5-5.5), and Cr 99 µmol/L (70-110). What test or investigation would be most helpful in clarifying the diagnosis?
Your Answer:
Correct Answer: C reactive protein
Explanation:Diagnosis and Management of Hypothyroidism
In this case, the patient presents with symptoms of tiredness, weight gain, and bradycardia on examination, along with a smooth non-tender goitre and low sodium on U&E testing. These clues suggest a diagnosis of hypothyroidism, which can be confirmed through thyroid function testing. C reactive protein is a nonspecific result that may indicate possible infection or inflammation, while a chest x-ray can help rule out chest pathology as an alternative cause for the hyponatraemia. If the thyroid function testing is normal and the chest x-ray is unremarkable, an ENT referral may be appropriate. Ultrasound is indicated if there is a suspicion of nodularity within the thyroid gland. By following these steps, healthcare professionals can effectively diagnose and manage hypothyroidism in patients.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 39
Incorrect
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A 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 40
Incorrect
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A 55-year-old man presents to his General Practitioner complaining that he has woken up with a ‘wonky’ smile. On examination, the right side of his mouth is drooping; there is right-sided facial weakness and he cannot lift his eyebrow on the right. He has no vesicles in his ears or on his face and is otherwise well, with no other neurological findings.
What is the most likely diagnosis?Your Answer:
Correct Answer: Idiopathic Bell’s palsy
Explanation:Facial Paralysis: Understanding the Causes and Symptoms
Facial paralysis can be caused by a variety of factors, including stroke, brain tumours, and viral infections. The most common type of facial paralysis is Bell’s palsy, which is often idiopathic in nature. In Bell’s palsy, the brow is paralyzed due to a lower motor neuron facial nerve palsy. While the underlying cause is often unknown, viruses such as herpes simplex type 1 have been implicated. Other potential causes include mononeuropathy in diabetes or sarcoid, Lyme disease, and posterior fossa tumours.
Fortunately, the majority of patients with Bell’s palsy recover significantly within six weeks to three months, with around 70% making a full recovery. Treatment typically involves prednisolone and vigilant eye care.
It’s important to differentiate Bell’s palsy from other potential causes of facial paralysis, such as stroke or brain tumours. In a stroke, the brow would not be paralyzed due to an upper motor neuron lesion. While a posterior fossa tumour can cause facial palsy, it is less common than Bell’s palsy. Paralysis is a nonspecific diagnosis and not the best answer, while Ramsay Hunt syndrome is associated with the varicella-zoster virus and typically presents with concomitant shingles, which is not present in this patient.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 41
Incorrect
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A 6-year-old boy comes to you complaining of sudden and severe pain in his right ear after recently having an ear infection. During examination, you notice a perforated eardrum. He has a soccer game next week and is eager to play. What advice would you give him regarding this situation?
Your Answer:
Correct Answer: Avoid swimming until the perforation is completely healed
Explanation:It is recommended to refrain from swimming until a perforated tympanic membrane has fully healed, which typically takes longer than a week. Using a swimming cap may not offer adequate protection. Antibiotics should only be prescribed if there is an infection present, and oral antibiotics are preferred over drops.
Perforated Tympanic Membrane: Causes and Management
A perforated tympanic membrane, also known as a ruptured eardrum, is often caused by an infection but can also result from barotrauma or direct trauma. This condition can lead to hearing loss and increase the risk of otitis media.
In most cases, no treatment is necessary as the tympanic membrane will typically heal on its own within 6-8 weeks. However, it is important to avoid getting water in the ear during this time. Antibiotics may be prescribed if the perforation occurs after an episode of acute otitis media. This approach is supported by the 2008 Respiratory Tract Infection Guidelines from NICE.
If the tympanic membrane doesn’t heal by itself, myringoplasty may be performed. This surgical procedure involves repairing the perforation with a graft of tissue taken from another part of the body. With proper management, a perforated tympanic membrane can be successfully treated and hearing can be restored.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 42
Incorrect
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A mother whose 12-year-old son had a history of glue ear when younger requests a copy of his medical records from the practice manager. Which of the following statements regarding access to medical records is not accurate?
Your Answer:
Correct Answer: A fee can be charged for a print out of her medical records
Explanation:Under the General Data Protection Regulations and the Data Protection Act 2018, it is no longer permissible to charge a fee for obtaining a basic copy of medical records.
Accessing Medical Records: Patients’ Rights and Key Principles
Accessing medical records is a fundamental right of patients, which is protected by the 1998 Data Protection Act and the 1990 Access to Health Records Act. The key principles governing this right include the patient’s right to view their medical records, the right of competent children to access their records, and the right of parents to request access to their children’s records if they are under 16 years old.
Doctors have a responsibility to ensure that they do not release information that may harm a patient’s emotional or physical health. Additionally, under the Data Protection Act, access to medical records should be granted within 28 days. It is important to note that following the General Data Protection Regulations and the Data Protection Act 2018, a fee cannot be charged for a simple copy of medical notes.
In summary, patients have the right to access their medical records, and doctors have a responsibility to ensure that this access is granted in a timely and appropriate manner. The key principles outlined above provide a framework for ensuring that patients’ rights are respected and protected.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 43
Incorrect
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A 26-year-old female presents with nasal symptoms.
She has no significant past medical history. She reports frequent sneezing, a permanent feeling of nasal blockage, and intermittent bilateral non-purulent rhinorrhoea which have been a problem on and off for the last few years. There is no systemic unwellness. She has not identified any specific pattern to her symptoms which she describes are 'fairly persistent'.
On further questioning there doesn't appear to be a seasonal pattern to her symptoms, she doesn't own or have contact with any pets, and she works in an office where there doesn't seem to be any form of occupational trigger. She has no respiratory symptoms and examination of her chest including peak flow measurement is normal.
She has recently been using oral cetirizine regularly and also sodium cromoglycate eye drops both of which she has purchased over the counter. Despite daily use of both for the last four to six weeks her symptoms are no better and remain persistent. Examination reveals no anatomical abnormalities or red flag features.
You discuss further investigation to look into possible allergen identification and also further treatment options.
Which of the following is the next most appropriate pharmacological step in trying to manage her symptoms?Your Answer:
Correct Answer: Add in an intranasal corticosteroid (for example, mometasone)
Explanation:Guidelines recommend oral non-sedating antihistamines, topical nasal corticosteroids or antihistamines, and anti-inflammatory eye drops for the treatment of allergic and non-allergic rhinitis. Mild symptoms can be treated with oral and/or topical antihistamines, while intranasal corticosteroids are the treatment of choice for moderate to severe symptoms. Short courses of oral corticosteroids may be used in conjunction with intranasal corticosteroids for severe nasal blockage. Topical ipratropium and leukotriene receptor antagonists may also be added for persistent symptoms.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 44
Incorrect
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You are requested to conduct a home visit for Edna, a 72-year-old woman, who reports sudden onset of dizziness that started four days ago. The dizziness has been constant since then and causes her to feel unsteady while walking. She has a medical history of migraines and rheumatoid arthritis but has never experienced similar episodes before. She consumes 21 units of alcohol per week and has never smoked.
During the examination, she can stand and walk but requires support from furniture. You attempt to perform a Romberg test, but she starts to sway as soon as she closes her eyes. Both tympanic membranes appear normal. Cranial nerve examination is unremarkable except for marked nystagmus on vertical gaze. The rest of her neurological examination is normal.
What is the most probable diagnosis?Your Answer:
Correct Answer: Cerebrovascular accident
Explanation:When experiencing sudden dizziness, it can be challenging to determine if it is caused by a cerebrovascular accident (CVA). To differentiate between central (related to the central nervous system) and peripheral (related to the inner ear) causes of vertigo, doctors look for the presence of vertical nystagmus. If present, it indicates a central cause. Other signs of a central cause include the presence of other neurological symptoms and risk factors for CVAs. Labyrinthitis and benign paroxysmal positional vertigo are peripheral causes of vertigo that would cause lateral nystagmus. A space occupying lesion may cause central vertigo, but symptoms would likely have a more gradual onset. Vestibular migraines are a central cause that can cause vertical nystagmus, but the vertigo typically lasts for 4-72 hours, so the persistence of symptoms would not fit this diagnosis.
Vertigo is a condition characterized by a false sensation of movement in the body or environment. There are various causes of vertigo, each with its own unique characteristics. Viral labyrinthitis, for example, is typically associated with a recent viral infection, sudden onset, nausea and vomiting, and possible hearing loss. Vestibular neuronitis, on the other hand, is characterized by recurrent vertigo attacks lasting hours or days, but with no hearing loss. Benign paroxysmal positional vertigo is triggered by changes in head position and lasts for only a few seconds. Meniere’s disease, meanwhile, is associated with hearing loss, tinnitus, and a feeling of fullness or pressure in the ears. Elderly patients with vertigo may be experiencing vertebrobasilar ischaemia, which is accompanied by dizziness upon neck extension. Acoustic neuroma, which is associated with hearing loss, vertigo, and tinnitus, is also a possible cause of vertigo. Other causes include posterior circulation stroke, trauma, multiple sclerosis, and ototoxicity from medications like gentamicin.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 45
Incorrect
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You see a 26-year-old man with a five day history of a sore throat. He has been feverish and has had a marked sore throat with pain when swallowing. He tells you that he has felt progressively worse over the last five days.
On examination, he has a temperature of 38.2°C and bilateral tonsillar exudates. There is some tender cervical lymphadenopathy present.
You discuss with him the role of antibiotic treatment and feel that his condition warrants treatment. He has no allergies and you prescribe a course of phenoxymethylpenicillin.
What duration of antibiotic treatment should you prescribe?Your Answer:
Correct Answer: 5 to 10 days
Explanation:Penicillin V: The Antibiotic of Choice for Sore Throat Treatment
Provided that there are no contraindications, penicillin V is the preferred antibiotic for treating sore throat. It is highly effective, affordable, and has a proven safety record. Additionally, it is a narrow-spectrum antibiotic, which helps prevent the development of antibiotic resistance.
Based on current evidence and guidelines, a 5 to 10-day course of penicillin V is recommended to ensure maximum eradication of the infection. The NICE Clinical Knowledge Summaries visual summary guide provides further information on antibiotic selection and duration of use for treating sore throat, based on available evidence and guideline documents.
In summary, penicillin V is the antibiotic of choice for treating sore throat, and a 5 to 10-day course is recommended for optimal results.
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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 56-year-old man presents with a sudden onset of hearing loss in his right ear for the past 2 days. He denies any history of trauma and reports feeling generally well. He also reports experiencing tinnitus and vertigo in his affected ear.
During the examination, the patient has a moderate amount of earwax in both ears. There is no tenderness in his pinna, tragal or mastoid areas. The tympanic membrane appears normal in the small amount that is visible. The patient has evident hearing loss in his right ear.
When performing Weber's test, the patient localizes the sound to his left side. Rinne's test is positive bilaterally, with air conduction being better than bone.
What is the most appropriate next step in management?Your Answer:
Correct Answer: Urgent referral to ENT
Explanation:When a patient experiences sudden hearing loss, it is crucial to distinguish between conductive and sensorineural hearing loss. If it is sensorineural, urgent referral to an ENT specialist is necessary.
To identify sensorineural hearing loss, both Weber’s and Rinne’s tests are used. If the sound is louder on one side in Weber’s test, it could indicate either an ipsilateral conductive hearing loss or a contralateral sensorineural hearing loss. Rinne’s test is then used to differentiate between the two. In sensorineural hearing loss, both air and bone conduction are equally diminished, resulting in a false positive result. In conductive hearing loss, bone conduction is better than air conduction.
Ear irrigation is not appropriate for sensorineural hearing loss as it is not caused by earwax. Intranasal corticosteroids are also not effective in treating acute hearing loss, as their main role is in managing eustachian tube dysfunction.
While routine referral to an ENT specialist is necessary, sudden hearing loss always requires urgent referral.
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 47
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 48
Incorrect
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A 42-year-old female patient complains of left-sided facial muscle weakness that has been present for 72 hours. She has no known medical conditions and is not taking any medications. The symptoms started during a camping trip, and she believes that her delay in seeking medical attention may have contributed to the severity of her condition. Upon examination, she exhibits left-sided facial nerve palsy with no forehead movement. All other cranial nerves appear normal, and there are no neurological deficits in her upper or lower limbs. What is the best course of action for managing this patient's condition?
Your Answer:
Correct Answer: Commence oral prednisolone
Explanation:The recommended treatment for this woman’s symptoms and signs of Bell’s palsy is oral prednisolone, which should be prescribed within 72 hours of symptom onset. Antiviral treatments, either alone or in combination with prednisolone, are not recommended as they have been shown to be ineffective or have weak evidence of benefit. Referring to an ENT specialist is not necessary unless there are signs of worsening neurological disturbance or systemic upset. Self-care measures alone are not sufficient and additional treatment such as eye care should be provided.
Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It typically affects individuals between the ages of 20 and 40, and is more common in pregnant women. The condition is characterized by a lower motor neuron facial nerve palsy that affects the forehead, while sparing the upper face. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.
The management of Bell’s palsy has been a topic of debate, with various treatment options proposed in the past. However, there is now consensus that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, with some experts recommending it for severe cases. Eye care is also crucial to prevent exposure keratopathy, and patients may need to use artificial tears and eye lubricants. If they are unable to close their eye at bedtime, they should tape it closed using microporous tape.
Follow-up is essential for patients who show no improvement after three weeks, as they may require urgent referral to ENT. Those with more long-standing weakness may benefit from a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within three to four months. However, untreated cases can result in permanent moderate to severe weakness in around 15% of patients.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 49
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 50
Incorrect
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A 14-year-old female presents with acute tonsillitis.
She has been feeling unwell for the past five days with a high fever and a sore throat. Upon examination, you notice marked tonsillar exudate bilaterally and tender cervical lymphadenopathy. Given her condition, you believe that antibiotic treatment is necessary. However, her medical notes indicate a previous penicillin allergy. What would be an appropriate antibiotic to prescribe in this situation?Your Answer:
Correct Answer: Clarithromycin
Explanation:Antibiotic Treatment for Sore Throat
Penicillin V remains the preferred antibiotic for treating sore throat due to its effectiveness, affordability, safety, and narrow spectrum. This helps prevent the development of antibiotic resistance. However, individuals who are allergic to penicillin should take either erythromycin or clarithromycin for five days. The clinical knowledge summaries website provides evidence-based recommendations for antibiotic selection, drawing from guidance from SIGN, Royal College of Paediatrics and Child Health, and Public Health England.
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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 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 52
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 53
Incorrect
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A 56-year-old woman presents to the clinic for evaluation. She has been experiencing bloody, serous discharge from her left nostril for the past three weeks and reports that her nose feels constantly congested. The patient has a 30-year history of smoking 20 cigarettes per day and a medical history of COPD. On examination, her blood pressure is 132/72 mmHg, pulse is regular at 85 beats per minute, and she is unable to breathe through her left nostril. Laboratory results show a hemoglobin level of 120 g/L (normal range 115-160), white blood cell count of 7.0 ×109/L (normal range 4.5-10), and platelet count of 199 ×109/L (normal range 150-450). Her sodium level is 138 mmol/L (normal range 135-145), potassium level is 4.5 mmol/L (normal range 3.5-5.5), and creatinine level is 105 µmol/L (normal range 70-110). An electrocardiogram reveals sinus rhythm. What is the most appropriate course of action?
Your Answer:
Correct Answer: ENT referral within 2 weeks
Explanation:Suspected Nasopharyngeal Carcinoma
The suspicion is that the patient may have an underlying nasopharyngeal carcinoma, likely related to smoking, which is causing a blocked left nostril and bloody, serous discharge. It is important not to delay referral to an ear, nose, and throat (ENT) specialist by performing investigations through the GP outpatient radiology service. Imaging of the sinuses may be appropriate to determine the extent of any tumor, but this would be done as part of the pre-surgery workup rather than as outpatient GP investigations. A trial of intranasal steroids is not appropriate as a diagnosis of allergic rhinitis is unlikely, and this would waste valuable time in addressing any underlying tumor. Nasopharyngeal cancers are more common in people from southern China, including Hong Kong, Singapore, Vietnam, Malaysia, and the Philippines.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 54
Incorrect
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An 77-year-old-man presents to your clinic with complaints of persistent right ear pain and discharge. He was previously diagnosed with otitis externa and prescribed antibiotic ear drops by a colleague, followed by further antibiotic drops and tramadol by an out of hours doctor. However, his symptoms have not improved and the pain has become unbearable.
The patient has a medical history of type-2 diabetes mellitus and hypertension, and takes metformin, gliclazide, ramipril, and atorvastatin regularly. He has no known drug allergies and doesn't smoke or drink alcohol.
Upon examination, debris is observed in the right ear canal, but the tympanic membrane remains visible. There is no erythema of the pinna or mastoid swelling, and cranial nerve examination is normal.
What is the most appropriate course of action?Your Answer:
Correct Answer: Refer urgently to on-call ENT team
Explanation:If a patient with otitis externa experiences worsening pain that doesn’t respond to strong painkillers, it is important to refer them urgently to an ENT specialist. This is especially true if the patient has a history of diabetes, as they are at a higher risk of developing malignant (necrotising) otitis externa. In advanced stages, this condition can cause facial nerve palsy on the same side as the affected ear. Treatment typically involves a long course of intravenous antibiotics, which is why prompt ENT assessment is crucial.
While oral antibiotics such as ciprofloxacin may be prescribed alongside ear drops if there is concern about deep tissue infection, most patients will require IV antibiotics. However, the priority in this situation is to escalate the case to an ENT specialist rather than focusing on pain relief or swabbing the ear canal. It is also important to avoid syringing the ear, as this can worsen the condition.
Malignant Otitis Externa: A Rare but Serious Infection
Malignant otitis externa is a type of ear infection that is uncommon but can be serious. It is typically found in individuals who are immunocompromised, with 90% of cases occurring in diabetics. The infection starts in the soft tissues of the external auditory meatus and can progress to involve the soft tissues and bony ear canal, eventually leading to temporal bone osteomyelitis.
Key features in the patient’s history include diabetes or immunosuppression, severe and persistent ear pain, temporal headaches, and purulent otorrhea. In some cases, patients may also experience dysphagia, hoarseness, and facial nerve dysfunction.
Diagnosis is typically done through a CT scan, and non-resolving otitis externa with worsening pain should be referred urgently to an ENT specialist. Treatment involves intravenous antibiotics that cover pseudomonas infections.
In summary, malignant otitis externa is a rare but serious infection that requires prompt diagnosis and treatment. Patients with diabetes or immunosuppression should be particularly vigilant for symptoms and seek medical attention if they experience persistent ear pain or other related symptoms.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 55
Incorrect
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A 65-year-old woman comes to her doctor complaining of dizziness. She experiences sudden onset dizziness and nausea when she rolls over in bed in the morning, which goes away after about 20 seconds if she keeps her head still. After these episodes, she feels unsteady and light-headed for several hours. The patient has a history of recurrent otitis media and her family has a history of otosclerosis.
What is the most crucial initial test that needs to be done?Your Answer:
Correct Answer: Dix-Hallpike manoeuvre
Explanation:The presence of vertigo, tinnitus, and hearing loss are key indicators for the diagnosis of Meniere’s disease, which is a common cause of dizziness. Other factors such as recurrent otitis media and family history of otosclerosis may be misleading. Audiometry is a recommended test for Meniere’s disease, while CT head is useful for otosclerosis and MRI scan is the preferred diagnostic tool for acoustic neuroma.
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 56
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 57
Incorrect
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A 63-year-old man comes to the clinic with his wife for evaluation. He has been experiencing a change in his voice with constant hoarseness and a chronic dry cough for the past six weeks. He attributes this to a previous cold and chest infection and believes it will improve over time.
He is a heavy smoker, consuming 25 cigarettes per day for the past 50 years. He has a history of COPD and is currently taking a high dose Seretide inhaler. On examination, his BP is 145/85 mmHg, pulse is 75 and regular, and chest auscultation reveals scattered wheezing.
Investigations reveal:
Hb 134 g/L (135-180)
WCC 8.0 ×109/L (4.5-10)
PLT 179 ×109/L (150-450)
Na 137 mmol/L (135-145)
K 4.7 mmol/L (3.5-5.5)
Cr 122 µmol/L (70-110)
ECG shows sinus rhythm.
CXR (arranged by another GP partner) shows no mass lesion identified.
What is the most appropriate course of action?Your Answer:
Correct Answer: Urgent ENT referral
Explanation:Urgent Investigation for Hoarseness
Under NICE guidance, patients who present with hoarseness for more than three weeks require urgent investigation for possible cancer. In this case, a chest x-ray did not show an underlying cancer, but an ENT referral for laryngoscopy is warranted.
While inadequate oral hygiene after inhaler use leading to candida infection is a possibility, the absence of oral candida makes it unlikely. Speech therapy is an option to maximize vocal effectiveness, and it is effective for hoarseness related to organic pathology such as nodules or polyps, and non-organic laryngeal dysfunction (for example, muscle tension dysphonia).
Stopping the use of Seretide is inappropriate because it is likely to worsen symptoms of COPD and is unlikely to elucidate the underlying cause of the hoarseness. It is important to investigate the cause of hoarseness to ensure prompt and appropriate treatment.
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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 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 59
Incorrect
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You see a 50-year-old woman who has come to see you after the nurse was unable to remove all the earwax from her left ear. She came to see you for advice on what to do next.
According to NICE, which is the most appropriate next step in management?Your Answer:
Correct Answer: Offer manual syringing
Explanation:Guidelines for earwax Removal
According to NICE guidelines, if earwax irrigation is unsuccessful, patients should repeat the use of wax softeners or instil water into the ear canal 15 minutes before attempting ear irrigation again. If the second attempt is also unsuccessful, patients should be referred to a specialist ear care service or ENT. It is important to note that manual syringing should not be offered as a method of earwax removal. These guidelines aim to ensure safe and effective earwax removal practices.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 60
Incorrect
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A 28-year-old female, originally from Malta, presents with complaints of oral and genital ulcers. She has a history of recurrent ulcers and scarring from previous episodes. Other than the ulcers, she appears to be in good health. Upon reviewing her medical records, it is noted that she has a history of arthritis and anterior uveitis. What is the most probable diagnosis that connects all of these symptoms?
Your Answer:
Correct Answer: Behçet's disease
Explanation:Oral and Genital Ulceration: A Sign of Behçet’s Disease
Oral ulceration can be a symptom of various diseases, both local and systemic. However, when combined with genital ulceration, the differential diagnosis narrows down, and clinicians should consider potential systemic causes. One such disease is Behçet’s disease, a multisystem vasculitic disorder that typically presents with recurrent oral and genital ulcers. Patients with Behçet’s may also experience arthritis and uveitis. This disease is more common in individuals of Mediterranean and eastern backgrounds.
Inflammatory bowel disease is also a possible differential diagnosis, but it typically presents with gastrointestinal symptoms such as abdominal pain, blood/mucous in the stool, and altered bowel habits. Crohn’s disease can cause oral ulceration and perianal disease, while ulcerative colitis can cause aphthous ulcers in the mouth. Eye problems and arthritis are also associated with inflammatory bowel disease.
Reactive arthritis is characterized by a triad of arthritis, conjunctivitis, and urethritis, but ulceration is not a feature. Rheumatoid arthritis is another multisystem vasculitic disorder that can have various clinical manifestations, including eye problems, but recurrent oral and genital ulcers are not typical. Stevens-Johnson syndrome, on the other hand, is an acute problem characterized by blistering and mucous membrane erosions triggered by drugs, infections, or systemic illnesses, but it doesn’t involve arthritis or uveitis.
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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 26-year-old man presents to your emergency clinic with worsening pain in his right ear. He had previously been diagnosed with otitis externa and started on antibiotic ear drops by another physician four days ago. However, he reports that the pain has only gotten worse and he has been unable to apply the drops for the past 24 hours due to swelling of the canal. Upon examination, you notice that the right external auditory canal is completely swollen shut and you are unable to see any further. The patient's vital signs are normal.
What is the most appropriate course of action for management?Your Answer:
Correct Answer: Refer to on-call ENT
Explanation:If topical antibiotics do not provide relief for otitis externa, it is recommended to refer the patient to an ear, nose, and throat (ENT) specialist. This is because the infection can cause swelling and narrowing of the ear canal, making it difficult for antibiotic drops to be effective. In such cases, microsuction and insertion of a pope wick may be necessary, which requires the expertise of an ENT specialist.
Ear syringing should not be performed during an active infection as it will not be helpful.
Steroids are often included in antibiotic ear drops, but they will not be effective if the drops cannot reach the ear canal.
Oral antibiotics, such as ciprofloxacin, may be prescribed alongside topical antibiotics if there is concern of a deep tissue infection. However, this is unlikely in a young and otherwise healthy patient, and the primary treatment remains antibiotic drops.
If necrotising otitis externa is suspected, a CT scan may be helpful, but this would be arranged by an ENT specialist and is not necessary in most cases.
Understanding Otitis Externa: Causes, Features, and Management
Otitis externa is a prevalent condition that often prompts primary care visits in the UK. It is characterized by ear pain, itch, and discharge, and can be caused by bacterial or fungal infections, seborrhoeic dermatitis, or contact dermatitis. Swimming is also a common trigger for otitis externa. Upon examination, the ear canal may appear red, swollen, or eczematous.
The recommended initial management for otitis externa is the use of topical antibiotics or a combination of topical antibiotics with a steroid. However, if the tympanic membrane is perforated, aminoglycosides are traditionally not used. If there is canal debris, removal may be necessary, and if the canal is extensively swollen, an ear wick may be inserted. Second-line options include taking a swab inside the ear canal, considering contact dermatitis secondary to neomycin, or using oral antibiotics such as flucloxacillin if the infection is spreading. Empirical use of an antifungal agent may also be considered.
It is important to note that if a patient fails to respond to topical antibiotics, they should be referred to an ENT specialist. Malignant otitis externa is a more severe form of the condition that is more common in elderly diabetics. It involves the extension of infection into the bony ear canal and the soft tissues deep to the bony canal, and may require intravenous antibiotics. While some ENT doctors disagree, concerns about ototoxicity may arise with the use of aminoglycosides in patients with perforated tympanic membranes.
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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 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 63
Incorrect
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A 30 year old female smoker presents with painful aphthous ulcers and has been using a topical analgesic (benzydamine hydrochloride gel) for 3 weeks without relief. There is no indication of joint or bowel issues in her medical history or physical examination. She is in good health otherwise. What would be the most suitable course of action to take next?
Your Answer:
Correct Answer: Refer urgently to secondary care
Explanation:If an oral ulcer persists for more than 3 weeks without explanation, it is important to refer the patient to secondary care urgently to rule out the possibility of malignancy. While smoking is a risk factor for both oral malignancy and aphthous ulcers, it is not a reason for referral. Interestingly, quitting smoking can actually make aphthous ulcers worse. Over-the-counter local analgesics like Difflam (benzydamine hydrochloride) and Bonjela can provide relief from symptoms, but there is no evidence that they can reduce the frequency or duration of ulceration. Some evidence suggests that antibacterial mouthwashes (such as chlorhexidine) and topical corticosteroids (such as hydrocortisone oromucosal tablets) can help to shorten the duration and severity of symptoms, but they do not reduce the frequency of recurrence.
Aphthous mouth ulcers are painful sores that are circular or oval in shape and are found only in the mouth. They are not associated with any systemic disease and often occur repeatedly, usually starting in childhood. These ulcers can be caused by damage to the mouth, such as biting the cheek or brushing too hard, or may be due to a genetic predisposition. Other factors that can trigger these ulcers include stress, certain foods, stopping smoking, and hormonal changes related to the menstrual cycle.
Aphthous ulcers are characterized by their round or oval shape, a clearly defined margin, a yellowish-grey slough on the floor, and a red periphery. They usually appear on non-keratinized mucosal surfaces, such as the inside of the lips, cheeks, floor of the mouth, or undersurface of the tongue. In most cases, investigations are not necessary, but they may be considered if an underlying systemic disease is suspected.
Treatment for aphthous ulcers involves avoiding any factors that may trigger them and providing symptomatic relief for pain, discomfort, and swelling. This may include using a low potency topical corticosteroid, an antimicrobial mouthwash, or a topical analgesic. Most ulcers will heal within two weeks without leaving any scars. However, if a mouth ulcer persists for more than three weeks, it is important to seek urgent referral to a specialist.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 64
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 65
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 66
Incorrect
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A 50-year-old man presents with vertigo, reporting a recurrent feeling that the environment is spinning. What is the leading cause of vertigo?
Your Answer:
Correct Answer: Benign paroxysmal positional vertigo
Explanation:Vertigo is most commonly caused by BPPV.
Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo that occurs suddenly when there is a change in head position. It is more prevalent in individuals over the age of 55 and is less common in younger patients. Symptoms of BPPV include dizziness and vertigo, which can be accompanied by nausea. Each episode typically lasts for 10-20 seconds and can be triggered by rolling over in bed or looking upwards. A positive Dix-Hallpike manoeuvre, which is indicated by vertigo and rotatory nystagmus, can confirm the diagnosis of BPPV.
Fortunately, BPPV has a good prognosis and usually resolves on its own within a few weeks to months. Treatment options include the Epley manoeuvre, which is successful in around 80% of cases, and vestibular rehabilitation exercises such as the Brandt-Daroff exercises. While medication such as Betahistine may be prescribed, it tends to have limited effectiveness. However, it is important to note that around half of individuals with BPPV may experience a recurrence of symptoms 3-5 years after their initial diagnosis.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 67
Incorrect
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A 29-year-old man contacts his GP seeking advice for his seasonal allergic rhinitis. He has been managing his symptoms with intranasal decongestants, but lately, he has noticed that they are only partially effective. He experiences a runny nose and occasional sneezing, but there are no red flag symptoms such as unilateral obstruction or cacosmia. He has already taken the maximum dose of over-the-counter decongestants and is wondering if the GP can prescribe a higher dose.
Your Answer:
Correct Answer: Stop the intranasal decongestant
Explanation:Prolonged use of intranasal decongestants like oxymetazoline should be avoided due to the development of tachyphylaxis, where increasing doses are needed to achieve the same effect. Additionally, stopping the medication can lead to rebound symptoms known as rhinitis medicamentosa. Therefore, it is best to encourage patients to discontinue the decongestant rather than prescribing a higher dose. Oral decongestants like pseudoephedrine are not commonly prescribed due to limited evidence supporting their effectiveness. For patients with allergic rhinitis, short-term use of oral corticosteroids may be recommended for severe symptoms, but intranasal corticosteroids and antihistamines are more practical options. Patients should also be advised on self-help strategies like allergen avoidance. Referral to an ENT specialist is not necessary for most cases of allergic rhinitis, except for those with red flags, suspected structural abnormalities, diagnostic uncertainty, or persisting symptoms despite optimal primary care management.
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 68
Incorrect
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A 72-year-old man presents with a four month history of left sided hearing loss. He denies any pain, discharge tinnitus, vertigo or other symptoms of note. He is an ex-smoker with a 45 year pack history.
On examination otoscopy of the right ear appears normal whilst the left ear shows a dullness to the tympanic membrane with air bubbles within the middle ear, the external auditory canal is clear. Rinne's test shows bone conduction better than air conduction in the left ear and air conduction better than bone conduction in the right ear. Weber's test lateralises to the left.
What is the most appropriate cause of action?Your Answer:
Correct Answer: Two week wait referral to local ENT service
Explanation:Understanding Head and Neck Cancer: Symptoms and Referral Criteria
Head and neck cancer is a broad term that encompasses various types of cancer, including oral cavity cancers, pharynx cancers, and larynx cancers. Some of the common symptoms of head and neck cancer include a persistent sore throat, hoarseness, neck lump, and mouth ulcer.
To ensure timely diagnosis and treatment, the National Institute for Health and Care Excellence (NICE) has established referral criteria for suspected cancer pathways. For instance, individuals aged 45 and above with persistent unexplained hoarseness or an unexplained lump in the neck should be referred for an appointment within two weeks to rule out laryngeal cancer.
Similarly, people with unexplained ulceration in the oral cavity lasting for more than three weeks or a persistent and unexplained lump in the neck should be referred for an appointment within two weeks to assess for possible oral cancer. Dentists should also consider an urgent referral for people with a lump on the lip or in the oral cavity or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
Lastly, individuals with an unexplained thyroid lump should be referred for an appointment within two weeks to rule out thyroid cancer. By following these referral criteria, healthcare professionals can ensure that individuals with head and neck cancer receive prompt and appropriate care.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 69
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 70
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 71
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 72
Incorrect
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A 29-year-old man presents with decreased hearing in his left ear. Upon examination, there are no signs of acute infection, but both eardrums appear dull. Tuning-fork tests are performed, revealing that bone conduction is heard better than air conduction on the left side (the affected ear) during Rinne's test, while Weber's test localizes to the left ear. Rinne's test on the right side shows air conduction better than bone conduction. What type of hearing loss is present in this patient?
Your Answer:
Correct Answer: Right-sided conductive hearing loss
Explanation:Differentiating Types of Hearing Loss: A Case Study
In this case study, the patient presents with hearing loss in their right ear. To determine the type of hearing loss, various tests were conducted.
Right-sided conductive hearing loss was ruled out as bone conduction was better than air conduction in the affected ear. Left-sided conductive hearing loss was also ruled out as Rinne’s test was normal on the left side.
Non-organic hearing loss was considered but ultimately ruled out as the patient’s history was convincing and their tympanic membrane appeared normal.
Left-sided sensorineural hearing loss and right-sided sensorineural hearing loss were both ruled out as they would have caused a reduction in both air and bone conduction.
The final diagnosis was right-sided conductive hearing loss. It is important to differentiate between the types of hearing loss as treatment options vary depending on the cause.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 73
Incorrect
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A father brings his 5-year-old daughter to the General Practitioner with symptoms consistent with otitis media, which have started in the last 48 hours. On examination, there is a perforation of the tympanic membrane and purulent discharge from the ear. The child has a temperature of 36.5 °C and her heart rate is within normal parameters.
What would be the most appropriate treatment in this situation?Your Answer:
Correct Answer: Start oral antibiotics
Explanation:Management of Acute Otitis Media in Children: Treatment Options
Acute otitis media is a common childhood infection that can cause pain, fever, and hearing loss. When managing this condition, healthcare providers have several treatment options to consider. Here are some possible approaches:
Immediate Oral Antibiotics: If the child has otorrhoea or bilateral infection, or is under two years old, immediate oral antibiotics are recommended. Parents should be informed that the typical duration of acute otitis media is around three days, but it can last up to one week.
Delayed Antibiotics: In cases where otorrhoea and tympanic perforation are absent, or the child presents at an earlier stage, a prescription for delayed antibiotics may be appropriate. Parents should be advised on when to start the antibiotics, such as if the child experiences persistent fevers or worsening pain.
Oral Decongestants: According to guidance from the National Institute for Health and Care Excellence (NICE), decongestants are not recommended for the management of acute otitis media.
Referral to Ear, Nose and Throat: Immediate referral to an Ear, Nose and Throat specialist is necessary if the child is younger than three months and has tympanic perforation, shows signs of systemic sepsis, or has complicated otitis media (e.g., venous sinus thrombosis, meningitis, or mastoiditis). If none of these features are present, starting with oral antibiotics is reasonable.
Analgesia Only: While analgesia can help alleviate pain, it should not be the only treatment offered if the child has a perforation and otorrhoea. Antibiotics should also be prescribed in this case.
Treatment Options for Acute Otitis Media in Children
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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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What is the correct option regarding nasal polyps?
Your Answer:
Correct Answer: Have a pinkish red appearance
Explanation:Nasal Polyps: Causes, Symptoms, and Treatment
Nasal polyps are growths that develop in the nasal passages, with the majority arising in the ethmoid sinuses. While allergy is the main cause, there may also be an infective component. Antrochoanal polyps, which are associated with chronic infection, are much rarer and arise from the maxillary sinuses. These growths have a yellowish-grey appearance, and any pink or red polyps should be regarded as suspicious.
Symptoms of nasal polyps include blockage of the nasal passages, leading to anosmia or loss of smell. Treatment typically involves the use of topical steroids, which can help to reduce the size of the polyps. However, surgical removal may be necessary in some cases, and recurrence is common. While smell is usually restored after treatment, it may not always be fully regained. Overall, understanding the causes, symptoms, and treatment options for nasal polyps can help individuals to manage this condition effectively.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 75
Incorrect
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A 70-year-old man visits his doctor after his family complains about his hearing loss. He claims that they speak too softly, but admits that he struggles to hear in noisy settings. The patient reports feeling generally healthy, but has a history of hypertension and chronic obstructive pulmonary disease.
During the examination, the doctor discovers bilateral sensorineural hearing loss. Presbycusis is suspected as the cause and the patient is referred for audiometric testing.
What is the expected audiogram pattern for this individual?Your Answer:
Correct Answer: Bilateral high-frequency hearing loss. Air conduction better than bone
Explanation:Presbycusis is characterized by a bilateral loss of high-frequency hearing. This type of age-related hearing loss affects the inner ear and is often accompanied by difficulty hearing in noisy environments. In sensorineural hearing loss, air conduction is more effective than bone conduction, which is the opposite of conductive hearing loss. Therefore, the correct answer is ‘Bilateral high-frequency hearing loss. Air conduction is more effective than bone conduction.’
Understanding Presbycusis: Age-Related Hearing Loss
Presbycusis is a type of hearing loss that affects older individuals. It is a sensorineural hearing loss that typically affects high-frequency hearing bilaterally, leading to difficulties in understanding conversations, especially in noisy environments. The condition progresses slowly as the sensory hair cells and neurons in the cochlea atrophy over time. Although certain factors are associated with presbycusis, it is distinct from noise-related hearing loss.
The prevalence of presbycusis increases with age, with an estimated 25-30% of 65-74 year-olds and 40-50% of those over 75 years experiencing impaired hearing in the USA. The exact cause of presbycusis is unknown, but it is likely multifactorial. Arteriosclerosis, diabetes, accumulated exposure to noise, drug exposure, stress, and genetics are some of the factors that may contribute to the development of presbycusis.
Patients with presbycusis typically present with a chronic, slowly progressing history of difficulty understanding speech, increased volume needed for television or radio, difficulty using the telephone, loss of directionality of sound, and worsening of symptoms in noisy environments. Hyperacusis, a heightened sensitivity to certain frequencies of sound, and tinnitus, a ringing or buzzing in the ears, may also occur but are less common.
To diagnose presbycusis, otoscopy is performed to rule out other causes of hearing loss, such as otosclerosis or conductive hearing loss. Tympanometry is used to assess middle ear function, and audiometry is used to confirm bilateral sensorineural hearing loss. Blood tests may also be performed to rule out other underlying conditions.
In summary, presbycusis is an age-related hearing loss that affects a significant portion of the elderly population. Although the exact cause is unknown, it is likely due to a combination of factors. Patients with presbycusis may experience difficulty understanding speech, increased volume needed for audio devices, and other symptoms. Diagnosis is made through a combination of physical examination and hearing tests.
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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 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 77
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 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 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 80
Incorrect
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A 52-year-old woman presents with complaints of sore gums. She reports that her gums have been bleeding and sore on and off for several years, but she has not sought dental care. Upon examination, there is evidence of recent bleeding and receding gums.
What is the most suitable INITIAL course of action?Your Answer:
Correct Answer: Advise the patient to go to a general dental practitioner
Explanation:Treatment Options for Chronic Gingivitis
Chronic gingivitis is a common condition that can lead to gum inflammation, bleeding, and discomfort. Here are some treatment options for patients with chronic gingivitis:
1. Go to a general dental practitioner: Regular oral hygiene advice and treatment from a general dental practitioner can help manage chronic gingivitis.
2. Avoid prescribing antibiotics: Antibiotics are not indicated for chronic gingivitis, and their overuse can lead to antibiotic resistance.
3. Avoid prescribing mouthwash: While mouthwash can help prevent plaque and gingivitis, it is not effective for established plaque and cannot stop periodontitis from progressing.
4. Consider temporary pain relief: Saline mouthwash can provide temporary pain and swelling relief.
5. Prescribe metronidazole for acute necrotising ulcerative gingivitis: If the patient has punched-out gingival ulcers covered with a white, yellowish, or grey pseudomembrane, metronidazole 400 mg three times daily for one week may be necessary.
6. Refer to oral surgery for severe symptoms or suspicion of malignancy: Referral to oral surgery would only be necessary for severe or rapidly progressive symptoms or suspicion of malignancy.
By following these treatment options, patients with chronic gingivitis can manage their symptoms and improve their oral health.
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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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A 28-year-old male patient comes in with a recent onset headache that has been bothering him for the past 5 days. He reports experiencing facial pain, fevers, a dry cough, thin yellow discharge from his nose, and nasal congestion. His temperature is normal at 37.4ºC and he experiences pain when pressure is applied to his maxillary area.
Based on the probable diagnosis, what would be the best course of treatment?Your Answer:
Correct Answer: Analgesia
Explanation:For this patient with acute sinusitis, analgesia is the most appropriate treatment to alleviate facial pain. Cefalexin, a broad-spectrum antibiotic, is not typically recommended for sinusitis, especially if it is suspected to be caused by a viral trigger. Intranasal corticosteroids should only be considered for chronic sinusitis or if symptoms persist for 10 days or more. Intranasal decongestants can provide short-term relief for nasal symptoms, but their long-term use can lead to dependence. Therefore, simple analgesia is the best option for this patient.
Acute sinusitis is a condition where the mucous membranes of the paranasal sinuses become inflamed. This inflammation is usually caused by infectious agents such as Streptococcus pneumoniae, Haemophilus influenza, and rhinoviruses. Certain factors can predispose individuals to this condition, including nasal obstruction, recent local infections, swimming/diving, and smoking. Symptoms of acute sinusitis include facial pain, nasal discharge, and nasal obstruction. Treatment options include analgesia, intranasal decongestants or nasal saline, and intranasal corticosteroids. Oral antibiotics may be necessary for severe presentations, but they are not typically required. In some cases, an initial viral sinusitis can worsen due to secondary bacterial infection, which is known as double-sickening.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 82
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 83
Incorrect
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A 50-year-old woman comes to the clinic complaining of vertigo for the past 3 days. She reports feeling like 'the room is spinning' when she turns over in bed or looks upwards, lasting for about 10 seconds each time. She experiences some nausea but denies vomiting, hearing loss, or tinnitus. The patient states that she has been feeling generally well lately.
What is the examination technique used to diagnose the probable condition in this case, and what are the expected results of this examination?Your Answer:
Correct Answer: Dix-Hallpike manoeuvre-rotatory nystagmus
Explanation:If rotatory nystagmus is observed during the Dix-Hallpike manoeuvre, it is likely that the patient has benign paroxysmal positional vertigo (BPPV). This is supported by the patient’s history of vertigo lasting less than 1 minute when changing head position. The Dix-Hallpike manoeuvre is the recommended examination by NICE to diagnose BPPV and can provoke rotatory upbeat nystagmus.
It is important to note that while the Dix-Hallpike manoeuvre is specific to BPPV, it produces rotatory nystagmus rather than vertical nystagmus. The Epley manoeuvre is used as a treatment for BPPV, not as a diagnostic tool.
Unterberger’s test is not used to diagnose BPPV, but rather to assess vertigo and examine for labyrinth dysfunction, which may be associated with hearing loss and tinnitus.
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 84
Incorrect
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A 47-year-old woman visits her GP complaining of constant right-sided hearing difficulty, tinnitus, and vertigo that have been present for the past two months and have worsened recently. Upon examination, there is no wax in either auditory canal, and the tympanic membranes appear normal.
What would be the most suitable course of action for management?Your Answer:
Correct Answer: Refer urgently to ENT
Explanation:If a patient is suspected to have an acoustic neuroma, it is crucial to refer them to an ENT specialist as soon as possible. The ENT specialist can conduct necessary tests such as audiograms and imaging to confirm or rule out the diagnosis. An ECG is not required based on the patient’s history, and hospitalization is not necessary. While an audiogram may be helpful, it is best to refer the patient directly to ENT for an MRI Head and audiogram together. A trial of medication and follow-up would not be appropriate in this case, as prompt initiation of further investigations is necessary. Meniere’s disease is a potential alternative diagnosis, but the constant and progressive nature of the patient’s symptoms is not typical of Meniere’s, which is usually episodic.
Vestibular schwannomas, also known as acoustic neuromas, make up about 5% of intracranial tumors and 90% of cerebellopontine angle tumors. These tumors typically present with a combination of vertigo, hearing loss, tinnitus, and an absent corneal reflex. The specific symptoms can be predicted based on which cranial nerves are affected. For example, cranial nerve VIII involvement can cause vertigo, unilateral sensorineural hearing loss, and unilateral tinnitus. Bilateral vestibular schwannomas are associated with neurofibromatosis type 2.
If a vestibular schwannoma is suspected, it is important to refer the patient to an ear, nose, and throat specialist urgently. However, it is worth noting that these tumors are often benign and slow-growing, so observation may be appropriate initially. The diagnosis is typically confirmed with an MRI of the cerebellopontine angle, and audiometry is also important as most patients will have some degree of hearing loss. Treatment options include surgery, radiotherapy, or continued observation.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 85
Incorrect
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A 30-year-old woman presents with bilateral inflamed tonsils, an inability to swallow both solids and liquids, and inflamed cervical lymph nodes.
Select the most appropriate management option.Your Answer:
Correct Answer: Referral to hospital for admission
Explanation:When to Admit a Patient with a Sore Throat: Indications and Recommendations
Admission to the hospital for a sore throat is necessary in certain cases. One such case is when the patient cannot swallow, making oral treatments ineffective. A Paul-Bunnell test may be considered, but it is not the first-line management. An ultrasound scan is only necessary for unexplained cervical lymphadenopathy.
According to NICE, hospital admission is recommended for sore throat cases that are immediately life-threatening, such as acute epiglottitis or Kawasaki disease. Other indications include dehydration or reluctance to take fluids, suppurative complications like quinsy, immunosuppression, and signs of being markedly systemically unwell.
It is important to be aware of these indications and recommendations to ensure proper management and treatment of sore throat cases.
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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 27-year-old man urgently books an appointment at your clinic. He complains of left-sided facial pain and malaise that has been ongoing for two weeks. He mentions that his symptoms initially improved after a week, but then worsened again, and he now feels worse than he did initially. He has no significant medical history.
During the examination, you note a low-grade fever of 37.9 degrees, but all other observations are normal. Anterior rhinoscopy reveals a purulent discharge from the left middle meatus, but there are no abnormalities in the eyes or periorbital tissues.
What is the most probable diagnosis?Your Answer:
Correct Answer: Bacterial sinusitis
Explanation:The man’s symptoms suggest bacterial sinusitis, as he has experienced a double sickening where his symptoms initially improved but then suddenly worsened. This is often caused by a secondary bacterial infection following a viral rhinosinusitis. The presence of a fever and purulent discharge seen on rhinoscopy further support this diagnosis.
Trigeminal neuralgia would not cause a fever, while sialadenitis would result in swelling of only one salivary gland. Cavernous sinus thrombosis is a rare complication of bacterial sinusitis and is not likely in this case.
Acute sinusitis is a condition where the mucous membranes of the paranasal sinuses become inflamed. This inflammation is usually caused by infectious agents such as Streptococcus pneumoniae, Haemophilus influenza, and rhinoviruses. Certain factors can predispose individuals to this condition, including nasal obstruction, recent local infections, swimming/diving, and smoking. Symptoms of acute sinusitis include facial pain, nasal discharge, and nasal obstruction. Treatment options include analgesia, intranasal decongestants or nasal saline, and intranasal corticosteroids. Oral antibiotics may be necessary for severe presentations, but they are not typically required. In some cases, an initial viral sinusitis can worsen due to secondary bacterial infection, which is known as double-sickening.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 87
Incorrect
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A 32-year-old woman presents with periodic spontaneous attacks of vertigo, nausea, tinnitus and reduced hearing in the left ear. She has had these attacks for the last 1-2 years. She has a feeling of aural fullness and discomfort in the left ear in advance of an attack which persists during an attack. Attacks can last up to 2-3 hours each time and occur in clusters over a few weeks. After an attack she feels worn out for a day or two and slightly unsteady.
When seen she is asymptomatic and head and neck examination is normal. No current hearing impairment is reported or apparent.
Which of the following is the most appropriate management approach?Your Answer:
Correct Answer: Refer her to an Ear, Nose and Throat specialist
Explanation:Meniere’s Disease: Symptoms and Diagnosis
This patient is presenting with symptoms consistent with Meniere’s disease, including episodic spontaneous vertigo, tinnitus, hearing loss, and aural fullness. Meniere’s disease is characterized by acute attacks lasting a few hours, occurring in clusters, and followed by periods of remission. While there are no specific diagnostic tests for the condition, audiometric testing can be helpful in demonstrating sensorineural low-to-mid frequency hearing loss. Referral to ENT services is recommended to confirm the diagnosis.
Brandt-Daroff exercises are not recommended for managing Meniere’s disease, as they are used for benign paroxysmal positional vertigo. An MRI brain scan would not be an appropriate next step in primary care based on this presentation. While audiometric assessment can be useful, it is not the best option as ENT services can arrange any necessary testing and appropriately investigate the condition. Attacks in Meniere’s disease typically settle within 24 hours, and prolonged attacks should prompt consideration of an alternative diagnosis. Referral to ENT services can provide support and input on a multidisciplinary level, which can be key if worsening symptoms, such as persistent hearing impairment, develop 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 88
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 89
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 90
Incorrect
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A 65-year-old man presents to your clinic with a chief complaint of progressive difficulty in swallowing over the past 3 months. Upon further inquiry, he reports a weight loss of approximately 2 kilograms, which he attributes to decreased food intake. He denies any pain with swallowing or regurgitation of food. During the consultation, you observe a change in his voice quality. What is the probable diagnosis?
Your Answer:
Correct Answer: Oesophageal carcinoma
Explanation:When a patient experiences progressive dysphagia and weight loss, it is important to investigate for possible oesophageal carcinoma as these are common symptoms. Laryngeal nerve damage can also cause hoarseness in patients with this type of cancer. While achalasia may present with similar symptoms, patients typically have difficulty swallowing both solids and liquids equally, and may experience intermittent regurgitation of food. On the other hand, oesophageal spasm is characterized by pain during swallowing.
Oesophageal Cancer: Types, Risk Factors, Features, Diagnosis, and Treatment
Oesophageal cancer used to be mostly squamous cell carcinoma, but adenocarcinoma is now becoming more common, especially in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett’s. Adenocarcinoma is usually located near the gastroesophageal junction, while squamous cell tumours are found in the upper two-thirds of the oesophagus. The most common presenting symptom is dysphagia, followed by anorexia and weight loss, vomiting, and other possible features such as odynophagia, hoarseness, melaena, and cough.
To diagnose oesophageal cancer, upper GI endoscopy with biopsy is used, and endoscopic ultrasound is preferred for locoregional staging. CT scanning of the chest, abdomen, and pelvis is used for initial staging, and FDG-PET CT may be used for detecting occult metastases if metastases are not seen on the initial staging CT scans. Laparoscopy is sometimes performed to detect occult peritoneal disease.
Operable disease is best managed by surgical resection, with the most common procedure being an Ivor-Lewis type oesophagectomy. However, the biggest surgical challenge is anastomotic leak, which can result in mediastinitis. In addition to surgical resection, many patients will be treated with adjuvant chemotherapy.
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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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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 92
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 93
Incorrect
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You encounter a 30-year-old mother of two who is experiencing recurrent Meniere's disease. She has been suffering from tinnitus and mild hearing loss on the right side for nearly 2 years. Every 2 months, she has an episode of vertigo accompanied by nausea and vomiting, which lasts up to 7 days and causes her significant distress. While under the care of the ENT team, she is curious about any available treatments to prevent Meniere's disease attacks.
What would be your initial recommendation?Your Answer:
Correct Answer: Betahistine
Explanation:To prevent recurrent attacks of Meniere’s disease, doctors often prescribe betahistine. While prochlorperazine and promethazine teoclate can be used to treat acute attacks, they are not effective in preventing them. Betahistine, taken at an initial dose of 16 mg three times a day, can help reduce the frequency and severity of symptoms such as hearing loss, tinnitus, and vertigo. Diuretics are not recommended for treating Meniere’s disease in primary care. Although some other drugs, such as corticosteroids, have been used historically to treat Meniere’s disease, there is limited evidence to support their use and they should only be used under the supervision of an ENT specialist.
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 94
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 95
Incorrect
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A 20-year-old Asian female presents with gingival hypertrophy. What is the most likely cause of her condition?
Your Answer:
Correct Answer: Phenytoin
Explanation:Causes of Gum Hypertrophy
Gum hypertrophy, or an abnormal increase in the size of the gums, can be caused by various factors. One of the common causes is the use of certain drugs such as phenytoin, which is used to treat seizures. Acute myeloid leukaemias can also lead to gum hypertrophy.
Scurvy, a condition caused by vitamin C deficiency, can result in swollen and bleeding gums, but it is not typically associated with true gingival hypertrophy. Instead, petechiae, or small red or purple spots, may appear on the mucosae.
Lead toxicity can cause pigmentation of the gums, while carbamazepine, a medication used to treat seizures and bipolar disorder, is not typically associated with gum hypertrophy. However, it can cause other side effects such as ataxia, drowsiness, and blood dyscrasias.
In summary, while gum hypertrophy can be caused by various factors, phenytoin and acute myeloid leukaemias are the most likely culprits. Scurvy may cause swollen and bleeding gums, but it is not typically associated with true gingival hypertrophy. Lead toxicity can cause pigmentation of the gums, while carbamazepine is not typically associated with gum hypertrophy.
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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 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 97
Incorrect
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A 25-year-old man presents with a three-month history of weight loss, night sweats, and painful lumps in his neck that worsen with alcohol consumption. What is the most probable diagnosis?
Your Answer:
Correct Answer: Hodgkin’s lymphoma
Explanation:Differential Diagnosis of Painful Lymphadenopathy
Painful lymphadenopathy can be a rare but significant symptom in the diagnosis of certain conditions. In Hodgkin’s lymphoma, pain on alcohol ingestion in involved lymph nodes is a strong indication of the disease, although the reasons for the pain are unknown. On the other hand, glandular fever, lymph node metastases from laryngeal cancer, recurrent tonsillitis, and tuberculosis are incorrect differential diagnoses for painful lymphadenopathy.
Glandular fever, caused by the Epstein-Barr virus, presents with fever, lymphadenopathy, pharyngitis, rash, and periorbital edema. However, lymphadenopathy is always bilateral and symmetrical, and the disease is usually self-limiting. Lymph node metastases from laryngeal cancer may present with a lump in the neck, but chronic hoarseness is the most common early symptom, and systemic symptoms are not present. Recurrent tonsillitis may cause anterior cervical lymph nodes to enlarge and become tender, but it is usually accompanied by a sore throat. Finally, while cervical nodes are commonly affected in tuberculous lymphadenitis, they may present as abscesses with discharging sinuses, and lymph node pain on drinking alcohol doesn’t occur in tuberculosis.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 98
Incorrect
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A 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 99
Incorrect
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A 25-year-old woman comes to the clinic with a single enlarged lymph node on the left side of her neck. She reports first noticing it during a cold she had about four weeks ago, and it has since increased in size, causing her to become more worried. During the examination, you observe a cervical lymph node with a diameter of 3 cm. There are no other abnormal findings. Routine blood tests reveal mild normochromic normocytic anemia and an elevated ESR of 72, but are otherwise normal.
What is the most appropriate next step to confirm the diagnosis?Your Answer:
Correct Answer: CXR
Explanation:Suspected Hodgkin’s Lymphoma in Primary Care
This patient’s presentation of a solitary enlarged lymph node, mild anaemia, and raised ESR falls within the age range for possible Hodgkin’s lymphoma. While constitutional symptoms are only present in a minority of cases, it is important to consider this diagnosis and refer urgently for excision biopsy of the lymph node. CXR and CT are important for staging, but not for confirming the diagnosis in primary care. Rapidly enlarging neck masses of greater than three weeks duration should be referred urgently to a specialist without first arranging imaging. Upper GI pathology is less likely given the absence of symptoms, and routine referral to haematology is not appropriate. NICE guidelines recommend considering a suspected cancer pathway referral for Hodgkin’s lymphoma in adults presenting with unexplained lymphadenopathy, taking into account any associated symptoms.
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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 2-year-old girl is brought to the clinic by her parents who are worried about her constant tugging on her left ear and increased fussiness over the past 24 hours.
During the examination, the child's temperature is found to be 38.5ºC, and the left tympanic membrane appears red. There is no discharge in the ear canal, the right ear is normal, and there are no signs of mastoiditis. The child has no significant medical history and is not taking any medications.
What is the most appropriate course of action for managing this patient?Your Answer:
Correct Answer: Regular analgesia, call back in 3 days time if the symptoms are not resolving
Explanation:Parents should be informed that antibiotics are not always necessary for treating acute otitis media in children. The condition typically resolves on its own within 24-72 hours without the need for antibiotics. Pain relief medication can be used to alleviate discomfort and reduce fever during this time. However, if symptoms persist for more than 4 days or worsen, parents should seek medical attention. Immediate antibiotic prescription is not recommended unless the child is under 2 years old, has bilateral otitis media, otorrhoea, or is immunocompromised. Amoxicillin is the first-line therapy, while erythromycin and clarithromycin are alternative options for children allergic to penicillin. Topical antibiotics are not recommended for treating otitis media, and oral antibiotics should be used if necessary. Referral to the emergency department is not necessary unless there are signs of complications such as acute mastoiditis, meningitis, or facial nerve paralysis. Swabbing the ear is not useful, even if there is discharge present, as the condition is likely to have resolved before culture results become available.
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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