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Question 1
Correct
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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: 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 2
Incorrect
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A 23-year-old male presents with hearing difficulties. You conduct an assessment of his auditory system, which includes Rinne's and Weber's tests:
Rinne's test: Left ear - bone conduction > air conduction; Right ear - air conduction > bone conduction
Weber's test: Lateralizes to the left side
What is the significance of these test results?Your Answer:
Correct Answer: Left conductive deafness
Explanation: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 3
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 4
Incorrect
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You are evaluating a middle-aged woman who has come in with sudden onset of facial weakness on one side. What is the most significant risk factor for developing Bell's palsy in this patient?
Your Answer:
Correct Answer: Pregnancy
Explanation:Bell’s palsy is three times more likely to occur in pregnant women. While sarcoidosis can lead to facial nerve palsy, it is not directly linked to Bell’s palsy.
Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It typically affects individuals between the ages of 20 and 40, and is more common in pregnant women. The condition is characterized by a lower motor neuron facial nerve palsy that affects the forehead, while sparing the upper face. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.
The management of Bell’s palsy has been a topic of debate, with various treatment options proposed in the past. However, there is now consensus that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, with some experts recommending it for severe cases. Eye care is also crucial to prevent exposure keratopathy, and patients may need to use artificial tears and eye lubricants. If they are unable to close their eye at bedtime, they should tape it closed using microporous tape.
Follow-up is essential for patients who show no improvement after three weeks, as they may require urgent referral to ENT. Those with more long-standing weakness may benefit from a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within three to four months. However, untreated cases can result in permanent moderate to severe weakness in around 15% of patients.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 5
Incorrect
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In your afternoon clinic, you come across a 45-year-old male patient complaining of vertigo. He had a recent upper respiratory tract infection and has been experiencing vertigo since then. He also reports a ringing sound in his right ear and decreased hearing. Along with vertigo, he is experiencing nausea and vomiting. On examination, he has fine horizontal nystagmus but no focal neurological signs. Which symptom or sign is unique to labyrinthitis and not vestibular neuronitis?
Your Answer:
Correct Answer: Hearing loss
Explanation:Viral labyrinthitis may cause hearing loss, while vestibular neuronitis doesn’t typically result in hearing loss. However, both conditions can cause symptoms such as nausea and vomiting, vertigo, and nystagmus. Therefore, the options stating that these symptoms are exclusive to one condition or the other are incorrect.
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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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 7
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 8
Incorrect
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A 49-year-old man presents to you with concerns about a sudden hearing loss in his left ear. He was watching TV with his wife the previous night when he went to the bathroom. Upon returning, he noticed that he could no longer hear speech or music from his left ear and instead, he could only hear a loud hissing sound.
Upon examination, both ears, ear canals, and tympanic membranes appear normal. Combined Weber's and Rinne's tests reveal that he has a sensorineural hearing loss on the left side.
What is the most probable cause of this man's symptoms?Your Answer:
Correct Answer: Idiopathic
Explanation:Sudden sensorineural hearing loss in the UK is mostly idiopathic, with potential underlying causes being URTI-related viral infections and microvascular obstruction to the blood flow in the cochlea. However, there are also much rarer causes such as acoustic neuroma or other intracranial tumors, trauma, blasts and loud noise, barotrauma from SCUBA diving and flights, meningitis, herpes zoster, syphilis, immunological disease, AIDS, MS, Meniere’s disease, Lyme disease, and stroke. It is important not to assume that a man married to another man has a disease related to this, even in exam questions.
When a patient experiences a sudden loss of hearing, it is crucial to conduct a thorough examination to determine whether it is conductive or sensorineural hearing loss. If it is the latter, known as sudden-onset sensorineural hearing loss (SSNHL), it is imperative to refer the patient to an ear, nose, and throat (ENT) specialist immediately. The majority of SSNHL cases have no identifiable cause, making them idiopathic. To rule out the possibility of a vestibular schwannoma, an MRI scan is typically performed. ENT specialists administer high-dose oral corticosteroids to all patients with SSNHL.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 9
Incorrect
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A 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 10
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 11
Incorrect
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A 55-year-old man presents to his General Practitioner (GP) with multiple symptoms affecting his nose and throat. He has long-standing nasal congestion, but over the past week has also been suffering from a painful lesion in his mouth, sore throat and hoarse voice. On examination, he has bilateral, grey nasal swellings, a solitary yellow ulcer of 4 mm diameter on the oral mucosa, a multinodular goitre and unilateral parotid enlargement. He states that the parotid lump has been there for a few months, at least. His GP suspects cancer.
Which of the following presentations warrants specialist referral under the 2-week rule?
Your Answer:
Correct Answer: The discrete slow-growing lump in the right parotid gland
Explanation:Common Head and Neck Symptoms and Referral Guidelines
The following are common head and neck symptoms and the appropriate referral guidelines:
1. Discrete slow-growing lump in the right parotid gland: Any unexplained lump in the head or neck requires a 2-week rule referral. A discrete, persistent, unilateral lump in the parotid gland requires an urgent referral, imaging, and further investigation to determine the nature of the mass.
2. Solitary, painful ulcer on the oral mucosa, of 1-week duration: This is most likely to be an aphthous ulcer. An unexplained oral ulceration lasting more than three weeks, or an unexplained neck lump, would warrant a 2-week wait referral.
3. A 7-day history of hoarseness and sore throat: Patients over the age of 45 with persistent unexplained hoarseness should be referred using the cancer pathway. After seven days, this is most likely to be an upper respiratory tract infection.
4. Diffuse multinodular thyroid swelling: For suspected thyroid cancer, the single referral criterion is an âunexplained thyroid lumpâ. The most likely diagnosis in this patient is a multinodular goitre.
5. Nasal obstruction and bilateral grey swellings visible by nasal speculum: Bilateral nasal swellings of this description are almost certainly polyps. These can initially be managed in primary care. Unilateral polyps should be referred to the ear, nose and throat clinic.
Head and Neck Symptoms and Referral Guidelines
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 12
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 13
Incorrect
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A 60-year-old man comes to the clinic 3 days after being hit on the left side of his head. He reports experiencing muffled hearing on the left side since the incident. Upon examination, there are no visible bruises, but both ears are covered by a thin, translucent layer of wax. Rinne's test reveals that the tuning fork is more audible when placed on the mastoid bone on the left side. On Weber's test, the sound is heard most clearly on the left side. What is the probable diagnosis?
Your Answer:
Correct Answer: Perforated eardrum
Explanation:Differentiating between tympanic membrane perforation and sensorineural hearing loss due to skull trauma is crucial. Rinne’s test can help identify conductive hearing loss in the affected ear, while Weber’s test can rule out sensorineural hearing loss on the right.
Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness
Rinne’s and Weber’s tests are used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test indicates that BC is better than AC, suggesting conductive deafness.
Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking the patient which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.
The table below summarizes the interpretation of Rinne and Weber tests. A normal result indicates that AC is greater than BC bilaterally and the sound is midline. Conductive hearing loss is indicated by BC being greater than AC in the affected ear and AC being greater than BC in the unaffected ear, with the sound lateralizing to the affected ear. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, with the sound lateralizing to the unaffected ear.
Overall, Rinne’s and Weber’s tests are useful tools for differentiating between conductive and sensorineural deafness, allowing for appropriate management and treatment.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 14
Incorrect
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A 23-year-old female presents with severe right-sided ear pain, muffled hearing, and watery discharge for the past 3 days. The patient also reports intense itching in the affected ear. Upon examination, the tympanic membrane is intact, but the external auditory canal is inflamed, red, and swollen with purulent debris and wax. Pulling the pinna causes the patient significant pain. The mastoid process is normal and not tender to palpation. Rinne's and Weber's tests confirm conductive hearing loss. What is the recommended first-line treatment for this patient?
Your Answer:
Correct Answer: Topical antibiotic + a topical steroid for 1-2 weeks
Explanation:Understanding Otitis Externa: Causes, Features, and Management
Otitis externa is a prevalent condition that often prompts primary care visits in the UK. It is characterized by ear pain, itch, and discharge, and can be caused by bacterial or fungal infections, seborrhoeic dermatitis, or contact dermatitis. Swimming is also a common trigger for otitis externa. Upon examination, the ear canal may appear red, swollen, or eczematous.
The recommended initial management for otitis externa is the use of topical antibiotics or a combination of topical antibiotics with a steroid. However, if the tympanic membrane is perforated, aminoglycosides are traditionally not used. If there is canal debris, removal may be necessary, and if the canal is extensively swollen, an ear wick may be inserted. Second-line options include taking a swab inside the ear canal, considering contact dermatitis secondary to neomycin, or using oral antibiotics such as flucloxacillin if the infection is spreading. Empirical use of an antifungal agent may also be considered.
It is important to note that if a patient fails to respond to topical antibiotics, they should be referred to an ENT specialist. Malignant otitis externa is a more severe form of the condition that is more common in elderly diabetics. It involves the extension of infection into the bony ear canal and the soft tissues deep to the bony canal, and may require intravenous antibiotics. While some ENT doctors disagree, concerns about ototoxicity may arise with the use of aminoglycosides in patients with perforated tympanic membranes.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 15
Incorrect
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A 2-year-old boy is presented by his father with bilateral earache. The child has been experiencing this for the past week despite taking regular paracetamol and neurofen.
During the examination, the child's temperature is recorded at 39.2ÂșC. His pulse rate is 130 beats per minute and both ears show congested, red, and bulging tympanic membranes.
What is the best course of action for managing this condition?Your Answer:
Correct Answer: Amoxicillin
Explanation:For most cases of acute otitis media, it is recommended to avoid or delay the use of antibiotics. However, a prescription may be necessary for individuals who are systemically unwell, have co-morbidities that put them at high-risk, experience ongoing symptoms for at least 4 days without improvement, children under 2 years old with bilateral otitis media, or those with perforation and/or discharge in the ear canal. Amoxicillin is the preferred first-line drug, while acetic acid spray, otomize spray, and flucloxacillin can be used for otitis externa. Although symptoms should typically be monitored, this patient meets some of the criteria for antibiotic prescription.
Acute otitis media is a common condition in young children, often caused by bacterial infections following viral upper respiratory tract infections. Symptoms include ear pain, fever, and hearing loss, and diagnosis is based on criteria such as the presence of a middle ear effusion and inflammation of the tympanic membrane. Antibiotics may be prescribed in certain cases, and complications can include perforation of the tympanic membrane, hearing loss, and more serious conditions such as meningitis and brain abscess.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 16
Incorrect
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A 20-year-old, previously healthy, female presents with a nine day history of fever, sore throat and fatigue.
On examination of her throat, there are palatal petechiae and white tonsillar exudates. Two days ago, another doctor prescribed amoxicillin, and she has since developed a widespread maculopapular rash.
What is the diagnosis?Your Answer:
Correct Answer: Infectious mononucleosis
Explanation:Understanding Infectious Mononucleosis
Infectious mononucleosis, also known as glandular fever, is a common disease that affects young adults. It is caused by the Epstein-Barr virus, which is excreted through nasopharyngeal secretions, primarily saliva, and can be transmitted through person-to-person contact, earning it the nickname kissing disease. While some carriers may not exhibit symptoms, others may experience acute illness characterized by sore throat, fever, lethargy, lymphadenopathy, palatal petechiae, splenomegaly, hepatitis, and haemolytic anaemia. Rashes may also occur, particularly if the patient is given amoxicillin or ampicillin, which should not be confused with the disease.
When diagnosing infectious mononucleosis, it is important to consider other differential diagnoses such as streptococcal sore throat, HIV seroconversion illness, diphtheria, and leukaemia. These conditions share many common symptoms, but the appearance of a rash after the patient has been given amoxicillin can help confirm the diagnosis. Understanding the signs and symptoms of infectious mononucleosis and its differential diagnoses can aid in 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 17
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 18
Incorrect
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A 25-year-old man presents to the General Practitioner with a swollen ear. He plays amateur rugby and was punched during a match the previous day. The upper pinna is fluctuant and mildly erythematous, but there are no other injuries. What is the most suitable management option?
Your Answer:
Correct Answer: Early drainage and compression
Explanation:Auricular Haematoma: Causes, Symptoms, and Treatment
Auricular haematoma is a common facial injury that results from direct trauma to the anterior auricle. It is often seen in athletes such as wrestlers, rugby players, and footballers. The condition occurs when shearing forces cause separation of the perichondrium from the underlying cartilage, leading to tearing of the perichondrial blood vessels and hematoma formation.
If left untreated, the haematoma can lead to avascular necrosis of the auricular cartilage, resulting in a ‘cauliflower ear’ deformity. To prevent this, evacuation of the haematoma is necessary. This can be done through aspiration with a 10 ml syringe attached to a wide needle or by incision and drainage. Compression is also necessary to prevent reoccurrence.
However, infection may be a complication, and if it worsens, patients may need to be admitted to the hospital for intravenous antibiotics and surgical exploration. Patients with recurrent haematomas or haematomas more than seven days old may also need surgical debridement.
In conclusion, auricular haematoma is a serious condition that requires prompt treatment to prevent complications. Athletes and individuals who engage in activities that put them at risk of this injury should take precautions to avoid it.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 19
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 20
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 39.2ÂșC, 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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