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  • Question 1 - You are requested to evaluate a 42-year-old woman who has come in with...

    Correct

    • You are requested to evaluate a 42-year-old woman who has come in with a nosebleed and was initially assessed by one of the medical students. You get ready to conduct rhinoscopy in order to locate the source of bleeding.

      What is the probable location of epistaxis?

      Your Answer: Kiesselbach plexus

      Explanation:

      Most nosebleeds, also known as epistaxis, occur at a specific area called Little’s area.

      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.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      20.1
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  • Question 2 - A 7-year-old boy presents with a sore throat and a dry cough that...

    Incorrect

    • A 7-year-old boy presents with a sore throat and a dry cough that has been present for five days. He has no medical history of note, takes no medication and reports no known drug allergies. On examination, he is febrile with a temperature of 38.5°C and has a few tender anterior cervical lymph nodes. His throat and tonsils appear red and inflamed, and you can see copious exudate on his right tonsil.
      Using the FeverPAIN Score to assess his sore throat, which of the following would be the MOST APPROPRIATE management for him at this stage?

      Your Answer: She requires immediate hospital admission

      Correct Answer: She should be offered a 'back-up prescription' for penicillin V

      Explanation:

      The FeverPAIN score is a scoring system 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, recommendations for antibiotic use are as follows: a score of 0-1 indicates an unlikely streptococcal infection, with antibiotics not recommended; a score of 2-3 suggests a 34-40% chance of streptococcus, and delayed prescribing of antibiotics may be considered; a score of 4 or higher indicates a 62-65% chance of streptococcus, and immediate antibiotic use is recommended for severe cases, or a short back-up prescription may be given for 48 hours.

      The Fever PAIN score was developed through a study involving 1760 adults and children aged three and over. It was tested in a trial comparing three prescribing strategies: empirical delayed prescribing, score-directed prescribing, and a combination of the score with a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and reduced antibiotic prescribing by one third. The addition of the NPT did not provide any additional benefit.

      According to the current NICE guidelines, if antibiotics are necessary, phenoxymethylpenicillin is recommended as the first-choice antibiotic. In cases of true penicillin allergy, clarithromycin can be used as an alternative. For pregnant women with a penicillin allergy, erythromycin is prescribed. It is important to note that the threshold for prescribing antibiotics should be lower for individuals at risk of rheumatic fever and vulnerable groups managed in primary care, such as infants, the elderly, and those who are immunosuppressed or immunocompromised. Antibiotics should not be withheld if the person has severe symptoms and there are concerns about their clinical condition.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      14.7
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  • Question 3 - A 3-year-old toddler comes in with a high temperature, trouble swallowing, and drooling....

    Incorrect

    • A 3-year-old toddler comes in with a high temperature, trouble swallowing, and drooling. Speaking is also challenging for the child. The medical team calls in a senior anesthesiologist and an ENT specialist, who diagnose the child with acute epiglottitis.
      What is the preferred investigation method considered the most reliable in this case?

      Your Answer: Throat swab and culture

      Correct Answer: Fibre-optic laryngoscopy

      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.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      34.1
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  • Question 4 - A 45-year-old woman comes in with brief episodes of vertigo that worsen in...

    Correct

    • A 45-year-old woman comes in with brief episodes of vertigo that worsen in the morning and are triggered by head movement and rolling over in bed. The episodes only last a few minutes. She experiences nausea during the attacks but has not vomited. There is no history of hearing loss or tinnitus.

      What is the recommended treatment for the most probable diagnosis in this scenario?

      Your Answer: The Epley manoeuvre

      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.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      14.7
      Seconds
  • Question 5 - A 4 year old is brought into the emergency department by worried parents....

    Correct

    • 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 38.9ºC and there is redness over the mastoid. You suspect mastoiditis. What is the most probable causative bacteria?

      Your 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.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      41.2
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  • Question 6 - A 62 year old male is brought to the emergency department after experiencing...

    Incorrect

    • 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: Hyper inflate the cuff

      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.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      19.8
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  • Question 7 - A 14-year-old girl comes in with a sudden onset of a painful throat...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      11.4
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  • Question 8 - A 60-year-old woman presents with a nosebleed that started after sneezing 20 minutes...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      16.4
      Seconds
  • Question 9 - You evaluate a 60-year-old man who has a past medical history of hearing...

    Incorrect

    • You evaluate a 60-year-old man who has a past medical history of hearing impairment.
      Which ONE statement is accurate regarding the tuning fork hearing tests conducted?

      Your Answer: The tuning fork should be initially placed outside the external auditory canal for a Weber’s test

      Correct Answer: A false negative Rinne’s test can occur if the patient has a severe sensorineural deficit

      Explanation:

      A 512 Hz tuning fork is commonly used for both the Rinne’s and Weber’s tests. However, a lower-pitched 128 Hz tuning fork is typically used to assess vibration sense in a peripheral nervous system examination. While a 256 Hz tuning fork can be used for either test, it is considered less reliable.

      To perform the 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. Next, the top of the tuning fork is 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 to 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. The sound will disappear earlier on the mastoid and outside the external auditory canal compared to the other ear, but it will still be heard outside the canal.

      To perform the Weber’s test, the 512 Hz tuning fork is made to vibrate and then placed on the center of the patient’s forehead. The patient is then asked if they perceive the sound in the middle of the forehead or if it lateralizes to one side or the other.

      If the sound lateralizes to one side, it can indicate either ipsilateral conductive hearing loss or contralateral sensorineural hearing loss.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      22.8
      Seconds
  • Question 10 - You evaluate a 60-year-old man with a previous diagnosis of hearing impairment.
    Which tuning...

    Incorrect

    • 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: 256 Hz

      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.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      22.3
      Seconds

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