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Question 1
Incorrect
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A 3 year old child is brought to the emergency department by worried parents as they witnessed the child inserting a small toy into his ear. During examination, you observe a foreign object located in the anterior region of the middle ear of the right side. What would be the most suitable initial method for removing the foreign body?
Your Answer: Foley catheter balloon traction
Correct Answer: Mother's kiss
Explanation:The Mum’s Blow technique is commonly used in cases of nasal obstruction. It requires blocking one nostril and having one of the parents, usually the mother, blow air into the child’s mouth. Alternatively, a bag valve mask can be utilized. This method is often the initial choice for young children as it is gentle and does not cause much discomfort.
Further Reading:
Foreign bodies in the ear or nose are a common occurrence, especially in children between the ages of 2 and 8. Foreign bodies in the ear are more common than those in the nose. Symptoms of foreign bodies in the ear may include ear pain, a feeling of fullness, impaired hearing, discharge, tinnitus, and vertigo. It is important to consider referral to an ENT specialist for the removal of potentially harmful foreign bodies such as glass, sharp objects, button batteries, and tightly wedged items. ENT involvement is also necessary if there is a perforation of the eardrum or if the foreign body is embedded in the eardrum.
When preparing a patient for removal, it is important to establish rapport and keep the patient relaxed, especially if they are a young child. The patient should be positioned comfortably and securely, and ear drops may be used to anesthetize the ear. Removal methods for foreign bodies in the ear include the use of forceps or a hook, irrigation (except for batteries, perforations, or organic material), suction, and magnets for ferrous metal foreign bodies. If there is an insect in the ear, it should be killed with alcohol, lignocaine, or mineral oil before removal.
After the foreign body is removed, it is important to check for any residual foreign bodies and to discharge the patient with appropriate safety net advice. Prophylactic antibiotic drops may be considered if there has been an abrasion of the skin.
Foreign bodies in the nose are less common but should be dealt with promptly due to the risk of posterior dislodgement into the airway. Symptoms of foreign bodies in the nose may include nasal discharge, sinusitis, nasal pain, epistaxis, or blood-stained discharge. Most nasal foreign bodies are found on the anterior or middle third of the nose and may not show up on x-rays.
Methods for removing foreign bodies from the nose include the mother’s kiss technique, suction, forceps, Jobson horne probe, and foley catheter. The mother’s kiss technique involves occluding the patent nostril and having a parent blow into the patient’s mouth. A foley catheter can be used by inserting it past the foreign body and inflating the balloon to gently push the foreign body out. ENT referral may be necessary if the foreign body cannot be visualized but there is a high suspicion, if attempts to remove the foreign body have failed, if the patient requires sed
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 2
Incorrect
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A 35 year old is admitted to the emergency department after a severe assault resulting in facial and head trauma. The patient presents with continuous nasal discharge, and a fellow healthcare provider expresses concern about potential cerebrospinal fluid (CSF) rhinorrhea. What is the most suitable test to confirm this diagnosis?
Your Answer: Nasal discharge tested for sodium ion concentration
Correct Answer: Nasal discharge tested for beta-2 transferrin
Explanation:If someone is suspected to have CSF rhinorrhoea, their nasal discharge should be tested for beta-2 transferrin. This test is considered the most accurate diagnostic method to confirm the presence of CSF rhinorrhoea and has replaced glucose testing.
Further Reading:
Zygomatic injuries, also known as zygomatic complex fractures, involve fractures of the zygoma bone and often affect surrounding bones such as the maxilla and temporal bones. These fractures can be classified into four positions: the lateral and inferior orbital rim, the zygomaticomaxillary buttress, and the zygomatic arch. The full extent of these injuries may not be visible on plain X-rays and may require a CT scan for accurate diagnosis.
Zygomatic fractures can pose risks to various structures in the face. The temporalis muscle and coronoid process of the mandible may become trapped in depressed fractures of the zygomatic arch. The infraorbital nerve, which passes through the infraorbital foramen, can be injured in zygomaticomaxillary complex fractures. In orbital floor fractures, the inferior rectus muscle may herniate into the maxillary sinus.
Clinical assessment of zygomatic injuries involves observing facial asymmetry, depressed facial bones, contusion, and signs of eye injury. Visual acuity must be assessed, and any persistent bleeding from the nose or mouth should be noted. Nasal injuries, including septal hematoma, and intra-oral abnormalities should also be evaluated. Tenderness of facial bones and the temporomandibular joint should be assessed, along with any step deformities or crepitus. Eye and jaw movements must also be evaluated.
Imaging for zygomatic injuries typically includes facial X-rays, such as occipitomental views, and CT scans for a more detailed assessment. It is important to consider the possibility of intracranial hemorrhage and cervical spine injury in patients with facial fractures.
Management of most zygomatic fractures can be done on an outpatient basis with maxillofacial follow-up, assuming the patient is stable and there is no evidence of eye injury. However, orbital floor fractures should be referred immediately to ophthalmologists or maxillofacial surgeons. Zygomatic arch injuries that restrict mouth opening or closing due to entrapment of the temporalis muscle or mandibular condyle also require urgent referral. Nasal fractures, often seen in conjunction with other facial fractures, can be managed by outpatient ENT follow-up but should be referred urgently if there is uncontrolled epistaxis, CSF rhinorrhea, or septal hematoma.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 3
Incorrect
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You assess a patient with one-sided hearing loss, ringing in the ears, and numbness in the face. An MRI scan shows the presence of an acoustic neuroma.
Which of the following nerves is the LEAST likely to be affected?Your Answer: Trigeminal nerve
Correct Answer: Trochlear nerve
Explanation:An acoustic neuroma, also referred to as a vestibular schwannoma, is a slow-growing tumor that develops from the Schwann cells of the vestibulocochlear nerve (8th cranial nerve). These growths are typically found at the cerebellopontine angle or within the internal auditory canal.
The most commonly affected nerves are the vestibulocochlear and trigeminal nerves. Patients typically experience a gradual deterioration of hearing in one ear, along with numbness and tingling in the face, ringing in the ears, and episodes of dizziness. Headaches may also be present, and in rare cases, the facial nerve, glossopharyngeal nerve, vagus nerve, or accessory nerve may be affected.
It’s important to note that the trochlear nerve, which passes through the superior orbital fissure, is not impacted by an acoustic neuroma.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 4
Correct
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You evaluate a 60-year-old man with a previous diagnosis of hearing impairment.
Which tuning fork should be utilized to conduct a Weber's test on this individual?Your Answer: 512 Hz
Explanation:A 512 Hz tuning fork is recommended for conducting both the Rinne’s and Weber’s tests. However, a lower-pitched 128 Hz tuning fork is commonly used to assess vibration sense during a peripheral nervous system examination. Although a 256 Hz tuning fork can be used for both tests, it is considered less reliable.
To perform the Weber’s test, the 512 Hz tuning fork should be set in motion and then placed on the center of the patient’s forehead. The patient should be asked if they perceive the sound in the middle of their forehead or if it is heard more on one side.
If the sound is heard more on one side, it may indicate either ipsilateral conductive hearing loss or contralateral sensorineural hearing loss.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 5
Incorrect
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Your consultant has observed that the senior medical students assigned to the department have a limited understanding of vertigo. You have been tasked with delivering a teaching session on the typical causes of vertigo. In relation to vestibular neuronitis, which of the following statements is accurate?
Your Answer: Presents with episodic bouts of vertigo typically lasting less than 20 seconds brought on by change of head position
Correct Answer: Benign paroxysmal positional vertigo develops in around 10% of people following an episode of vestibular neuritis
Explanation:Vestibular neuritis is a common complication of vestibular neuronitis, characterized by a following of people experiencing symptoms such as persistent dizziness, unsteadiness, and fear of falling. However, a rare complication called phobic postural vertigo may also occur, where individuals experience these symptoms despite not actually falling.
On the other hand, benign paroxysmal positional vertigo (BPPV) presents with short episodes of vertigo, usually lasting less than 20 seconds, triggered by changes in head position. In contrast, vestibular neuronitis causes constant vertigo, even when at rest, which can be worsened by head movements.
Recovery from vestibular neuronitis is a gradual process that typically takes a few weeks, up to 6 weeks. It is believed that this condition is caused by inflammation of the vestibular nerve following a viral infection. On the other hand, BPPV is thought to occur due to the presence of cellular debris or crystal formation in the semicircular canals.
Further Reading:
Vestibular neuritis, also known as vestibular neuronitis, is a condition characterized by sudden and prolonged vertigo of peripheral origin. It is believed to be caused by inflammation of the vestibular nerve, often following a viral infection. It is important to note that vestibular neuritis and labyrinthitis are not the same condition, as labyrinthitis involves inflammation of the labyrinth. Vestibular neuritis typically affects individuals between the ages of 30 and 60, with a 1:1 ratio of males to females. The annual incidence is approximately 3.5 per 100,000 people, making it one of the most commonly diagnosed causes of vertigo.
Clinical features of vestibular neuritis include nystagmus, which is a rapid, involuntary eye movement, typically in a horizontal or horizontal-torsional direction away from the affected ear. The head impulse test may also be positive. Other symptoms include spontaneous onset of rotational vertigo, which is worsened by changes in head position, as well as nausea, vomiting, and unsteadiness. These severe symptoms usually last for 2-3 days, followed by a gradual recovery over a few weeks. It is important to note that hearing is not affected in vestibular neuritis, and symptoms such as tinnitus and focal neurological deficits are not present.
Differential diagnosis for vestibular neuritis includes benign paroxysmal positional vertigo (BPPV), labyrinthitis, Meniere’s disease, migraine, stroke, and cerebellar lesions. Management of vestibular neuritis involves drug treatment for nausea and vomiting associated with vertigo, typically through short courses of medication such as prochlorperazine or cyclizine. If symptoms are severe and fluids cannot be tolerated, admission and administration of IV fluids may be necessary. General advice should also be given, including avoiding driving while symptomatic, considering the suitability to work based on occupation and duties, and the increased risk of falls. Follow-up is required, and referral is necessary if there are atypical symptoms, symptoms do not improve after a week of treatment, or symptoms persist for more than 6 weeks.
The prognosis for vestibular neuritis is generally good, with the majority of individuals fully recovering within 6 weeks. Recurrence is thought to occur in 2-11% of cases, and approximately 10% of individuals may develop BPPV following an episode of vestibular neuritis. A very rare complication of vestibular neuritis is ph
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 6
Correct
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You are requested to evaluate a 75-year-old male who has been referred to the emergency department after visiting his local Bootsâą store for a hearing assessment. The patient reports experiencing pain and hearing impairment on the right side a few days prior to the examination. The nurse who examined the patient's ears before conducting the audiogram expressed concerns regarding malignant otitis externa.
What is the primary cause of malignant otitis externa?Your Answer: Pseudomonas aeruginosa
Explanation:Malignant otitis externa, also known as necrotising otitis externa, is a severe infection that affects the external auditory canal and spreads to the temporal bone and nearby tissues, leading to skull base osteomyelitis. The primary cause of this condition is usually an infection by Pseudomonas aeruginosa. It is commonly observed in older individuals with diabetes.
Further Reading:
Otitis externa is inflammation of the skin and subdermis of the external ear canal. It can be acute, lasting less than 6 weeks, or chronic, lasting more than 3 months. Malignant otitis externa, also known as necrotising otitis externa, is a severe and potentially life-threatening infection that can spread to the bones and surrounding structures of the ear. It is most commonly caused by Pseudomonas aeruginosa.
Symptoms of malignant otitis externa include severe and persistent ear pain, headache, discharge from the ear, fever, malaise, vertigo, and profound hearing loss. It can also lead to facial nerve palsy and other cranial nerve palsies. In severe cases, the infection can spread to the central nervous system, causing meningitis, brain abscess, and sepsis.
Acute otitis externa is typically caused by Pseudomonas aeruginosa or Staphylococcus aureus, while chronic otitis externa can be caused by fungal infections such as Aspergillus or Candida albicans. Risk factors for otitis externa include eczema, psoriasis, dermatitis, acute otitis media, trauma to the ear canal, foreign bodies in the ear, water exposure, ear canal obstruction, and long-term antibiotic or steroid use.
Clinical features of otitis externa include itching of the ear canal, ear pain, tenderness of the tragus and/or pinna, ear discharge, hearing loss if the ear canal is completely blocked, redness and swelling of the ear canal, debris in the ear canal, and cellulitis of the pinna and adjacent skin. Tender regional lymphadenitis is uncommon.
Management of acute otitis externa involves general ear care measures, optimizing any underlying medical or skin conditions that are risk factors, avoiding the use of hearing aids or ear plugs if there is a suspected contact allergy, and avoiding the use of ear drops if there is a suspected allergy to any of its ingredients. Treatment options include over-the-counter acetic acid 2% ear drops or spray, aural toileting via dry swabbing, irrigation, or microsuction, and prescribing topical antibiotics with or without a topical corticosteroid. Oral antibiotics may be prescribed in severe cases or for immunocompromised individuals.
Follow-up is advised if symptoms do not improve within 48-72 hours of starting treatment, if symptoms have not fully resolved
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 7
Incorrect
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A 45-year-old man presents with a history of gradually worsening left-sided hearing loss and tinnitus. He also reports occasional episodes of dizziness. During the examination, his hearing is significantly reduced in the left ear, and the Weber's test shows lateralization to the right. Additionally, he experiences tingling sensations on the left side of his face and has decreased sensation on that side. The rest of his cranial nerve examination appears normal.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Vestibular schwannoma
Explanation:This patient has come in with a past medical history of hearing loss and ringing in the ears on the right side, along with a nerve problem in the right trigeminal nerve. These symptoms are consistent with a growth in the cerebellopontine angle, such as a vestibular schwannoma (also known as an acoustic neuroma).
A vestibular schwannoma typically affects the 5th and 8th cranial nerves and is known to present with the following symptoms:
– Gradually worsening hearing loss on one side
– Numbness and tingling in the face
– Ringing in the ears
– DizzinessIn some cases, the patient may also have a history of headaches, and in rare instances, the 7th, 9th, and 10th cranial nerves may be affected.
It is recommended that this patient be referred to an ear, nose, and throat specialist or a neurosurgeon for further evaluation, which may include an MRI scan. The main treatment options for vestibular schwannoma include surgery, radiotherapy, and stereotactic radiosurgery.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 8
Incorrect
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A middle-aged individual comes in with hearing loss on one side, ringing in the ears, dizziness, and numbness in the face. An MRI scan shows the presence of an acoustic neuroma.
Which of the following nerves is the LEAST likely to be affected?Your Answer:
Correct Answer: Trochlear nerve
Explanation:An acoustic neuroma, also referred to as a vestibular schwannoma, is a slow-growing tumor that develops from the Schwann cells of the vestibulocochlear nerve (8th cranial nerve). These growths are typically found at the cerebellopontine angle or within the internal auditory canal.
The most commonly affected nerves are the vestibulocochlear and trigeminal nerves. Patients typically present with a gradual deterioration of hearing in one ear, along with numbness and tingling in the face, ringing in the ears, and episodes of dizziness. Additionally, some patients may have a history of headaches. In rare cases, the facial nerve, glossopharyngeal nerve, vagus nerve, or accessory nerve may also be affected.
It is important to note that the trochlear nerve, which passes through the superior orbital fissure, is not impacted by an acoustic neuroma.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 9
Incorrect
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A 60-year-old woman presents with a nosebleed that started after sneezing 20 minutes ago. She is currently using tissues to catch the drips and you have been asked to see her urgently by the triage nurse. Her vital signs are stable, and she has no signs of low blood pressure. You assess the patient and recommend applying firm pressure to the soft, cartilaginous part of the nose for at least 10 minutes.
What is the most effective measure to help stop the bleeding?Your Answer:
Correct Answer: Sucking an ice cube
Explanation:When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s condition. If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated.
Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula. Blood samples, including a full blood count, urea and electrolytes, clotting profile, and group and save (depending on the amount of blood loss), should be sent for analysis. Patients should be assigned to a majors or closely observed area, as dislodgement of a blood clot can lead to severe bleeding.
First aid measures to control bleeding include the following steps:
1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there is evidence of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the nasopharynx.
2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
4. If the patient is unable to comply, an alternative technique is to ask a relative, staff member, or use an external pressure device like a swimmer’s nose clip.
5. It is important to dispel the misconception that compressing the bones will help stop the bleeding. Applying ice to the neck or forehead does not influence nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may reduce nasal blood flow.If bleeding stops with first aid measures, it is recommended to apply a topical antiseptic preparation to reduce crusting and vestibulitis. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 10
Incorrect
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A 45-year-old patient arrives at the emergency department with a complaint of sudden hearing loss. During the examination, tuning fork tests are conducted. Weber's test shows lateralization to the left side, Rinne's test is negative on the left ear and positive on the right ear.
Based on this assessment, which of the following can be inferred?Your Answer:
Correct Answer: Right sided conductive hearing loss
Explanation:In cases of conductive hearing loss, the Rinne test result is negative on the affected side, meaning that bone conduction is greater than air conduction. Additionally, the Weber test result will lateralize to the affected side. If the Weber test lateralizes to the right, it indicates either sensorineural hearing loss in the left ear (opposite side) or conductive hearing loss in the right ear (same side). A positive Rinne test result, where air conduction is greater than bone conduction, is typically seen in individuals with normal hearing or sensorineural hearing loss. In the case of conductive hearing loss in the right ear, a negative Rinne test result would be expected on the right side, indicating that bone conduction is greater than air conduction.
Further Reading:
Hearing loss is a common complaint that can be caused by various conditions affecting different parts of the ear and nervous system. The outer ear is the part of the ear outside the eardrum, while the middle ear is located between the eardrum and the cochlea. The inner ear is within the bony labyrinth and consists of the vestibule, semicircular canals, and cochlea. The vestibulocochlear nerve connects the inner ear to the brain.
Hearing loss can be classified based on severity, onset, and type. Severity is determined by the quietest sound that can be heard, measured in decibels. It can range from mild to profound deafness. Onset can be sudden, rapidly progressive, slowly progressive, or fluctuating. Type of hearing loss can be either conductive or sensorineural. Conductive hearing loss is caused by issues in the external ear, eardrum, or middle ear that disrupt sound transmission. Sensorineural hearing loss is caused by problems in the cochlea, auditory nerve, or higher auditory processing pathways.
To diagnose sensorineural and conductive deafness, a 512 Hz tuning fork is used to perform Rinne and Weber’s tests. These tests help determine the type of hearing loss based on the results. In Rinne’s test, air conduction (AC) and bone conduction (BC) are compared, while Weber’s test checks for sound lateralization.
Cholesteatoma is a condition characterized by the abnormal accumulation of skin cells in the middle ear or mastoid air cell spaces. It is believed to develop from a retraction pocket that traps squamous cells. Cholesteatoma can cause the accumulation of keratin and the destruction of adjacent bones and tissues due to the production of destructive enzymes. It can lead to mixed sensorineural and conductive deafness as it affects both the middle and inner ear.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 11
Incorrect
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A 38 year old male presents to the emergency department with a three day history of left sided otalgia. You note the patient takes methotrexate to control psoriatic arthritis. On examination you note the left tympanic membrane is bulging and appears cloudy centrally with peripheral erythema. The remaining examination of the head and neck reveals no other abnormalities. The patients observations are shown below.
Blood pressure 130/80 mmHg
Pulse 92 bpm
Respiration rate 18 bpm
Temperature 37.9ÂșC
Oxygen saturations 98% on air
You advise the patient you feel he would benefit from antibiotics. The patient tells you he has no known drug allergies. What is the most appropriate antibiotic to issue?Your Answer:
Correct Answer: Amoxicillin
Explanation:Amoxicillin is the preferred antibiotic for treating acute otitis media (AOM). It is the first choice for patients who do not have a penicillin allergy. According to NICE guidelines, a 5-7 day course of amoxicillin is recommended for treating this condition.
Further Reading:
Acute otitis media (AOM) is an inflammation in the middle ear accompanied by symptoms and signs of an ear infection. It is commonly seen in young children below 4 years of age, with the highest incidence occurring between 9 to 15 months of age. AOM can be caused by viral or bacterial pathogens, and co-infection with both is common. The most common viral pathogens include respiratory syncytial virus (RSV), rhinovirus, adenovirus, influenza virus, and parainfluenza virus. The most common bacterial pathogens include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes.
Clinical features of AOM include ear pain (otalgia), fever, a red or cloudy tympanic membrane, and a bulging tympanic membrane with loss of anatomical landmarks. In young children, symptoms may also include crying, grabbing or rubbing the affected ear, restlessness, and poor feeding.
Most children with AOM will recover within 3 days without treatment. Serious complications are rare but can include persistent otitis media with effusion, recurrence of infection, temporary hearing loss, tympanic membrane perforation, labyrinthitis, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis.
Management of AOM involves determining whether admission to the hospital is necessary based on the severity of systemic infection or suspected acute complications. For patients who do not require admission, regular pain relief with paracetamol or ibuprofen is advised. Decongestants or antihistamines are not recommended. Antibiotics may be offered immediately for patients who are systemically unwell, have symptoms and signs of a more serious illness or condition, or have a high risk of complications. For other patients, a decision needs to be made on the antibiotic strategy, considering the rarity of acute complications and the possible adverse effects of antibiotics. Options include no antibiotic prescription with advice to seek medical help if symptoms worsen rapidly or significantly, a back-up antibiotic prescription to be used if symptoms do not improve within 3 days, or an immediate antibiotic prescription with advice to seek medical advice if symptoms worsen rapidly or significantly.
The first-line antibiotic choice for AOM is a 5-7 day course of amoxicillin. For individuals allergic to or intolerant of penicillin, a 5â7 day course of clarithromycin or erythromycin (erythromycin is preferred in pregnant women).
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 12
Incorrect
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A 60-year-old woman comes in with a nosebleed that began after blowing her nose an hour ago. You assessed her when she arrived 30 minutes ago and recommended that she try to stop the bleeding by pinching the soft, cartilaginous part of her nose. She has been doing this since then, but her nose is still bleeding. During the examination, you can see bleeding points in both nostrils. What is the most suitable next step to take?
Your Answer:
Correct Answer: Pack the nose with nasal tampons, e.g. Rapid Rhinos
Explanation:When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s condition. If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated.
Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula. Blood samples, including a full blood count, urea and electrolytes, clotting profile, and group and save (depending on the amount of blood loss), should be sent for analysis. Patients should be assigned to a majors or closely observed area, as dislodgement of a blood clot can lead to severe bleeding.
First aid measures to control bleeding include the following steps:
1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there is evidence of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the nasopharynx.
2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
4. If the patient is unable to comply, an alternative technique is to ask a relative, staff member, or use an external pressure device like a swimmer’s nose clip.
5. It is important to dispel the misconception that compressing the bones will help stop the bleeding. Applying ice to the neck or forehead does not influence nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may reduce nasal blood flow.If bleeding stops with first aid measures, it is recommended to apply a topical antiseptic preparation to reduce crusting and vestibulitis. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 13
Incorrect
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A 14 year old presents to the emergency department with a 4 day history of left sided otalgia. On examination the patient's temperature is 38.5°C and there is a swollen and tender area over the mastoid process.
What is the most suitable initial approach for managing this patient?Your Answer:
Correct Answer: Intravenous ceftriaxone and metronidazole
Explanation:The first step in managing acute mastoiditis is to administer broad spectrum intravenous antibiotics. The British Society of Otology recommends using intravenous ceftriaxone once daily in combination with intravenous metronidazole three times daily as the initial treatment. However, the specific antibiotic regimen may vary depending on the local antimicrobial policy.
Further Reading:
Mastoiditis is an infection of the mastoid air cells, which are located in the mastoid process of the skull. It is usually caused by the spread of infection from the middle ear. The most common organism responsible for mastoiditis is Streptococcus pneumoniae, but other bacteria and fungi can also be involved. The infection can spread to surrounding structures, such as the meninges, causing serious complications like meningitis or cerebral abscess.
Mastoiditis can be classified as acute or chronic. Acute mastoiditis is a rare complication of acute otitis media, which is inflammation of the middle ear. It is characterized by severe ear pain, fever, swelling and redness behind the ear, and conductive deafness. Chronic mastoiditis is usually associated with chronic suppurative otitis media or cholesteatoma and presents with recurrent episodes of ear pain, headache, and fever.
Mastoiditis is more common in children, particularly those between 6 and 13 months of age. Other risk factors include immunocompromised patients, those with intellectual impairment or communication difficulties, and individuals with cholesteatoma.
Diagnosis of mastoiditis involves a physical examination, blood tests, ear swab for culture and sensitivities, and imaging studies like contrast-enhanced CT or MRI. Treatment typically involves referral to an ear, nose, and throat specialist, broad-spectrum intravenous antibiotics, pain relief, and myringotomy (a procedure to drain fluid from the middle ear).
Complications of mastoiditis are rare but can be serious. They include intracranial abscess, meningitis, subperiosteal abscess, neck abscess, venous sinus thrombosis, cranial nerve palsies, hearing loss, labyrinthitis, extension to the zygoma, and carotid artery arteritis. However, most patients with mastoiditis have a good prognosis and do not experience long-term ear problems.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 14
Incorrect
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A 22-year-old presents to the emergency department with a nosebleed. You observe that they have blood-soaked tissue paper held against the nose, blocking the opening of the left nostril, and blood stains on the front of their shirt. What is the most appropriate initial management for this patient?
Your Answer:
Correct Answer: Advise the patient to sit forward and pinch just in front of the bony septum firmly and hold it for 15 minutes
Explanation:To control epistaxis, it is recommended to have the patient sit upright with their upper body tilted forward and their mouth open. Firmly pinch the cartilaginous part of the nose, specifically in front of the bony septum, and maintain pressure for 10-15 minutes without releasing it.
Further Reading:
Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.
The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.
If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.
Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.
In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 15
Incorrect
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A 45-year-old man presents with brief episodes of vertigo that are worse in the evening and is triggered by head movement and turning in bed. Each episode lasts only a couple of minutes. He experiences nausea during the attacks but has not vomited. He has no previous history of hearing loss or tinnitus.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Benign paroxysmal positional vertigo (BPPV)
Explanation:Benign paroxysmal positional vertigo (BPPV) occurs when there is dysfunction in the inner ear. This dysfunction causes the otoliths, which are located in the utricle, to become dislodged from their normal position and migrate into one of the semicircular canals over time. As a result, these detached otoliths continue to move even after head movement has stopped, leading to vertigo due to the conflicting sensation of ongoing movement with other sensory inputs.
While the majority of BPPV cases have no identifiable cause (idiopathic), approximately 40% of cases can be attributed to factors such as head injury, spontaneous labyrinthine degeneration, post-viral illness, middle ear surgery, or chronic middle ear disease.
The main clinical features of BPPV include symptoms that are provoked by head movement, rolling over, and upward gaze. These episodes are typically brief, lasting less than 5 minutes, and are often worse in the mornings. Unlike other inner ear disorders, BPPV does not cause hearing loss or tinnitus. Nausea is a common symptom, while vomiting is rare. The Dix-Hallpike test can be used to confirm the diagnosis of BPPV.
It is important to note that vestibular suppressant medications have not been proven to be beneficial in managing BPPV. These medications do not improve symptoms or reduce the duration of the disease.
The treatment of choice for BPPV is the Epley manoeuvre. This maneuver aims to reposition the dislodged otoliths back into the utricles from the semicircular canals. A 2014 Cochrane review concluded that the Epley manoeuvre is a safe and effective treatment for BPPV, with a number needed to treat of 2-4.
Referral to an ENT specialist is recommended for patients with BPPV in the following situations: if the treating clinician is unable to perform or access the Epley manoeuvre, if the Epley manoeuvre has not been beneficial after repeated attempts (minimum two), if the patient has been symptomatic for more than 4 weeks, or if the patient has experienced more than 3 episodes of BPPV.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 16
Incorrect
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A 35-year-old diving instructor complains of pain and discharge in his right ear. Upon examination, you observe redness in the ear canal along with a significant amount of pus and debris.
What is the SINGLE most probable organism responsible for this condition?Your Answer:
Correct Answer: Pseudomonas aeruginosa
Explanation:Otitis externa, also known as swimmer’s ear, is a condition characterized by infection and inflammation of the ear canal. Common symptoms include pain, itching, and discharge from the ear. Upon examination with an otoscope, the ear canal will appear red and there may be pus and debris present.
There are several factors that can increase the risk of developing otitis externa, including skin conditions like psoriasis and eczema. Additionally, individuals who regularly expose their ears to water, such as swimmers, are more prone to this condition.
The most common organisms that cause otitis externa are Pseudomonas aeruginosa (50%), Staphylococcus aureus (23%), Gram-negative bacteria like E.coli (12%), and fungal species like Aspergillus and Candida (12%).
Treatment for otitis externa typically involves the use of topical antibiotic and corticosteroid combinations, such as Betnesol-N or Sofradex. In some cases, when the condition persists, referral to an ear, nose, and throat specialist may be necessary for auditory cleaning and the placement of an antibiotic-soaked wick.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 17
Incorrect
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A 28 year old male comes to the emergency department complaining of a sore throat that has been bothering him for the past 2 days. The patient mentions that he has been experiencing a dry cough on and off for the past day or two. During the examination, the patient's temperature is measured at 38.4°C, blood pressure at 132/86 mmHg, and pulse rate at 90 bpm. Both tonsils appear inflamed with white/yellow exudate visible on their surface, and there is tenderness when palpating the enlarged anterior cervical lymph nodes.
What would be the most appropriate course of action for managing this patient?Your Answer:
Correct Answer: Prescribe phenoxymethylpenicillin 500 mg four times daily for 10 days
Explanation:Phenoxymethylpenicillin is the preferred antibiotic for treating streptococcal sore throat, especially in patients with a CENTOR score of 3/4 and a FeverPAIN score of 4/5. In such cases, antibiotics are necessary to effectively treat the infection.
Further Reading:
Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.
Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.
When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.
Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.
To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 18
Incorrect
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A 35-year-old woman comes in with a painful swelling on the left side of her face. The pain and swelling appear to get worse before meals and then gradually improve after eating. During the examination, a solid lump can be felt in the submandibular region. There is no redness, and the patient has no fever and is in good overall health.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Sialolithiasis
Explanation:Sialolithiasis is a condition in which a calcified stone (sialolith) forms inside a salivary gland. The submandibular gland (Wharton’s duct) is the most common site, accounting for about 90% of cases, while the parotid gland is the second most affected. In rare instances, sialoliths can also develop in the sublingual gland or minor salivary glands.
The presence of a sialolith obstructs the flow of saliva, leading to pain and swelling in the affected gland during eating. The pain is most intense when salivary flow is high, such as before and during meals, and gradually subsides within an hour after eating. By palpating the floor of the mouth with both hands, a stone may be detected, and sometimes it can even be seen at the opening of the duct. If there is an accompanying infection, pus may be expressed from the gland.
To assess salivary flow, acidic foods like lemon juice can be used as a simple test. X-rays of the mouth’s floor can reveal the presence of a stone. Patients should be referred to an ear, nose, and throat specialist (ENT) for the removal of the stone.
Sialadenitis refers to inflammation of the salivary glands and can be either acute or chronic. Acute sialadenitis is most commonly caused by a bacterial infection, usually ascending from Staphylococcus aureus or Streptococcus viridans. It can occur as a result of sialolithiasis or poor oral hygiene. Clinically, there will be a painful swelling in the affected gland area, with redness of the overlying skin and potential swelling of the cheek and nearby regions. Patients often experience general malaise, with a low-grade fever and elevated inflammatory markers.
Parotitis, on the other hand, refers to inflammation of one or both parotid glands. This inflammation can be caused by bacteria (particularly Staphylococcus aureus), viruses (such as mumps), or tuberculosis.
Sjögren’s syndrome is an autoimmune disorder characterized by dry eyes and dry mouth.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 19
Incorrect
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A 4 year old boy is brought to the emergency department by his parents due to a 4 day history of fever, irritability, and pain in his left ear. On examination, there is a tender, erythematous, boggy swelling behind his ear. What is the most probable underlying cause?
Your Answer:
Correct Answer: Acute otitis media
Explanation:Acute mastoiditis commonly occurs as a complication of acute otitis media (AOM). In this case, the patient exhibits symptoms indicative of acute mastoiditis. The infection typically spreads from the middle ear tympanic cavity (acute otitis media) to the mastoid antrum through a narrow canal within the petrous temporal bone.
Further Reading:
Mastoiditis is an infection of the mastoid air cells, which are located in the mastoid process of the skull. It is usually caused by the spread of infection from the middle ear. The most common organism responsible for mastoiditis is Streptococcus pneumoniae, but other bacteria and fungi can also be involved. The infection can spread to surrounding structures, such as the meninges, causing serious complications like meningitis or cerebral abscess.
Mastoiditis can be classified as acute or chronic. Acute mastoiditis is a rare complication of acute otitis media, which is inflammation of the middle ear. It is characterized by severe ear pain, fever, swelling and redness behind the ear, and conductive deafness. Chronic mastoiditis is usually associated with chronic suppurative otitis media or cholesteatoma and presents with recurrent episodes of ear pain, headache, and fever.
Mastoiditis is more common in children, particularly those between 6 and 13 months of age. Other risk factors include immunocompromised patients, those with intellectual impairment or communication difficulties, and individuals with cholesteatoma.
Diagnosis of mastoiditis involves a physical examination, blood tests, ear swab for culture and sensitivities, and imaging studies like contrast-enhanced CT or MRI. Treatment typically involves referral to an ear, nose, and throat specialist, broad-spectrum intravenous antibiotics, pain relief, and myringotomy (a procedure to drain fluid from the middle ear).
Complications of mastoiditis are rare but can be serious. They include intracranial abscess, meningitis, subperiosteal abscess, neck abscess, venous sinus thrombosis, cranial nerve palsies, hearing loss, labyrinthitis, extension to the zygoma, and carotid artery arteritis. However, most patients with mastoiditis have a good prognosis and do not experience long-term ear problems.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 20
Incorrect
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You evaluate a 60-year-old man with a previous diagnosis of hearing impairment.
Which tuning fork should be utilized to conduct a Rinne's test on this individual?Your Answer:
Correct Answer: 512 Hz
Explanation:A 512 Hz tuning fork is commonly used for both the Rinne’s and Weber’s tests. However, a lower-pitched fork, such as a 128 Hz tuning fork, is typically used to assess vibration sense during a peripheral nervous system examination. Although a 256 Hz tuning fork can be used for either test, it is considered less reliable for both.
To perform a Rinne’s test, the 512 Hz tuning fork is first made to vibrate and then placed on the mastoid process until the sound is no longer heard. The top of the tuning fork is then positioned 2 cm away from the external auditory meatus, and the patient is asked to indicate where they hear the sound loudest.
In individuals with normal hearing, the tuning fork should still be audible outside the external auditory canal even after it is no longer appreciated on the mastoid. This is because air conduction should be greater than bone conduction.
In cases of conductive hearing loss, the patient will no longer hear the tuning fork once it is no longer appreciated on the mastoid. This suggests that their bone conduction is greater than their air conduction, indicating an obstruction in the passage of sound waves through the ear canal into the cochlea. This is considered a true negative result.
However, a Rinne’s test may yield a false negative result if the patient has a severe unilateral sensorineural deficit and senses the sound in the unaffected ear through the transmission of sound waves through the base of the skull.
In sensorineural hearing loss, the ability to perceive the tuning fork on both the mastoid and outside the external auditory canal is equally diminished compared to the opposite ear. Although the sound will still be heard outside the external auditory canal, it will disappear earlier on the mastoid process and outside the external auditory canal compared to the other ear.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 21
Incorrect
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A 62 year old male is brought to the emergency department after experiencing difficulty breathing. You observe that he has had a tracheostomy for a long time due to being on a ventilator for an extended period following a severe car accident. You provide high flow oxygen and try to pass a suction catheter after removing the inner tracheostomy tube, but you are unable to do so. What should be the next step in managing this patient?
Your Answer:
Correct Answer: Deflate the cuff
Explanation:If a patient with a tracheostomy is experiencing difficulty breathing and it is not possible to pass a suction catheter, the next step is to deflate the cuff. Deflating the cuff can help determine if the tracheostomy tube is obstructed or displaced by allowing air to flow around the tube within the airway. The following steps are followed in order: 1) Remove the inner tube and any speaking cap/valve if present. 2) Attempt to pass the suction catheter. 3) If the suction catheter cannot be passed, deflate the cuff. 4) If the patient’s condition does not stabilize or improve, the tracheostomy tube may need to be removed. This process is summarized in the green algorithm.
Further Reading:
Patients with tracheostomies may experience emergencies such as tube displacement, tube obstruction, and bleeding. Tube displacement can occur due to accidental dislodgement, migration, or erosion into tissues. Tube obstruction can be caused by secretions, lodged foreign bodies, or malfunctioning humidification devices. Bleeding from a tracheostomy can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue.
When assessing a patient with a tracheostomy, an ABCDE approach should be used, with attention to red flags indicating a tracheostomy or laryngectomy emergency. These red flags include audible air leaks or bubbles of saliva indicating gas escaping past the cuff, grunting, snoring, stridor, difficulty breathing, accessory muscle use, tachypnea, hypoxia, visibly displaced tracheostomy tube, blood or blood-stained secretions around the tube, increased discomfort or pain, increased air required to keep the cuff inflated, tachycardia, hypotension or hypertension, decreased level of consciousness, and anxiety, restlessness, agitation, and confusion.
Algorithms are available for managing tracheostomy emergencies, including obstruction or displaced tube. Oxygen should be delivered to the face and stoma or tracheostomy tube if there is uncertainty about whether the patient has had a laryngectomy. Tracheostomy bleeding can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue. Tracheo-innominate fistula (TIF) is a rare but life-threatening complication that occurs when the tracheostomy tube erodes into the innominate artery. Urgent surgical intervention is required for TIF, and management includes general resuscitation measures and specific measures such as bronchoscopy and applying direct digital pressure to the innominate artery.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 22
Incorrect
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A 2-year-old toddler comes in with a high-grade fever, excessive drooling, and inability to speak. The child has evident stridor and a rapid heart rate. During the examination, there is tenderness in the front of the neck around the hyoid bone and swollen lymph nodes in the neck.
What is the immediate urgent treatment needed for this patient?Your Answer:
Correct Answer: Intubation
Explanation:Acute epiglottitis is inflammation of the epiglottis, which can be life-threatening if not treated promptly. When the soft tissues surrounding the epiglottis are also affected, it is called acute supraglottitis. This condition is most commonly seen in children between the ages of 3 and 5, but it can occur at any age, with adults typically presenting in their 40s and 50s.
In the past, Haemophilus influenzae type B was the main cause of acute epiglottitis, but with the introduction of the Hib vaccination, it has become rare in children. Streptococcus spp. is now the most common causative organism. Other potential culprits include Staphylococcus aureus, Pseudomonas spp., Moraxella catarrhalis, Mycobacterium tuberculosis, and the herpes simplex virus. In immunocompromised patients, Candida spp. and Aspergillus spp. infections can occur.
The typical symptoms of acute epiglottitis include fever, sore throat, painful swallowing, difficulty swallowing secretions (especially in children who may drool), muffled voice, stridor, respiratory distress, rapid heartbeat, tenderness in the front of the neck over the hyoid bone, ear pain, and swollen lymph nodes in the neck. Some patients may also exhibit the tripod sign, where they lean forward on outstretched arms to relieve upper airway obstruction.
To diagnose acute epiglottitis, fibre-optic laryngoscopy is considered the gold standard investigation. However, this procedure should only be performed by an anaesthetist in a setting prepared for intubation or tracheostomy in case of airway obstruction. Other useful tests include a lateral neck X-ray to look for the thumbprint sign, throat swabs, blood cultures, and a CT scan of the neck if an abscess is suspected.
When dealing with a case of acute epiglottitis, it is crucial not to panic or distress the patient, especially in pediatric cases. Avoid attempting to examine the throat with a tongue depressor, as this can trigger spasm and worsen airway obstruction. Instead, keep the patient as calm as possible and immediately call a senior anaesthetist, a senior paediatrician, and an ENT surgeon. Nebulized adrenaline can be used as a temporary measure if there is critical airway obstruction.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 23
Incorrect
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A 30-year-old woman comes in with facial swelling that worsens when she eats. You suspect she may have sialolithiasis.
Which salivary gland is most likely to be impacted?Your Answer:
Correct Answer: Submandibular gland
Explanation:Sialolithiasis is a medical condition characterized by the formation of a calcified stone, known as a sialolith, within one of the salivary glands. The submandibular gland, specifically Wharton’s duct, is the site of approximately 90% of these occurrences, while the parotid gland accounts for most of the remaining cases. In rare instances, sialoliths may also develop in the sublingual gland or minor salivary glands.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 24
Incorrect
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A 62-year-old man presents with severe otalgia in his right ear that has been gradually worsening over the past few weeks. He describes the pain as being âconstantâ and he has been unable to sleep for several nights. His family have noticed that the right side of his face appears to be âdroopingâ. His past medical history includes poorly controlled type 2 diabetes mellitus. On examination, he has a right-sided lower motor neuron facial nerve palsy. His right ear canal is very swollen and purulent exudate is visible.
What is the SINGLE most likely causative organism?Your Answer:
Correct Answer: Pseudomonas aeruginosa
Explanation:Malignant otitis externa (MOE), also known as necrotizing otitis externa, is a rare form of ear canal infection that primarily affects elderly diabetic patients, particularly those with poorly controlled diabetes.
MOE initially infects the ear canal and gradually spreads to the surrounding bony structures and soft tissues. In 98% of cases, the responsible pathogen is Pseudomonas aeruginosa.
Typically, MOE presents with severe and unrelenting ear pain, which tends to worsen at night. Even after the swelling of the ear canal subsides with topical antibiotics, the pain may persist. Other symptoms may include pus drainage from the ear and temporal headaches. Approximately 50% of patients also experience facial nerve paralysis, and cranial nerves IX to XII may be affected as well.
To confirm the diagnosis, technetium scanning and contrast-enhanced CT scanning are usually performed to detect any extension of the infection into the surrounding bony structures.
If left untreated, MOE can be life-threatening and may lead to serious complications such as skull base osteomyelitis, subdural empyema, and cerebral abscess.
Treatment typically involves long-term administration of intravenous antibiotics. While surgical intervention is not effective for MOE, exploratory surgery may be necessary to obtain cultures of unusual organisms that are not responding adequately to intravenous antibiotics.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 25
Incorrect
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A 3-year-old toddler comes in with a high temperature, trouble swallowing, and difficulty speaking. The child is drooling and has been intubated by a senior anesthesiologist and ENT surgeon. After examination, the diagnosis is determined to be acute epiglottitis.
What is the MOST LIKELY organism responsible for this condition?Your Answer:
Correct Answer: Streptococcus spp.
Explanation:Acute epiglottitis is inflammation of the epiglottis, which can be life-threatening if not treated promptly. When the soft tissues surrounding the epiglottis are also affected, it is called acute supraglottitis. This condition is most commonly seen in children between the ages of 3 and 5, but it can occur at any age, with adults typically presenting in their 40s and 50s.
In the past, Haemophilus influenzae type B was the main cause of acute epiglottitis, but with the introduction of the Hib vaccination, it has become rare in children. Streptococcus spp. is now the most common causative organism. Other potential culprits include Staphylococcus aureus, Pseudomonas spp., Moraxella catarrhalis, Mycobacterium tuberculosis, and the herpes simplex virus. In immunocompromised patients, Candida spp. and Aspergillus spp. infections can occur.
The typical symptoms of acute epiglottitis include fever, sore throat, painful swallowing, difficulty swallowing secretions (especially in children who may drool), muffled voice, stridor, respiratory distress, rapid heartbeat, tenderness in the front of the neck over the hyoid bone, ear pain, and swollen lymph nodes in the neck. Some patients may also exhibit the tripod sign, where they lean forward on outstretched arms to relieve upper airway obstruction.
To diagnose acute epiglottitis, fibre-optic laryngoscopy is considered the gold standard investigation. However, this procedure should only be performed by an anaesthetist in a setting prepared for intubation or tracheostomy in case of airway obstruction. Other useful tests include a lateral neck X-ray to look for the thumbprint sign, throat swabs, blood cultures, and a CT scan of the neck if an abscess is suspected.
When dealing with a case of acute epiglottitis, it is crucial not to panic or distress the patient, especially in pediatric cases. Avoid attempting to examine the throat with a tongue depressor, as this can trigger spasm and worsen airway obstruction. Instead, keep the patient as calm as possible and immediately call a senior anaesthetist, a senior paediatrician, and an ENT surgeon. Nebulized adrenaline can be used as a temporary measure if there is critical airway obstruction.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 26
Incorrect
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A 35 year old male comes to the emergency department with a 3 hour history of nosebleed. You administer cautery to the right nostril which successfully stops the bleeding. You intend to release the patient. Which of the following medications would be the most suitable to prescribe?
Your Answer:
Correct Answer: Prescribe naseptin cream four times daily for 10 days
Explanation:After undergoing nasal cautery, it is recommended to follow these steps for proper treatment:
1. Gently dab the cauterized area with a clean cotton bud to remove any excess chemical or blood.
2. Apply a topical antiseptic preparation to the area.
3. As the first line of treatment, prescribe NaseptinÂź cream (containing chlorhexidine and neomycin) to be applied to the nostrils four times daily for a duration of 10 days. However, if the patient has allergies to neomycin, peanut, or soya, prescribe mupirocin nasal ointment instead. This should be applied to the nostrils two to three times a day for 5-7 days.
4. Advise the patient to avoid blowing their nose for a few hours.These steps will help ensure proper healing and minimize any potential complications after nasal cautery.
Further Reading:
Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.
The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.
If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.
Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.
In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 27
Incorrect
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A 28 year old female comes to the emergency department complaining of a sore throat that has been bothering her for the past 4 days. She denies having any cough or runny nose. During the examination, her temperature is measured at 37.7°C, blood pressure at 120/68 mmHg, and pulse rate at 88 bpm. Erythema is observed in the oropharynx and tonsils. The neck is nontender and no palpable masses are found.
What would be the most appropriate course of action for managing this patient?Your Answer:
Correct Answer: Discharge with self care advice
Explanation:Patients who have a CENTOR score of 0, 1, or 2 should be given advice on self-care and safety measures. In this case, the patient has a CENTOR score of 1/4 and a FeverPAIN score of 1, indicating that antibiotics are not necessary. The patient should be advised to drink enough fluids, use over-the-counter pain relievers like ibuprofen or paracetamol, try salt water gargling or medicated lozenges, and avoid hot drinks as they can worsen the pain. It is important to inform the patient that if they experience difficulty swallowing, develop a fever above 38ÂșC, or if their symptoms do not improve after 3 days, they should seek reassessment.
Further Reading:
Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.
Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.
When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.
Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.
To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken. can
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 28
Incorrect
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A 14-year-old girl comes in with a sudden onset of a painful throat that has been bothering her for the past day. She denies having a cough or any symptoms of a cold. During the examination, her temperature is measured at 38.5°C, and there is visible exudate on her right tonsil, which also appears to be swollen. No anterior cervical lymph nodes can be felt. What is her score on the Centor Clinical Prediction Score for assessing her sore throat?
Your Answer:
Correct Answer: 3
Explanation:There are two scoring systems that NICE recommends for assessing sore throat: the Centor Clinical Prediction Score and the FeverPAIN Score.
The Centor Clinical Prediction Score was initially developed as a tool to determine the likelihood of a group A beta-haemolytic Streptococcus (GABHS) infection in adults with a sore throat. This score was created and tested in US Emergency Departments, specifically for adult patients.
The Centor score evaluates patients based on several criteria, with one point given for each positive criterion. These criteria include a history of fever (temperature above 38°C), the presence of exudate or swelling on the tonsils, tender or swollen anterior cervical lymph nodes, and the absence of cough.
According to the current NICE guidance, the Centor score can be used to guide management in the following way:
– A score of 0 to 2 indicates a 3-17% likelihood of streptococcus isolation, and antibiotics are not recommended.
– A score of 3 to 4 indicates a 32-56% likelihood of streptococcus isolation, and immediate treatment with empirical antibiotics or a backup prescription should be considered.By utilizing these scoring systems, healthcare professionals can make more informed decisions regarding the management and treatment of patients with sore throat.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 29
Incorrect
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A 42-year-old patient arrives at the emergency department with a nosebleed that has been ongoing for 1 hour. The patient has been sitting down and applying continuous pressure to the soft part of the nose since being seen by the triage nurse 15 minutes ago. When asked to release the pressure for examination, an active bleeding point is observed in the anterior nasal septum of the right nostril.
What is the most suitable approach to managing this patient?Your Answer:
Correct Answer: Perform cautery of the bleeding point with a silver nitrate stick
Explanation:Nasal cautery is a suitable option for patients who are experiencing epistaxis (nosebleeds) and have not responded to initial measures. It is particularly effective when a specific bleeding point in the anterior nasal septum (known as Little’s area) has been identified. This procedure is recommended for adult patients who have already undergone an appropriate period of nasal pressure application (10-15 minutes). It is important to note that naseptin or mupirocin should not be used to control active bleeding, but rather after the bleeding has been successfully managed. Nasal packing, on the other hand, is a more invasive procedure that requires hospital admission and is typically reserved for cases where the bleeding point cannot be visualized or when cautery has been unsuccessful.
Further Reading:
Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.
The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.
If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.
Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.
In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 30
Incorrect
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A 60-year-old woman comes in with a nosebleed that began after blowing her nose an hour ago. You assessed her when she arrived 30 minutes ago and recommended that she try to stop the bleeding by pinching the soft, cartilaginous part of her nose. She has been doing this since then, but her nose is still bleeding. During the examination, you notice a small and easily visible bleeding spot in her right nostril.
What is the most suitable next step to take?Your Answer:
Correct Answer: Perform nasal cautery
Explanation:When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s airway and circulation.
If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated. Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula and collect blood samples for tests such as full blood count, urea and electrolytes, clotting studies, and blood typing and crossmatching (depending on the amount of blood loss). These patients should be closely monitored in a majors area or a designated observation area, as dislodgement of a blood clot can lead to severe bleeding.
First aid measures to control bleeding include the following steps:
1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there are signs of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the back of the throat.
2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
4. If the patient is unable to comply with pinching their own nose, an alternative technique is to ask a relative or staff member to apply external pressure using a device like a swimmer’s nose clip.
5. It is important to dispel the misconception that compressing the bones of the nose will help stop the bleeding. Applying ice to the neck or forehead has not been proven to affect nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may help reduce nasal blood flow.If bleeding stops with first aid measures, it may be beneficial to apply a topical antiseptic preparation to reduce crusting and inflammation. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 31
Incorrect
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A 25-year-old patient presents with a 48-hour history of right-sided facial weakness accompanied by pain behind the right ear. On examination, there is noticeable asymmetry in the face, with the patient unable to raise the right eyebrow or lift the right side of the mouth. There is no tenderness or swelling in the mastoid area, and the external auditory canal and tympanic membrane appear normal. Evaluation of the remaining cranial nerves shows no abnormalities, and there are no other focal neurological deficits detected. What is the most appropriate initial management for this patient?
Your Answer:
Correct Answer: Prescribe prednisolone 50 mg daily for 10 days
Explanation:The main treatment options for Bell’s palsy are oral prednisolone and proper eye care. Referral to a specialist is typically not necessary. It is recommended to start steroid treatment within 72 hours of symptom onset. Currently, NICE does not recommend the use of antiviral medications for Bell’s palsy.
Further Reading:
Bell’s palsy is a condition characterized by sudden weakness or paralysis of the facial nerve, resulting in facial muscle weakness or drooping. The exact cause is unknown, but it is believed to be related to viral infections such as herpes simplex or varicella zoster. It is more common in individuals aged 15-45 years and those with diabetes, obesity, hypertension, or upper respiratory conditions. Pregnancy is also a risk factor.
Diagnosis of Bell’s palsy is typically based on clinical symptoms and ruling out other possible causes of facial weakness. Symptoms include rapid onset of unilateral facial muscle weakness, drooping of the eyebrow and corner of the mouth, loss of the nasolabial fold, otalgia, difficulty chewing or dry mouth, taste disturbance, eye symptoms such as inability to close the eye completely, dry eye, eye pain, and excessive tearing, numbness or tingling of the cheek and mouth, speech articulation problems, and hyperacusis.
When assessing a patient with facial weakness, it is important to consider other possible differentials such as stroke, facial nerve tumors, Lyme disease, granulomatous diseases, Ramsay Hunt syndrome, mastoiditis, and chronic otitis media. Red flags for these conditions include insidious and painful onset, duration of symptoms longer than 3 months with frequent relapses, pre-existing risk factors, systemic illness or fever, vestibular or hearing abnormalities, and other cranial nerve involvement.
Management of Bell’s palsy involves the use of steroids, eye care advice, and reassurance. Steroids, such as prednisolone, are recommended for individuals presenting within 72 hours of symptom onset. Eye care includes the use of lubricating eye drops, eye ointment at night, eye taping if unable to close the eye at night, wearing sunglasses, and avoiding dusty environments. Reassurance is important as the majority of patients make a complete recovery within 3-4 months. However, some individuals may experience sequelae such as facial asymmetry, gustatory lacrimation, inadequate lid closure, brow ptosis, drooling, and hemifacial spasms.
Antiviral treatments are not currently recommended as a standalone treatment for Bell’s palsy, but they may be given in combination with corticosteroids on specialist advice. Referral to an ophthalmologist is necessary if the patient has eye symptoms such as pain, irritation, or itch.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 32
Incorrect
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A 70-year-old woman presents with a history of worsening right-sided hearing loss and tinnitus. She is also experiencing occasional episodes of vertigo. On examination, she has significantly reduced hearing in the right ear and her Weberâs test lateralizes to the left.
What is the SINGLE most appropriate investigation?Your Answer:
Correct Answer: MRI internal auditory meatus
Explanation:This patient is displaying symptoms and signs that are consistent with a vestibular schwannoma, which is also known as an acoustic neuroma. A vestibular schwannoma typically affects the 5th and 8th cranial nerves and is characterized by the following classic presentations: gradual deterioration of hearing in one ear, facial numbness and tingling, tinnitus, and vertigo. It is also possible for the patient to have a history of headaches, and in rare cases, the 7th, 9th, and 10th cranial nerves may be affected. It is recommended that this patient be referred to either an ENT specialist or a neurosurgeon for further assessment, including an MRI of the internal auditory meatus. The main treatment options for vestibular schwannoma include surgery, radiotherapy, and stereotactic radiosurgery.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 33
Incorrect
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A 45-year-old man is brought in to the Emergency Department by his wife. He is experiencing multiple episodes of vertigo, each lasting almost all day, before resolving spontaneously. He usually vomits during the attacks and complains of a sensation of fullness in his ears. He also states that his hearing has been worse than usual recently, and he is also experiencing symptoms of tinnitus.
What is the SINGLE most likely diagnosis?Your Answer:
Correct Answer: Meniereâs disease
Explanation:Meniereâs disease is a condition that affects the inner ear due to changes in fluid volume within the vestibular labyrinth. This leads to the progressive distension of the labyrinth, known as endolymphatic hydrops, which causes damage to the vestibular system and the cochlea. The classic symptoms associated with Meniereâs disease are vertigo, hearing loss, and tinnitus.
The main clinical features of Meniereâs disease include episodes of vertigo that typically last for 2-3 hours. These episodes are usually shorter than 24 hours in duration. Hearing loss, which is often gradual and affects only one ear, is also a common symptom. Tinnitus, a ringing or buzzing sound in the ears, is frequently associated with Meniereâs disease. Other symptoms may include a sensation of fullness or pressure in the ears, as well as nausea and vomiting. Nystagmus, an involuntary eye movement, may occur away from the side of the lesion. Meniereâs disease is more prevalent in individuals who suffer from migraines.
The management of Meniereâs disease aims to alleviate acute attacks, reduce their severity and frequency, and improve hearing while minimizing the impact of tinnitus. If Meniereâs disease is suspected, patients should be referred to an ear, nose, and throat specialist.
During acute attacks, medications such as prochlorperazine, cinnarizine, and cyclizine can help reduce nausea and vertigo symptoms. If vomiting is present, buccal or intramuscular administration of these medications may be necessary. In severe cases, hospital admission may be required to prevent dehydration.
For long-term prevention, lifestyle measures can be beneficial. Avoiding caffeine, chocolate, alcohol, and tobacco is recommended. Excessive fatigue should also be avoided. Following a low-salt diet may be helpful. Betahistine, a medication that initially starts at a dose of 16 mg three times a day, can be used for prophylaxis to reduce the frequency and severity of attacks. Diuretics may also be beneficial, but they are typically not recommended for primary care use.
Overall, the management of Meniereâs disease involves a combination of lifestyle changes and medication to control symptoms and improve the patient’s quality of life.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 34
Incorrect
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A 25-year-old man comes in with a persistent sore throat that has lasted for five days. He denies having a cough. During the examination, his temperature is measured at 39°C and a few tender anterior cervical lymph nodes are found. There is a noticeable amount of exudate on his right tonsil, which appears red and inflamed.
What is his FeverPAIN score?Your Answer:
Correct Answer: 4
Explanation:The FeverPAIN score is a scoring system that is recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, different recommendations are given regarding the use of antibiotics.
If the score is 0-1, it is unlikely to be a streptococcal infection, with only a 13-18% chance of streptococcus isolation. Therefore, antibiotics are not recommended in this case. If the score is 2-3, there is a higher chance (34-40%) of streptococcus isolation, so delayed prescribing of antibiotics is considered, with a 3-day ‘back-up prescription’. If the score is 4 or higher, there is a 62-65% chance of streptococcus isolation, and immediate antibiotic use is recommended if the infection is severe. Otherwise, a 48-hour short back-up prescription is suggested.
The Fever PAIN score was developed from a study that included 1760 adults and children aged three and over. It was then tested in a trial that compared three different prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, and combining the score with the use of a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and a reduction in antibiotic prescribing, both by one third. However, the addition of the NPT did not provide any additional benefit.
Overall, the FeverPAIN score is a useful tool for assessing acute sore throats and guiding antibiotic prescribing decisions. It has been shown to be effective in reducing unnecessary antibiotic use and improving patient outcomes.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 35
Incorrect
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A 52-year-old patient arrives at the emergency department with a complaint of sudden hearing loss. During the examination, tuning fork tests are conducted. Weber's test shows lateralization to the right side, while Rinne's test is negative on the right ear and positive on the left ear. Based on this assessment, which of the following can be inferred?
Your Answer:
Correct Answer: Conductive hearing loss in the right ear
Explanation:The combination of tests points to conductive hearing loss in the right ear. There is no indication from these tests of sensorineural loss in the left ear, as a positive Rinne test (AC > BC) in the left ear is typical of normal hearing or sensorineural loss (but sensorineural loss would not result in lateralization in Weber test). Thus, the correct inference is:
Conductive hearing loss in the right ear.
Further Reading:
Hearing loss is a common complaint that can be caused by various conditions affecting different parts of the ear and nervous system. The outer ear is the part of the ear outside the eardrum, while the middle ear is located between the eardrum and the cochlea. The inner ear is within the bony labyrinth and consists of the vestibule, semicircular canals, and cochlea. The vestibulocochlear nerve connects the inner ear to the brain.
Hearing loss can be classified based on severity, onset, and type. Severity is determined by the quietest sound that can be heard, measured in decibels. It can range from mild to profound deafness. Onset can be sudden, rapidly progressive, slowly progressive, or fluctuating. Type of hearing loss can be either conductive or sensorineural. Conductive hearing loss is caused by issues in the external ear, eardrum, or middle ear that disrupt sound transmission. Sensorineural hearing loss is caused by problems in the cochlea, auditory nerve, or higher auditory processing pathways.
To diagnose sensorineural and conductive deafness, a 512 Hz tuning fork is used to perform Rinne and Weber’s tests. These tests help determine the type of hearing loss based on the results. In Rinne’s test, air conduction (AC) and bone conduction (BC) are compared, while Weber’s test checks for sound lateralization.
Cholesteatoma is a condition characterized by the abnormal accumulation of skin cells in the middle ear or mastoid air cell spaces. It is believed to develop from a retraction pocket that traps squamous cells. Cholesteatoma can cause the accumulation of keratin and the destruction of adjacent bones and tissues due to the production of destructive enzymes. It can lead to mixed sensorineural and conductive deafness as it affects both the middle and inner ear.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 36
Incorrect
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You evaluate a 3-year-old who has been brought to the emergency department due to difficulty feeding, irritability, and a high fever. During the examination, you observe a red post-auricular lump, which raises concerns for mastoiditis. What is a commonly known complication associated with mastoiditis?
Your Answer:
Correct Answer: Facial nerve palsy
Explanation:Mastoiditis can lead to the development of cranial nerve palsies, specifically affecting the trigeminal (CN V), abducens (CN VI), and facial (CN VII) nerves. This occurs when the infection spreads to the petrous apex of the temporal bone, where these nerves are located. The close proximity of the sixth cranial nerve and the trigeminal ganglion, separated only by the dura mater, can result in inflammation and subsequent nerve damage. Additionally, the facial nerve is at risk as it passes through the mastoid via the facial canal.
Further Reading:
Mastoiditis is an infection of the mastoid air cells, which are located in the mastoid process of the skull. It is usually caused by the spread of infection from the middle ear. The most common organism responsible for mastoiditis is Streptococcus pneumoniae, but other bacteria and fungi can also be involved. The infection can spread to surrounding structures, such as the meninges, causing serious complications like meningitis or cerebral abscess.
Mastoiditis can be classified as acute or chronic. Acute mastoiditis is a rare complication of acute otitis media, which is inflammation of the middle ear. It is characterized by severe ear pain, fever, swelling and redness behind the ear, and conductive deafness. Chronic mastoiditis is usually associated with chronic suppurative otitis media or cholesteatoma and presents with recurrent episodes of ear pain, headache, and fever.
Mastoiditis is more common in children, particularly those between 6 and 13 months of age. Other risk factors include immunocompromised patients, those with intellectual impairment or communication difficulties, and individuals with cholesteatoma.
Diagnosis of mastoiditis involves a physical examination, blood tests, ear swab for culture and sensitivities, and imaging studies like contrast-enhanced CT or MRI. Treatment typically involves referral to an ear, nose, and throat specialist, broad-spectrum intravenous antibiotics, pain relief, and myringotomy (a procedure to drain fluid from the middle ear).
Complications of mastoiditis are rare but can be serious. They include intracranial abscess, meningitis, subperiosteal abscess, neck abscess, venous sinus thrombosis, cranial nerve palsies, hearing loss, labyrinthitis, extension to the zygoma, and carotid artery arteritis. However, most patients with mastoiditis have a good prognosis and do not experience long-term ear problems.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 37
Incorrect
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A 45-year-old presents to the emergency department complaining of occasional right-sided facial swelling over the past 3 days. The patient describes the swelling as uncomfortable and it occurs after eating a meal, but then goes away within an hour or so. The patient mentions that the swelling has gone down since arriving at the department. Upon examination, there is no visible redness or tenderness when the face is touched. The patient's vital signs are as follows:
Blood pressure: 142/82 mmHg
Pulse rate: 86 bpm
Respiration rate: 15 bpm
Temperature: 36.5ÂșC
What is the probable diagnosis?Your Answer:
Correct Answer: Sialolithiasis
Explanation:Salivary gland stones often cause intermittent swelling that tends to worsen during meal times. This pattern of symptoms is indicative of Sialolithiasis, which refers to the presence of stones in the salivary glands. In cases of acute sialadenitis, the affected gland or duct would typically be enlarged and tender to touch, accompanied by signs of infection such as redness or fever. While mucoepidermoid carcinoma is the most common type of salivary gland cancer, malignant salivary gland tumors are rare. On the other hand, pleomorphic adenoma is the most common benign neoplasm of the salivary glands, with an incidence rate of approximately 2-3.5 cases per 100,000 population. However, it is important to note that salivary gland stones are much more common than tumors, with an annual incidence rate that is 10 times higher.
Further Reading:
Salivary gland disease refers to various conditions that affect the salivary glands, which are responsible for producing saliva. Humans have three pairs of major salivary glands, including the parotid, submandibular, and sublingual glands, as well as numerous minor salivary glands. These glands produce around 1 to 1.5 liters of saliva each day, which serves several functions such as moistening and lubricating the mouth, dissolving food, aiding in swallowing, and protecting the mucosal lining.
There are several causes of salivary gland dysfunction, including infections (such as bacterial or viral infections like mumps), the presence of stones in the salivary ducts, benign or malignant tumors, dry mouth (xerostomia) due to medication, dehydration, or certain medical conditions like Sjögren’s syndrome, granulomatous diseases like sarcoidosis, and rare conditions like HIV-related lymphocytic infiltration. Mucoceles can also affect the minor salivary glands.
Salivary gland stones, known as sialolithiasis, are the most common salivary gland disorder. They typically occur in adults between the ages of 30 and 60, with a higher incidence in males. These stones can develop within the salivary glands or their ducts, leading to obstruction and swelling of the affected gland. Risk factors for stones include certain medications, dehydration, gout, smoking, chronic periodontal disease, and hyperparathyroidism. Diagnosis of salivary gland stones can be made through imaging techniques such as X-ray, ultrasound, sialography, CT, or MRI. Management options include conservative measures like pain relief, antibiotics if there is evidence of infection, hydration, warm compresses, and gland massage. Invasive options may be considered if conservative management fails.
Salivary gland infection, known as sialadenitis, can be caused by bacterial or viral pathogens. Decreased salivary flow, often due to factors like dehydration, malnutrition, immunosuppression, or certain medications, can contribute to the development of sialadenitis. Risk factors for sialadenitis include age over 40, recent dental procedures, Sjögren’s syndrome, immunosuppression, and conditions that decrease salivary flow. Staphylococcus aureus is the most common bacterial cause, while mumps is the most common viral cause. Ac
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 38
Incorrect
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A 45 year old man presents to the emergency department complaining of dizziness. The patient describes a sensation of the room spinning around him and a constant ringing in his ears. He mentions feeling nauseated and experiencing a decrease in his hearing ability. These symptoms began an hour ago, but he had a similar episode earlier in the week that lasted for 2-3 hours. The patient did not seek medical attention at that time, thinking the symptoms would resolve on their own. There is no significant medical history to note. Upon examination, the patient's vital signs are within normal range, and his cardiovascular and respiratory systems appear normal. The ears appear normal upon examination with an otoscope. Rinne's test reveals that air conduction is greater than bone conduction in both ears, while Weber's test shows lateralization to the right ear. When asked to march on the spot with his eyes closed, the patient stumbles and requires assistance to maintain balance. No other abnormalities are detected in the cranial nerves, and the patient's limbs exhibit normal power, tone, and reflexes.
What is the most likely diagnosis?Your Answer:
Correct Answer: Meniere's disease
Explanation:One type of brainstem infarction is characterized by the presence of complete deafness on the same side as the affected area. This condition is unlikely to be caused by a transient ischemic attack (TIA) or stroke due to the patient’s age and absence of risk factors. Benign paroxysmal positional vertigo (BPPV) causes brief episodes of vertigo triggered by head movements. On the other hand, vestibular neuronitis (also known as vestibular neuritis) causes a persistent sensation of vertigo rather than intermittent episodes.
Further Reading:
Meniere’s disease is a disorder of the inner ear that is characterized by recurrent episodes of vertigo, tinnitus, and low frequency hearing loss. The exact cause of the disease is unknown, but it is believed to be related to excessive pressure and dilation of the endolymphatic system in the middle ear. Meniere’s disease is more common in middle-aged adults, but can occur at any age and affects both men and women equally.
The clinical features of Meniere’s disease include episodes of vertigo that can last from minutes to hours. These attacks often occur in clusters, with several episodes happening in a week. 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 are common findings, and the Fukuda stepping test may also be positive. While symptoms are typically unilateral, bilateral symptoms may develop over time.
Rinne’s and Weber’s tests can be used to help diagnose Meniere’s disease. In Rinne’s test, air conduction should be better than bone conduction in both ears. In Weber’s test, the sound should be heard loudest in the unaffected (contralateral) side due to the sensorineural hearing loss.
The natural history of Meniere’s disease is that symptoms often resolve within 5-10 years, but most patients are left with some residual hearing loss. Psychological distress is common among patients with this condition.
The diagnostic criteria for Meniere’s disease include clinical features consistent with the disease, confirmed sensorineural hearing loss on audiometry, and exclusion of other possible causes.
Management of Meniere’s disease involves an ENT assessment to confirm the diagnosis and perform audiometry. Patients should be advised to inform the DVLA and may need to cease driving until their symptoms are under control. Acute attacks can be treated with buccal or intramuscular prochlorperazine, and hospital admission may be necessary in some cases. Betahistine may be beneficial for prevention of symptoms.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 39
Incorrect
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You are requested to evaluate a 75-year-old individual who has been examined by a medical student. The patient complained of swelling on one side of the face, and the medical student has tentatively diagnosed it as a salivary gland stone. Where is the most frequent location for salivary gland stones to occur?
Your Answer:
Correct Answer: Wharton's duct
Explanation:This area contains stones made of stone. The parotid duct opens into the vestibule of the mouth, specifically between the cheek and gums, at a spot called the parotid papilla. This papilla is located across from the second upper molar tooth.
The sublingual gland is drained by a series of 8-20 excretory ducts known as the ducts of Rivinus. The largest duct in this system is called Bartholin’s duct. It is worth noting that stones in the sublingual gland are extremely rare.Further Reading:
Salivary gland disease refers to various conditions that affect the salivary glands, which are responsible for producing saliva. Humans have three pairs of major salivary glands, including the parotid, submandibular, and sublingual glands, as well as numerous minor salivary glands. These glands produce around 1 to 1.5 liters of saliva each day, which serves several functions such as moistening and lubricating the mouth, dissolving food, aiding in swallowing, and protecting the mucosal lining.
There are several causes of salivary gland dysfunction, including infections (such as bacterial or viral infections like mumps), the presence of stones in the salivary ducts, benign or malignant tumors, dry mouth (xerostomia) due to medication, dehydration, or certain medical conditions like Sjögren’s syndrome, granulomatous diseases like sarcoidosis, and rare conditions like HIV-related lymphocytic infiltration. Mucoceles can also affect the minor salivary glands.
Salivary gland stones, known as sialolithiasis, are the most common salivary gland disorder. They typically occur in adults between the ages of 30 and 60, with a higher incidence in males. These stones can develop within the salivary glands or their ducts, leading to obstruction and swelling of the affected gland. Risk factors for stones include certain medications, dehydration, gout, smoking, chronic periodontal disease, and hyperparathyroidism. Diagnosis of salivary gland stones can be made through imaging techniques such as X-ray, ultrasound, sialography, CT, or MRI. Management options include conservative measures like pain relief, antibiotics if there is evidence of infection, hydration, warm compresses, and gland massage. Invasive options may be considered if conservative management fails.
Salivary gland infection, known as sialadenitis, can be caused by bacterial or viral pathogens. Decreased salivary flow, often due to factors like dehydration, malnutrition, immunosuppression, or certain medications, can contribute to the development of sialadenitis. Risk factors for sialadenitis include age over 40, recent dental procedures, Sjögren’s syndrome, immunosuppression, and conditions that decrease salivary flow. Staphylococcus aureus is the most common bacterial cause, while mumps is the most common viral cause. Ac
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 40
Incorrect
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A 60-year-old woman presents with a nosebleed that started after sneezing 20 minutes ago. She is currently using tissues to catch the drips, and you have been asked to see her urgently by the triage nurse. Her observations are normal, and she has no haemodynamic compromise. The nurse has gained IV access.
What is the SINGLE most appropriate INITIAL management step for this patient?Your Answer:
Correct Answer: Sit patient up and tell her to apply direct pressure to the soft, fleshy part of her nose
Explanation:The initial step in managing a patient with uncomplicated epistaxis is to have the patient sit up and instruct them to apply direct pressure to the soft, fleshy part of their nose for a duration of 10 minutes.
If the bleeding persists after the 10-minute period, the next course of action would be to insert a gauze swab or pledget soaked with a solution of adrenaline (1:10,000) and lidocaine (4%) into the nasal cavity. This should be left in place for approximately 10-15 minutes before removal. Following the removal, an attempt can be made to cauterize any bleeding point.
If the above measures prove ineffective, it would be appropriate to consider inserting a nasal pack such as a ‘rapid rhino’ pack or alternatively using ribbon gauze soaked in an oily paste like bismuth iodoform paraffin paste. At this stage, it is advisable to refer the patient to the on-call ENT specialist.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 41
Incorrect
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A 5-year-old girl is brought in with a history of high temperatures and severe right-sided ear pain. She had a very restless night, but her pain suddenly improved this morning. Since she has improved, there has been noticeable purulent discharge coming from her right ear. On examination, you are unable to visualise the tympanic membrane due to the presence of profuse discharge.
What is the SINGLE most appropriate next management step for this patient?Your Answer:
Correct Answer: Review patient again in 14 days
Explanation:This child has a past medical history consistent with acute purulent otitis media on the left side. The sudden improvement and discharge of pus from the ear strongly suggest a perforated tympanic membrane. It is not uncommon to be unable to see the tympanic membrane in these situations.
Initially, it is best to adopt a watchful waiting approach to tympanic membrane perforation. Spontaneous healing occurs in over 90% of patients, so only persistent cases should be referred for myringoplasty. There is no need for an urgent same-day referral in this case.
The use of topical corticosteroids and gentamicin is not recommended when there is a tympanic membrane perforation.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 42
Incorrect
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A 5-year-old child comes in with a high-grade fever, excessive drooling, and inability to speak. The child has obvious stridor and a rapid heart rate. During the examination, there is tenderness in the front of the neck around the hyoid bone and swollen lymph nodes in the neck.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Acute epiglottitis
Explanation:Acute epiglottitis is inflammation of the epiglottis, which can be life-threatening if not treated promptly. When the soft tissues surrounding the epiglottis are also affected, it is called acute supraglottitis. This condition is most commonly seen in children between the ages of 3 and 5, but it can occur at any age, with adults typically presenting in their 40s and 50s.
In the past, Haemophilus influenzae type B was the main cause of acute epiglottitis, but with the introduction of the Hib vaccination, it has become rare in children. Streptococcus spp. is now the most common causative organism. Other potential culprits include Staphylococcus aureus, Pseudomonas spp., Moraxella catarrhalis, Mycobacterium tuberculosis, and the herpes simplex virus. In immunocompromised patients, Candida spp. and Aspergillus spp. infections can occur.
The typical symptoms of acute epiglottitis include fever, sore throat, painful swallowing, difficulty swallowing secretions (especially in children who may drool), muffled voice, stridor, respiratory distress, rapid heartbeat, tenderness in the front of the neck over the hyoid bone, ear pain, and swollen lymph nodes in the neck. Some patients may also exhibit the tripod sign, where they lean forward on outstretched arms to relieve upper airway obstruction.
To diagnose acute epiglottitis, fibre-optic laryngoscopy is considered the gold standard investigation. However, this procedure should only be performed by an anaesthetist in a setting prepared for intubation or tracheostomy in case of airway obstruction. Other useful tests include a lateral neck X-ray to look for the thumbprint sign, throat swabs, blood cultures, and a CT scan of the neck if an abscess is suspected.
When dealing with a case of acute epiglottitis, it is crucial not to panic or distress the patient, especially in pediatric cases. Avoid attempting to examine the throat with a tongue depressor, as this can trigger spasm and worsen airway obstruction. Instead, keep the patient as calm as possible and immediately call a senior anaesthetist, a senior paediatrician, and an ENT surgeon. Nebulized adrenaline can be used as a temporary measure if there is critical airway obstruction.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 43
Incorrect
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A 25 year old female comes to the emergency department complaining of a sore throat that has been bothering her for the past 2 days. She denies having any cough or runny nose. During the examination, her temperature is measured at 37.7°C, blood pressure at 120/68 mmHg, and pulse rate at 88 bpm. The oropharynx and tonsils show signs of redness. The patient's neck is not tender and there are no palpable masses.
What is the CENTOR score for this patient?Your Answer:
Correct Answer: 1
Explanation:The CENTOR score is a tool used to assess the likelihood of a patient having a streptococcal infection, which is a common cause of sore throat. It is based on four clinical criteria: presence of tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough, and history of fever. Each criterion is assigned one point, with a maximum score of four.
In this case, the patient has a sore throat without cough or runny nose, and her temperature is slightly elevated at 37.7°C. The examination reveals redness in the oropharynx and tonsils, but no tender neck or palpable masses. Based on this information, the patient would score one point on the CENTOR score.
Further Reading:
Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.
Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.
When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.
Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.
To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken. can
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 44
Incorrect
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A 21 year old male presents to the emergency department with a 3 day history of a sore throat and fever. The patient denies having a cough. On examination, the patient's temperature is 37.9°C, blood pressure is 120/80 mmHg, and pulse rate is 90 bpm. There is visible white exudate on both tonsils, which are severely inflamed, and tenderness on palpation of the lymph nodes around the sternocleidomastoid muscles bilaterally.
What is this patient's FeverPAIN score?Your Answer:
Correct Answer: 4
Explanation:The FeverPAIN score is a clinical scoring system that helps determine the likelihood of a streptococcal infection and whether antibiotic treatment is necessary. It consists of several criteria that are assessed to assign a score.
Firstly, if the patient has a fever higher than 38°C, they score 0 or 1 depending on the presence or absence of this symptom.
Secondly, the presence of purulence, such as pharyngeal or tonsillar exudate, results in a score of 1.
Thirdly, if the patient sought medical attention within 3 days or less, they score 1.
Fourthly, if the patient has severely inflamed tonsils, they score 1.
Lastly, if the patient does not have a cough or coryza (nasal congestion), they score 1.
By adding up the scores from each criterion, the FeverPAIN score can help healthcare professionals determine the likelihood of a streptococcal infection and guide the decision on whether antibiotic treatment is necessary. In this particular case, the patient has a score of 4.
Further Reading:
Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.
Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.
When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.
Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.
To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken. can
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 45
Incorrect
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A 25-year-old presents to the emergency department with a complaint of haematemesis and haemoptysis that started 45 minutes ago. The patient had a tonsillectomy 5 days ago. The patient's vital signs are as follows:
Blood pressure: 120/70 mmHg
Pulse: 80 bpm
Respiration rate: 16 bpm
Temperature: 36.8ÂșC
During the examination, fresh clotted blood is observed in the left tonsillar fossa, but there is no active bleeding. The patient reports that they no longer feel blood dripping down their throat and does not cough up any blood in the next 45 minutes. What is the most appropriate management for this patient?Your Answer:
Correct Answer: Admit under ENT
Explanation:Patients who experience post-tonsillectomy bleeding, even if it stops, should be closely monitored and assessed by an ear, nose, and throat specialist before being discharged. It is important to note that minor bleeding episodes may occur before a more severe hemorrhage. Therefore, patients with post-tonsillectomy bleeds, even if they seem to have resolved, should be admitted to the hospital under the care of an ENT specialist.
Further Reading:
Tonsillectomy is a common procedure performed by ENT surgeons in the UK, with over 50,000 surgeries performed each year. While it is considered routine, there are risks of serious complications, including post-tonsillectomy bleeding. Approximately 5% of patients experience bleeding after the procedure, with most cases being self-limiting. However, severe bleeding can lead to hypovolemia and airway obstruction from clots, which can be life-threatening.
Post-tonsillectomy bleeding can be classified as primary (reactive) or secondary (delayed). Primary bleeding occurs within 24 hours of the procedure, while secondary bleeding occurs more than 24 hours post-procedure. Secondary bleeding is often caused by factors such as sloughing of eschar, trauma from solid food ingestion, tonsil bed infection, postoperative NSAID usage, or unknown causes.
Patients may present with symptoms such as vomiting blood, coughing up blood, tasting blood in the throat, finding blood on pillows or bed sheets, or excessive swallowing (especially in children). It is important for clinicians to assess the severity of blood loss, although it can be challenging to accurately estimate in children.
The ABCDE approach should be used to assess patients, with a focus on airway compromise, hemodynamic instability, and evidence of bleeding. Clinicians may use a head torch to identify any bleeding points, which may be actively bleeding or appear as fresh red clots. It is important to note that the tonsillar fossa may appear white or yellow, which is a normal postoperative finding.
Investigations such as a full blood count, coagulation profile, group and save, and venous blood gas may be performed to assess the patient’s condition. Senior support from ENT or anesthesiology should be called if there is active bleeding.
Management of post-tonsillectomy bleeding includes positioning the patient upright and keeping them calm, establishing intravenous access, administering fluids and blood products as needed, and administering tranexamic acid to stop bleeding. Bleeding points may require gentle suction removal of fresh clots, and topical medications such as Co-phenylcaine spray or topical adrenaline may be applied to the oropharynx. All patients with post-tonsillectomy bleeding should be assessed by ENT and observed for a prolonged period, typically 12-24 hours.
If bleeding remains uncontrolled, the patient should be kept nil by mouth in preparation for surgery, and early intervention.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 46
Incorrect
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A 60-year-old woman presents with a nosebleed that started after sneezing 20 minutes ago. She is currently using tissues to catch the drips and you have been asked to see her urgently by the triage nurse. Her vital signs are stable, and she has no signs of bleeding excessively. The nurse has inserted an IV line.
What should be the initial course of action in this case?Your Answer:
Correct Answer: Pinch the soft, cartilaginous part of the nose for 10-15 minutes
Explanation:When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s condition. If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated.
Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula. Blood samples, including a full blood count, urea and electrolytes, clotting profile, and group and save (depending on the amount of blood loss), should be sent for analysis. Patients should be assigned to a majors or closely observed area, as dislodgement of a blood clot can lead to severe bleeding.
First aid measures to control bleeding include the following steps:
1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there is evidence of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the nasopharynx.
2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
4. If the patient is unable to comply, an alternative technique is to ask a relative, staff member, or use an external pressure device like a swimmer’s nose clip.
5. It is important to dispel the misconception that compressing the bones will help stop the bleeding. Applying ice to the neck or forehead does not influence nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may reduce nasal blood flow.If bleeding stops with first aid measures, it is recommended to apply a topical antiseptic preparation to reduce crusting and vestibulitis. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 47
Incorrect
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A 65-year-old man presents with short episodes of vertigo that worsen in the morning and are triggered by head movement. You suspect a diagnosis of benign paroxysmal positional vertigo (BPPV).
Which straightforward bedside test can be conducted to confirm the diagnosis?Your Answer:
Correct Answer: The Dix-Hallpike test
Explanation:The Dix-Hallpike test is a straightforward examination that can be utilized to verify the diagnosis of benign paroxysmal positional vertigo (BPPV).
To conduct the Dix-Hallpike test, the patient is swiftly brought down to a supine position with the neck extended by the clinician executing the maneuver. The test yields a positive result if the patient experiences a recurrence of their vertigo symptoms and the clinician performing the test observes nystagmus.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 48
Incorrect
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A 45-year-old woman presents with a 4-week history of persistent hoarseness of her voice. She has also been bothered by a sore throat on and off but describes this as mild, and she has no other symptoms. On examination, she is afebrile, her chest is clear, and examination of her throat is unremarkable.
What is the SINGLE most appropriate next management step for this patient?Your Answer:
Correct Answer: Urgent referral to an ENT specialist (for an appointment within 2 weeks)
Explanation:Laryngeal cancer should be suspected in individuals who experience prolonged and unexplained hoarseness. The majority of laryngeal cancers, about 60%, occur in the glottis, and the most common symptom is dysphonia. If the cancer is detected early, the chances of a cure are excellent, with a success rate of approximately 90%.
Other clinical signs of laryngeal cancer include difficulty swallowing (dysphagia), the presence of a lump in the neck, a persistent sore throat, ear pain, and a chronic cough.
According to the current guidelines from the National Institute for Health and Care Excellence (NICE) regarding the recognition and referral of suspected cancer, individuals who are over the age of 45 and present with persistent unexplained hoarseness or an unexplained lump in the neck should be considered for a suspected cancer referral pathway. This pathway aims to ensure that these individuals are seen by a specialist within two weeks for further evaluation.
For more information, please refer to the NICE guidelines on the recognition and referral of suspected cancer.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 49
Incorrect
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A 4 year old is brought into the emergency department by worried parents. The child has been pulling at his right ear and has been fussy and crying for the past day. During the examination, you observe that the child has a temperature of 38.9ÂșC and there is redness over the mastoid. You suspect mastoiditis. What is the most probable causative bacteria?
Your Answer:
Correct Answer: Streptococcus pneumoniae
Explanation:The most commonly found organism in patients with mastoiditis is Streptococcus pneumoniae.
Further Reading:
Mastoiditis is an infection of the mastoid air cells, which are located in the mastoid process of the skull. It is usually caused by the spread of infection from the middle ear. The most common organism responsible for mastoiditis is Streptococcus pneumoniae, but other bacteria and fungi can also be involved. The infection can spread to surrounding structures, such as the meninges, causing serious complications like meningitis or cerebral abscess.
Mastoiditis can be classified as acute or chronic. Acute mastoiditis is a rare complication of acute otitis media, which is inflammation of the middle ear. It is characterized by severe ear pain, fever, swelling and redness behind the ear, and conductive deafness. Chronic mastoiditis is usually associated with chronic suppurative otitis media or cholesteatoma and presents with recurrent episodes of ear pain, headache, and fever.
Mastoiditis is more common in children, particularly those between 6 and 13 months of age. Other risk factors include immunocompromised patients, those with intellectual impairment or communication difficulties, and individuals with cholesteatoma.
Diagnosis of mastoiditis involves a physical examination, blood tests, ear swab for culture and sensitivities, and imaging studies like contrast-enhanced CT or MRI. Treatment typically involves referral to an ear, nose, and throat specialist, broad-spectrum intravenous antibiotics, pain relief, and myringotomy (a procedure to drain fluid from the middle ear).
Complications of mastoiditis are rare but can be serious. They include intracranial abscess, meningitis, subperiosteal abscess, neck abscess, venous sinus thrombosis, cranial nerve palsies, hearing loss, labyrinthitis, extension to the zygoma, and carotid artery arteritis. However, most patients with mastoiditis have a good prognosis and do not experience long-term ear problems.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 50
Incorrect
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You review a 25-year-old man who presented with a 20-minute history of epistaxis. The bleeding stopped promptly with basic first aid measures and he has remained stable for more than an hour with no signs of recurrent bleeding. You get ready to send him home.
Which of the following medications should be considered for discharge?Your Answer:
Correct Answer: Topical Naseptin cream
Explanation:When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s airway and circulation.
If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated. Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula and collect blood samples for tests such as full blood count, urea and electrolytes, clotting studies, and blood typing and crossmatching (depending on the amount of blood loss). These patients should be closely monitored in a majors area or a designated observation area, as dislodgement of a blood clot can lead to severe bleeding.
First aid measures to control bleeding include the following steps:
1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there are signs of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the back of the throat.
2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
4. If the patient is unable to comply with pinching their own nose, an alternative technique is to ask a relative or staff member to apply external pressure using a device like a swimmer’s nose clip.
5. It is important to dispel the misconception that compressing the bones of the nose will help stop the bleeding. Applying ice to the neck or forehead has not been proven to affect nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may help reduce nasal blood flow.If bleeding stops with first aid measures, it may be beneficial to apply a topical antiseptic preparation to reduce crusting and inflammation. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.
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This question is part of the following fields:
- Ear, Nose & Throat
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