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Question 1
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A 68-year-old woman visits her GP complaining of hearing loss and ringing in her ears for the past six months. She experienced this after being hospitalized for two weeks due to a soft tissue infection that was complicated by a bloodstream infection caused by methicillin-resistant Staphylococcus aureus. During her hospital stay, she was treated with flucloxacillin, gentamicin, and vancomycin. The tinnitus is present in both ears, and her ear and neurological examinations are normal. What is the probable underlying cause of this patient's tinnitus?
Your Answer: Ototoxic medication
Explanation:Differential diagnosis of hearing loss and tinnitus
Gentamicin-induced ototoxicity
A patient presenting with bilateral tinnitus and hearing loss after recent use of gentamicin is likely experiencing ototoxicity from this antibiotic. Gentamicin can damage the vestibular system and cause sensorineural hearing loss.
Bacteraemia and viral labyrinthitis
Bacteraemia, especially from methicillin-resistant S. aureus, would not cause tinnitus. Viral labyrinthitis may cause tinnitus, but it is usually accompanied by severe vertigo and hearing loss.
Hyperlipidaemia and noise-induced hearing loss
Hyperlipidaemia, particularly hypertriglyceridaemia, has been linked to an increased risk of noise-induced hearing loss and tinnitus. A low-cholesterol diet and atorvastatin may help alleviate these symptoms.
Ménière’s disease and betahistine
Ménière’s disease is a disorder of the inner ear characterized by excess endolymph, leading to severe vertigo, hearing loss, and tinnitus. Betahistine is a medication used to manage the symptoms of Ménière’s disease, but there is no cure for this condition.
Otosclerosis and conductive hearing loss
Otosclerosis is a condition that affects the bony ossicles of the ear, leading to conductive hearing loss. It results from abnormal sclerosis of the malleus, incus, and stapes, which are crucial for sound conduction from the outer to the inner ear.
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This question is part of the following fields:
- ENT
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Question 2
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A 48-year-old woman presents with a 10-day history of fever, sinus pain and fullness, bilateral yellow nasal discharge and difficulty smelling. Prior to this episode she describes having a minor cold, with sore throat and clear nasal discharge. She has no past medical history. On examination, her temperature is 38.2 °C and there is mild tenderness to palpation over the maxillofacial area. There are no nasal polyps. Her throat appears normal.
What should be included in the management of this patient's condition?Your Answer: Paracetamol
Explanation:Managing Acute Sinusitis: Treatment Options and Antibiotic Use
Acute sinusitis is a common condition that can cause discomfort and pain. Self-care measures such as paracetamol or ibuprofen can be used to manage symptoms of pain or fever. However, if symptoms persist for around ten days or more without improvement, a high-dose nasal corticosteroid may be prescribed for 14 days. While nasal corticosteroids may improve symptoms, they are not likely to affect how long they last and could cause systemic effects.
IV antibiotics should only be used in severe cases of systemic infection, intraorbital or periorbital complications, or intracranial complications. Systematic reviews and meta-analyses have shown that antibiotics, when compared with placebo, did not significantly increase the proportion of people in whom symptoms were cured or improved at 3–5 days follow-up. At 7–15 days follow-up, moderate quality evidence showed a statistically significant difference in effectiveness, but the clinical difference was small. This was not evident in the longer term.
For acute sinusitis following a cold, symptoms for <10 days are more commonly associated with a cold rather than viral or bacterial acute sinusitis. Prolonged symptoms (for around ten days or more without improvement) can be caused by either viral (more likely) or bacterial acute sinusitis. Only 0.5–2% of viral sinusitis is complicated by bacterial infection. Even then bacterial sinusitis is usually self-limiting and does not routinely need antibiotics. There is no evidence that topical antibiotics are useful in acute or chronic sinusitis. Understanding Treatment Options and Antibiotic Use for Acute Sinusitis
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This question is part of the following fields:
- ENT
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Question 3
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A 6-year-old asylum seeker from Africa presents to the Surgical Outpatient Clinic with a mass on the right side of his neck that has been growing in size. On examination, a mass is found on the side of the neck, behind the sternocleidomastoid muscle, which transilluminates brightly. What is the most probable diagnosis?
Your Answer: Cystic hygroma
Explanation:Differentiating Neck Abnormalities: Cystic Hygroma, Laryngocoele, Cervical Rib, Branchial Cyst, and Enlarged Lymph Node
Neck abnormalities can be challenging to differentiate, but understanding their characteristics can aid in proper diagnosis. Cystic hygromas are lymphatic abnormalities that are commonly found in the posterior triangle of the neck and transilluminate. They may not be noticeable at birth but typically grow as the child grows. Laryngoceles are abnormal cystic dilatations of the saccule or appendix of the laryngeal ventricle, which communicate with the lumen of the larynx and are filled with air. They are usually benign but can cause airway obstruction. Cervical ribs are extra ribs that arise from the seventh cervical vertebra and are located above the first rib. They do not transilluminate. Branchial cysts are remnants of the second branchial cleft and occur along the anterior border of the sternocleidomastoid, most commonly at the junction of the lower and middle thirds of the muscle. They do not transilluminate. Enlarged lymph nodes are usually secondary to an infection and settle to normal size after six to eight weeks. Understanding the characteristics of these neck abnormalities can aid in proper diagnosis and treatment.
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This question is part of the following fields:
- ENT
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Question 4
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A 28-year-old man presents with a swelling under the left jaw that comes and goes but leaves a dull ache behind. The problem has been present for around 2 weeks and is getting worse. The pain is most noticeable at mealtimes. In the last day, the swelling has become fixed and he reports an unpleasant taste in his mouth. He smokes five cigarettes a day and drinks ten units of alcohol a week, usually on a Saturday night. On examination, there is a smooth, tender swelling in the superior part of the left anterior triangle and, on inspection of the oral cavity, there is poor dentition and pus present just behind the lower incisors.
Which of the following is the most likely diagnosis?Your Answer: Submandibular gland infection
Explanation:Submandibular Gland Infection: Causes, Symptoms, and Management
A submandibular gland infection is often caused by the presence of a stone in the left submandibular duct, which can lead to a secondary infection due to the stasis of gland secretions. Stones are more common in the submandibular gland due to the length and tortuosity of the duct. Symptoms include a smooth, tender swelling, pain worse at mealtimes, and pus behind the lower incisors. Management involves antibiotics to treat the infection and referral to an ENT or oral surgeon for stone removal, which can usually be done under local anesthesia. In some cases, excision of the entire submandibular gland may be necessary. It is important to note that the presence of bacterial infection indicates an ongoing issue beyond just the stone. Other conditions, such as gingivostomatitis and dental abscess, can cause similar symptoms but have different underlying causes. Mumps, on the other hand, can cause swelling of the parotid gland, not the submandibular gland.
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This question is part of the following fields:
- ENT
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Question 5
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A 30-year-old woman presents with deteriorating hearing during pregnancy. There is no known family history of hearing loss. Upon examination, the tympanic membrane appears intact and pure tone audiometry indicates a conductive hearing loss with a Carhart notch.
What is the most probable location of the issue?Your Answer: Stapes
Explanation:Understanding Otosclerosis: Diagnosis and Treatment Options
Otosclerosis is a common autosomal dominant disorder that causes a conductive hearing loss, which typically worsens during pregnancy. The condition is caused by the fixation of the stapes bone in the ear, and it exhibits incomplete penetrance, meaning it can skip generations, and there may not be a positive family history of the condition.
Diagnosis of otosclerosis is typically made through examination findings and audiometry results. The Carhart notch, a dip seen on bone conduction audiometry, is a sign that is classically associated with otosclerosis. However, the tympanic membrane is unlikely to be the site of abnormality as it is mentioned that the tympanic membrane is intact on examination.
Treatment options for otosclerosis include amplification with hearing aids and medical treatment with sodium fluoride, which slows progression. Surgery, such as stapedectomy or stapedotomy, is becoming more popular and effective.
It is important to understand the diagnosis and treatment options for otosclerosis to effectively manage the condition and improve quality of life for those affected.
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This question is part of the following fields:
- ENT
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Question 6
Incorrect
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A 50-year-old woman comes to her GP complaining of a sore throat, coryzal symptoms, cough, feeling feverish and general malaise for the past week. She reports that she is eating and drinking well. Upon examination, her temperature is 37.1°C and her chest is clear. Her tonsils are inflamed, but there is no exudate. She has no significant medical history except for carpal tunnel syndrome. Based on her Fever PAIN score, what is the most suitable course of action?
Your Answer: Reassure and send home
Correct Answer: Safety net and review in 1 week if no improvement
Explanation:Using the FeverPAIN Score to Determine Antibiotic Use in Pharyngitis
Pharyngitis, or sore throat, is a common reason for patients to seek medical attention. However, not all cases of pharyngitis require antibiotics. In fact, inappropriate antibiotic use can lead to antibiotic resistance and other negative outcomes. To help providers determine which patients with pharyngitis have streptococcal pharyngitis, the FeverPAIN Score was developed.
The FeverPAIN Score assesses five factors: fever, presence of pus, how quickly symptoms attenuate, inflamed tonsils, and cough. A score of 0-1 is associated with a low likelihood of streptococcal infection, while a score of 4 or more is associated with a high likelihood. For patients with a score of 2 or 3, delayed antibiotic use may be appropriate.
In the case of a woman with inflamed tonsils, her FeverPAIN Score indicates that antibiotics are not necessary. However, it is important to safety net patients and review their condition in one week if there is no improvement. By using the FeverPAIN Score, providers can make informed decisions about antibiotic use in pharyngitis and help reduce the risk of antibiotic resistance.
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This question is part of the following fields:
- ENT
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Question 7
Incorrect
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A 30-year-old man visits his GP complaining of ear pain, itch and pus-like discharge that has been present for 3 days. He reports no fever and no hearing loss. The patient has a history of psoriasis. On examination, the doctor observes a raised red lesion on the ear with thick, silvery-white adherent scales. The tympanic membrane is intact and there is no visible mucous. The external auditory canal shows mild erythema and swelling. There is no palpable lymphadenopathy. What is the most appropriate treatment for this man's acute ear condition?
Your Answer: Topical antifungal agent
Correct Answer: Topical antibiotics
Explanation:Treatment Options for Otitis Externa
Otitis externa, commonly known as swimmer’s ear, is an infection of the outer ear canal. It can be caused by breaks in the skin, such as those seen in psoriasis. Treatment options depend on the severity of the infection and may include topical antibiotics, topical steroids, intravenous antibiotics, oral antibiotics, or topical antifungal agents.
Topical Antibiotics
The first line of treatment for otitis externa is topical antibacterial therapy. This may include 2% acetic acid, neomycin, or aminoglycosides. If swelling is severe, a wick may be inserted after cleaning the ear canal. Steroids may also be added to the ear drops to decrease inflammation and swelling, but their effectiveness is not always clear. Drops should be given for three days beyond the cessation of symptoms.Topical Steroids
In addition to antibiotics, steroids may be added to ear drops to reduce inflammation and swelling. However, they should be used in conjunction with antibiotics.Intravenous Antibiotics
If the infection is severe or unresponsive to oral antibiotics, intravenous antibiotics may be necessary. Topical cultures may be recommended to guide treatment in severe cases.Oral Antibiotics
Oral antibiotics are rarely needed for otitis externa but may be used if the infection is persistent, if associated otitis media is present, or if there is local or systemic spread. Signs of systemic spread include a temperature over 38.3 °C, severe initial pain, or lymphadenopathy.Topical Antifungal Agents
Fungal infections may present with white to off-white discharge or black, grey, bluish-green, or yellow discharge. Aspergillus spp. may be identified by small black or white conidiophores on white hyphae. Suspected fungal otitis externa can be treated with topical antifungal agents such as clotrimazole. -
This question is part of the following fields:
- ENT
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Question 8
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A surgeon prepares to excise the submandibular gland for a suspected malignancy in a pediatric patient. He incises the skin and the platysma in the neck below the gland, then proceeds to dissect the gland free of its bed. As he dissects the deep lobe, he notes the submandibular duct, which he mobilises, ligates and cuts anteriorly.
When cutting the duct, which of the following needs the most care to be taken to avoid damage?Your Answer: The lingual nerve
Explanation:Anatomy of the Submandibular Gland and Related Structures
The submandibular gland is composed of a superficial and deep part, with the facial artery passing between the gland and mandible and the facial vein indenting it superiorly. To access the deep lobe of the gland, both structures must be ligated and cut. The mandibular branch of the facial nerve is at risk of damage during the initial incision, while the lingual nerve is closely related to the submandibular duct and carries various fibers. The facial artery and vein may also be ligated during dissection, but are not as intimately related to the duct as the lingual nerve. The lesser petrosal branch of the glossopharyngeal nerve carries parasympathetic supply to the parotid gland and synapses in the otic ganglion.
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This question is part of the following fields:
- ENT
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Question 9
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A 45-year-old man visits his GP complaining of a lump under his chin that causes him pain and swelling, especially after eating a big meal. The facial nerve appears to be functioning normally. Upon examination, there is a tender swelling in the submandibular triangle.
What is the most probable diagnosis?Your Answer: Sialolithiasis
Explanation:Differential Diagnosis of Submandibular Swelling: Understanding the Causes
Submandibular swelling can be caused by various conditions, and it is important to understand the differential diagnosis to provide appropriate treatment. One of the most common causes is sialolithiasis, which is the formation of stones within the salivary glands. This condition obstructs the salivary ducts and can lead to infection, resulting in pain and swelling after eating. Sialolithiasis is more common in men over the age of 40 and typically affects the submandibular gland.
Sjögren syndrome is an autoimmune condition that causes dry mouth, dry eyes, and swelling of the salivary glands, usually bilaterally. However, unilateral acute pain and swelling after eating are more typical of a salivary stone, rather than Sjögren syndrome.
Pleomorphic adenomas are benign tumors that usually present as a painless lump, slowly enlarging over time. They do not typically cause acute pain and swelling.
Warthin’s tumor is another slow-growing lump that is commonly found in the tail of the parotid gland. Unlike sialolithiasis, it does not cause pain.
Adenoid cystic carcinoma is a malignant tumor that presents as a slowly enlarging mass over the parotid area. It does not typically cause pain, but if left unchecked, it can invade local structures such as the facial nerve.
In conclusion, understanding the differential diagnosis of submandibular swelling is crucial for proper diagnosis and treatment. Sialolithiasis, Sjögren syndrome, pleomorphic adenomas, Warthin’s tumor, and adenoid cystic carcinoma are all potential causes, and each requires a different approach to management.
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This question is part of the following fields:
- ENT
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Question 10
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A woman in her early 50s, who is a singer, has a history of thyroid surgery and needs another procedure due to recurrent thyroid carcinoma. Following the surgery, she experiences a change in her voice and is unable to reach high notes while singing. During flexible laryngoscopy, it is observed that her left vocal cord does not elongate during phonation.
Which nerve is likely to have been affected?Your Answer: External branch of the superior laryngeal nerve
Explanation:Nerves Related to the Thyroid Gland and Their Risks in Surgery
The thyroid gland is closely related to several nerves, including the external branch of the superior laryngeal nerve, recurrent laryngeal nerve, ansa cervicalis nerve, hypoglossal nerve, and lingual nerve. During neck dissection or surgery involving the thyroid or submandibular gland, these nerves may be at risk of damage.
The external branch of the superior laryngeal nerve innervates the cricothyroid muscle, which elongates the vocal cords. Damage to this nerve can result in an inability to produce high-frequency notes. The recurrent laryngeal nerve, on the other hand, innervates all intrinsic muscles of the thyroid except the cricothyroid muscle. Its injury can cause hoarseness and difficulty in adducting the vocal cords, leading to an aspiration risk.
The ansa cervicalis nerve is located superiorly to the thyroid and may be unavoidable to divide during surgery. The hypoglossal nerve is found even more superiorly and is at risk in submandibular gland excision and neck dissection. The lingual nerve is also located superiorly and may be at risk in submandibular gland excision, along with the hypoglossal nerve and the marginal mandibular branch of the facial nerve.
In summary, surgeons must be aware of the location and function of these nerves to minimize the risk of damage during thyroid or submandibular gland surgery.
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This question is part of the following fields:
- ENT
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