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  • Question 1 - A 50-year-old woman comes in with complaints of hearing loss. Tuning fork tests...

    Incorrect

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

      Your Answer: Right-sided conductive hearing loss

      Correct Answer: Left-sided sensorineural hearing loss

      Explanation:

      Tuning Fork Tests for Hearing Loss

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

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

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

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 2 - A 30 year old female smoker presents with painful aphthous ulcers and has...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 3 - A 27-year-old man urgently books an appointment at your clinic. He complains of...

    Incorrect

    • 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: Viral sinusitis

      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.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 4 - A 55-year-old smoker of 20 cigarettes a day, presents with a three month...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 5 - A 2-year-old boy is presented by his father with bilateral earache. The child...

    Correct

    • A 2-year-old boy is presented by his father with bilateral earache. The child has been experiencing this for the past week despite taking regular paracetamol and neurofen.

      During the examination, the child's temperature is recorded at 39.2ºC. His pulse rate is 130 beats per minute and both ears show congested, red, and bulging tympanic membranes.

      What is the best course of action for managing this condition?

      Your Answer: 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.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 6 - A 70-year-old man presents to your clinic with a complaint of recurrent nosebleeds...

    Incorrect

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

      Your Answer: Refer to ENT ‘hot clinic’

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

      Explanation:

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

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

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

      Understanding Epistaxis: Causes and Management

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

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

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

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

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 7 - A 47-year-old man visits his primary care physician with concerns about a persistent...

    Incorrect

    • A 47-year-old man visits his primary care physician with concerns about a persistent ulcer on his tongue that has been growing for a few weeks. He is a heavy smoker, consuming 30 cigarettes a day, and drinks alcohol regularly. Upon examination, the physician notes bilateral submandibular lymphadenopathy, multiple dental caries, and a 1-cm ulcer on the lateral border of his tongue. What is the most suitable course of action for managing this patient?

      Your Answer:

      Correct Answer: Refer under 2-week rule

      Explanation:

      Diagnosis and Management of Tongue Cancer

      Tongue cancer is a common type of oral cancer, with about 75% of cases occurring on the mobile tongue. It typically presents as a persistent growing lesion, which may be painless or painful. Carcinoma of the tongue base is often clinically silent until it infiltrates the musculature. Risk factors for tongue cancer include poor dental hygiene, smoking, drinking, and betel and pan consumption in ethnic minorities.

      All suspicious tongue lesions should be referred urgently under the 2-week rule for exclusion of malignancy. Treatment options for tongue cancer include surgery and radiotherapy. The overall 5-year survival rates are 60% for women and 40% for men.

      It is important to note that prescribing Tri Adcortyl® ointment or antibiotics would not be appropriate for the management of tongue cancer. Instead, urgent referral for further evaluation and treatment is necessary.

      In some cases, a chancre caused by syphilis may present as a solitary, painless, indurated, reddish ulcer on the oral mucosa. Therefore, testing for syphilis and treating if positive may be necessary in some cases. However, it is important to differentiate between syphilis and tongue cancer, as the management and prognosis differ significantly.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 8 - A 42-year-old man comes to your clinic complaining of ear pain. He had...

    Incorrect

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

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

      Your Answer:

      Correct Answer: Start amoxicillin

      Explanation:

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

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

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

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

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

      References: NICE Guidelines, Clinical Knowledge Summaries

      Acute otitis media is a common condition in young children, often caused by bacterial infections following viral upper respiratory tract infections. Symptoms include ear pain, fever, and hearing loss, and diagnosis is based on criteria such as the presence of a middle ear effusion and inflammation of the tympanic membrane. Antibiotics may be prescribed in certain cases, and complications can include perforation of the tympanic membrane, hearing loss, and more serious conditions such as meningitis and brain abscess.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 9 - A 48-year-old woman presents to the clinic for follow-up. She reports feeling increasingly...

    Incorrect

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

      Your Answer:

      Correct Answer: C reactive protein

      Explanation:

      Diagnosis and Management of Hypothyroidism

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

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 10 - A 50-year-old chef presents for a follow-up appointment after experiencing a left-sided Bell's...

    Incorrect

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

      What is the most suitable next step?

      Your Answer:

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

      Explanation:

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

      Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It typically affects individuals between the ages of 20 and 40, and is more common in pregnant women. The condition is characterized by a lower motor neuron facial nerve palsy that affects the forehead, while sparing the upper face. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.

      The management of Bell’s palsy has been a topic of debate, with various treatment options proposed in the past. However, there is now consensus that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, with some experts recommending it for severe cases. Eye care is also crucial to prevent exposure keratopathy, and patients may need to use artificial tears and eye lubricants. If they are unable to close their eye at bedtime, they should tape it closed using microporous tape.

      Follow-up is essential for patients who show no improvement after three weeks, as they may require urgent referral to ENT. Those with more long-standing weakness may benefit from a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within three to four months. However, untreated cases can result in permanent moderate to severe weakness in around 15% of patients.

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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 11 - A 42-year-old man who is a smoker presents with a 6-week history of...

    Incorrect

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

      Your Answer:

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

      Explanation:

      Importance of Prompt Referral for Laryngeal Carcinoma

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

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

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

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 12 - A 2-year-old girl is brought to the clinic by her parents who are...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 13 - You are requested to conduct a home visit for Edna, a 72-year-old woman,...

    Incorrect

    • 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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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 14 - As a GP visiting a residential home patient, you encounter a 74-year-old female...

    Incorrect

    • As a GP visiting a residential home patient, you encounter a 74-year-old female with a 4 week history of oral ulceration. The patient reports experiencing pain and bleeding due to the condition. She also mentions that her dentures have not been fitting well, leading her to stop using them. Additionally, she has lost a few kilograms in weight over the past few weeks. Based on NICE guidelines for suspected cancer, which aspects of this patient's history would necessitate referral (within 2 weeks) for oral cancer?

      Your Answer:

      Correct Answer: Unexplained ulceration in the oral cavity lasting for more than 3 weeks

      Explanation:

      Alcohol consumption is linked to 30% of cases in the UK.

      When to Refer Patients with Mouth Lesions for Oral Surgery

      Mouth lesions can be a cause for concern, especially if they persist for an extended period of time. In cases where there is unexplained oral ulceration or mass that lasts for more than three weeks, or red and white patches that are painful, swollen, or bleeding, a referral to oral surgery should be made within two weeks. Additionally, if a patient experiences one-sided pain in the head and neck area for more than four weeks, which is associated with earache but doesn’t result in any abnormal findings on otoscopy, or has an unexplained recent neck lump or a previously undiagnosed lump that has changed over a period of three to six weeks, a referral should be made.

      Patients who have persistent sore or painful throats or signs and symptoms in the oral cavity that last for more than six weeks and cannot be definitively diagnosed as a benign lesion should also be referred. It is important to note that the level of suspicion should be higher in patients who are over 40, smokers, heavy drinkers, and those who chew tobacco or betel nut (areca nut). By following these guidelines, healthcare professionals can ensure that patients with mouth lesions receive timely and appropriate care. For more information on this topic, please refer to the link provided.

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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 15 - A 49-year-old man presents with concerns about his hearing. He has a history...

    Incorrect

    • A 49-year-old man presents with concerns about his hearing. He has a history of recurrent Ménière disease which has resulted in significant hearing loss. He struggles to hear his coworkers at work and his partner has noticed that he needs to turn the volume up high on the television. He has not considered hearing aids due to negative stories he has heard about them.

      Upon reviewing his recent audiogram, it shows an 80 dB hearing loss at the 1,000 Hz and 2,000 Hz frequencies. The patient is interested in being referred for a cochlear implant.

      What is the recommended management plan?

      Your Answer:

      Correct Answer: Refer her for hearing aids

      Explanation:

      Individuals with severe to profound hearing loss, such as this woman, may benefit from a cochlear implant. It is not necessary for her to wait until her hearing worsens before seeking treatment. Ménière disease-related hearing loss, which is linked to inner ear issues and balance symptoms, can also be improved with a cochlear implant. While cochlear implants are available through the NHS, patients are typically required to have attempted hearing aids before being considered for the procedure.

      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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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 16 - A 50-year-old woman comes to the clinic complaining of vertigo for the past...

    Incorrect

    • 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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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 17 - A 4-year-old girl is brought to her General Practitioner by her parents because...

    Incorrect

    • 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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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 18 - You see a 30-year-old man who reports an acute onset of reduced hearing...

    Incorrect

    • You see a 30-year-old man who reports an acute onset of reduced hearing in his left ear. This started suddenly yesterday. He is otherwise well with no ear pain, fevers or systemic upset. Examination of ears and cranial nerves were unremarkable.

      Which is the most appropriate next step in management?

      Your Answer:

      Correct Answer: Refer to on-call ENT team

      Explanation:

      NICE Guidelines for Managing Sudden Hearing Loss in Adults

      The National Institute for Health and Care Excellence (NICE) released guidelines in June 2018 to provide recommendations on managing sudden or rapid onset hearing loss in adults. This type of hearing loss is not explained by external or middle ear causes.

      According to the guidelines, an immediate referral is recommended if the hearing loss developed suddenly within the past 30 days. If the hearing loss developed suddenly but it has been over 30 days or if it worsened rapidly, a two-week wait referral is advised. The guidelines also provide further recommendations if there are additional symptoms or signs such as facial droop.

      It is important to note that NICE defines sudden hearing loss as within 3 days and rapid worsening as 4-90 days. These guidelines aim to improve the management and treatment of sudden hearing loss in adults.

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  • Question 19 - A 50-year-old woman comes to the clinic complaining of persistent tinnitus in her...

    Incorrect

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

      Your Answer:

      Correct Answer: Acoustic neuroma

      Explanation:

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

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

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

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  • Question 20 - A 56-year-old woman presents to the clinic for evaluation. She has been experiencing...

    Incorrect

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

      Your Answer:

      Correct Answer: ENT referral within 2 weeks

      Explanation:

      Suspected Nasopharyngeal Carcinoma

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

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  • Question 21 - A 26-year-old man with sinusitis inquires about the safety of using Sudafed (pseudoephedrine)....

    Incorrect

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

      Your Answer:

      Correct Answer: Monoamine oxidase inhibitor

      Explanation:

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

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

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  • Question 22 - A 29-year-old man contacts his GP seeking advice for his seasonal allergic rhinitis....

    Incorrect

    • 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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  • Question 23 - A 57-year-old male patient complains of intense pain deep in his right ear...

    Incorrect

    • A 57-year-old male patient complains of intense pain deep in his right ear accompanied by dizziness and a sensation of the room spinning. Upon clinical examination, he displays a partial facial nerve paralysis on the right side and vesicular lesions on the anterior two-thirds of his tongue. What condition is the most probable diagnosis?

      Your Answer:

      Correct Answer: Ramsay Hunt syndrome

      Explanation:

      Although vesicular lesions are typically observed in the external auditory canal and pinna, they can also appear on the front two-thirds of the tongue and the soft palate.

      Understanding Ramsay Hunt Syndrome

      Ramsay Hunt syndrome, also known as herpes zoster oticus, is a condition that occurs when the varicella zoster virus reactivates in the geniculate ganglion of the seventh cranial nerve. The first symptom of this syndrome is often auricular pain, followed by facial nerve palsy and a vesicular rash around the ear. Other symptoms may include vertigo and tinnitus.

      To manage Ramsay Hunt syndrome, doctors typically prescribe oral aciclovir and corticosteroids. These medications can help reduce the severity of symptoms and prevent complications.

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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 24 - A 25-year-old woman comes to the clinic complaining of headaches and unilateral sensorineural...

    Incorrect

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

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

      What is the appropriate management plan for this patient?

      Your Answer:

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

      Explanation:

      Suspected Intracranial Tumour in a Middle-Aged Woman

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

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

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  • Question 25 - A 6-year-old boy comes to you complaining of sudden and severe pain in...

    Incorrect

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

      Your Answer:

      Correct Answer: Avoid swimming until the perforation is completely healed

      Explanation:

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

      Perforated Tympanic Membrane: Causes and Management

      A perforated tympanic membrane, also known as a ruptured eardrum, is often caused by an infection but can also result from barotrauma or direct trauma. This condition can lead to hearing loss and increase the risk of otitis media.

      In most cases, no treatment is necessary as the tympanic membrane will typically heal on its own within 6-8 weeks. However, it is important to avoid getting water in the ear during this time. Antibiotics may be prescribed if the perforation occurs after an episode of acute otitis media. This approach is supported by the 2008 Respiratory Tract Infection Guidelines from NICE.

      If the tympanic membrane doesn’t heal by itself, myringoplasty may be performed. This surgical procedure involves repairing the perforation with a graft of tissue taken from another part of the body. With proper management, a perforated tympanic membrane can be successfully treated and hearing can be restored.

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  • Question 26 - A 42-year-old man presents with a 'neck lump' that he has noticed over...

    Incorrect

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

      Your Answer:

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

      Explanation:

      Thyroid Swelling: Recognizing and Referring Suspected Cancer

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

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

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

    Incorrect

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

      What would you recommend as a possible option for her?

      Your Answer:

      Correct Answer: Offer short course of oral prednisolone

      Explanation:

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

      Understanding Allergic Rhinitis

      Allergic rhinitis is a condition that causes inflammation in the nose due to sensitivity to allergens such as dust mites, grass, tree, and weed pollens. It can be classified into seasonal, perennial, or occupational, depending on the timing and cause of symptoms. Seasonal rhinitis, which occurs due to pollens, is commonly known as hay fever. Symptoms of allergic rhinitis include sneezing, bilateral nasal obstruction, clear nasal discharge, post-nasal drip, and nasal pruritus.

      The management of allergic rhinitis involves allergen avoidance and medication. For mild-to-moderate intermittent or mild persistent symptoms, oral or intranasal antihistamines may be prescribed. For moderate-to-severe persistent symptoms or if initial drug treatment is ineffective, intranasal corticosteroids may be recommended. In some cases, a short course of oral corticosteroids may be necessary to cover important life events. Topical nasal decongestants, such as oxymetazoline, may also be used for short periods, but prolonged use can lead to tachyphylaxis and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) upon withdrawal.

      In summary, allergic rhinitis is a common condition that can cause discomfort and affect daily life. Understanding the different types of allergic rhinitis and its symptoms can help in managing the condition effectively. It is important to consult a healthcare professional for proper diagnosis and treatment.

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      • Ear, Nose And Throat, Speech And Hearing
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  • Question 28 - A 25-year-old male comes to the GP complaining of a lump in his...

    Incorrect

    • A 25-year-old male comes to the GP complaining of a lump in his throat and increasing hoarseness that has been present for the past 3 weeks. He reports having a cold 4 weeks ago but denies experiencing heartburn, weight loss, nausea and vomiting, or difficulty swallowing. He is a non-smoker and drinks 12 units of alcohol per week. There is no significant medical history to note.

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Laryngopharyngeal reflux

      Explanation:

      Laryngopharyngeal reflux may be the cause of globus and hoarseness in the absence of any red flags. This condition is often referred to as ‘silent’ reflux. While globus hystericus is a symptom of anxiety, it is unlikely to persist without other autonomic symptoms. Gastro-oesophageal reflux, on the other hand, is characterized by retrosternal burning and regurgitation that worsens when lying down or leaning forward and is relieved by antacids. Post-nasal drip, which is commonly triggered by colds and flu, typically presents with an intractable cough or throat clearing that is worse at night.

      Understanding Laryngopharyngeal Reflux

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

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

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

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  • Question 29 - Which medication is most strongly linked to an increased risk of cleft palate...

    Incorrect

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

      Your Answer:

      Correct Answer: Phenytoin

      Explanation:

      Medications and their effects on pregnancy

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

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

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

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

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  • Question 30 - A 20-year-old Asian female presents with gingival hypertrophy. What is the most likely...

    Incorrect

    • 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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