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  • Question 1 - A 12-year-old girl presents to the General Practitioner with severe right ear pain,...

    Incorrect

    • A 12-year-old girl presents to the General Practitioner with severe right ear pain, swelling, and itching. Her mother reports that it all started after her daughter began swimming lessons two months ago. During examination, the clinician notes tenderness when pulling the right ear upwards. Otoscopy is challenging due to the painful, swollen ear canal and white discharge. Additionally, the girl has tender cervical lymph nodes on the right side below the ear and experiences pain when moving her jaw sideways. She has a mild fever (38.3 °C), but the rest of the examination is unremarkable. What is the most appropriate management for this condition?

      Your Answer: Oral aminoglycosides

      Correct Answer: Topical acetic acid 2% spray (with wick placement) and oral antibiotics

      Explanation:

      The recommended treatment for this patient’s severe otitis externa involves a combination of topical acetic acid 2% spray with wick placement and oral antibiotics. The use of wick placement is necessary due to the swelling in the ear canal, which can hinder the effectiveness of the topical solution. Oral antibiotics are necessary in cases where the infection has spread to adjacent areas, as evidenced by the patient’s tender cervical lymphadenopathy. Flucloxacillin or clarithromycin are commonly used for severe cases. Cleaning and irrigation of the ear canal may be performed under otoscope guidance to remove debris and promote better absorption of topical medication. Oral aminoglycosides are effective but should only be used if the tympanic membrane is intact. NSAIDs can provide symptomatic relief but are not sufficient for treating severe otitis externa. While topical acetic acid 2% spray is a first-line treatment for mild cases, a combination of topical therapy and oral antibiotics is necessary for severe cases.

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  • Question 2 - A 28-year-old man presents with a swelling under the left jaw that comes...

    Incorrect

    • A 28-year-old man presents with a swelling under the left jaw that comes and goes but leaves a dull ache behind. The problem has been present for around 2 weeks and is getting worse. The pain is most noticeable at mealtimes. In the last day, the swelling has become fixed and he reports an unpleasant taste in his mouth. He smokes five cigarettes a day and drinks ten units of alcohol a week, usually on a Saturday night. On examination, there is a smooth, tender swelling in the superior part of the left anterior triangle and, on inspection of the oral cavity, there is poor dentition and pus present just behind the lower incisors.
      Which of the following is the most likely diagnosis?

      Your Answer: Dental abscess

      Correct Answer: Submandibular gland infection

      Explanation:

      Submandibular Gland Infection: Causes, Symptoms, and Management

      A submandibular gland infection is often caused by the presence of a stone in the left submandibular duct, which can lead to a secondary infection due to the stasis of gland secretions. Stones are more common in the submandibular gland due to the length and tortuosity of the duct. Symptoms include a smooth, tender swelling, pain worse at mealtimes, and pus behind the lower incisors. Management involves antibiotics to treat the infection and referral to an ENT or oral surgeon for stone removal, which can usually be done under local anesthesia. In some cases, excision of the entire submandibular gland may be necessary. It is important to note that the presence of bacterial infection indicates an ongoing issue beyond just the stone. Other conditions, such as gingivostomatitis and dental abscess, can cause similar symptoms but have different underlying causes. Mumps, on the other hand, can cause swelling of the parotid gland, not the submandibular gland.

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  • Question 3 - A 40-year-old patient experiences a severe nose bleed after being hit directly in...

    Correct

    • A 40-year-old patient experiences a severe nose bleed after being hit directly in the nose during a rugby game. The bleeding is resolved with direct pressure and packing of the nose. Which vascular territory is most likely to have been impacted?

      Your Answer: Kiesselbach’s plexus

      Explanation:

      Understanding Epistaxis: Causes and Management

      Epistaxis, or nosebleed, can occur from two areas: the anterior bleed from the Kiesselbach’s plexus and the posterior bleed from the sphenopalatine artery. The former is usually caused by trauma, while the latter is due to underlying pathologies such as hypertension or old age.

      To manage epistaxis, direct pressure to the bleeding point, packing of the nose, or surgical ligation or selective embolisation of the relevant artery may be necessary. It is important to check clotting and haemoglobin levels, especially in significant episodes of epistaxis that may lead to considerable blood loss, which can be masked by ingestion of the blood into the digestive tract.

      It is worth noting that the nasal artery and the superficial temporal artery are not involved in epistaxis, while the zygomatic artery has no significant role in it. Understanding the causes and management of epistaxis can help individuals respond appropriately to this common medical condition.

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  • Question 4 - Sophie is a 6-year-old overweight girl brought in by anxious parents who are...

    Correct

    • Sophie is a 6-year-old overweight girl brought in by anxious parents who are worried about her loud snoring and frequent interruptions in breathing which have been getting progressively worse. Although she has difficulty getting up from sleep, she does not have any daytime somnolence. However, her parents have been receiving complaints from the school teachers about her disruptive and inattentive behaviour in class. They have done a lot of research on the Internet and are demanding that Sophie has her tonsils removed. On examination, Sophie has a short, thick neck and grade III tonsils, but no other abnormalities.
      Which of the following is the next best step in management?

      Your Answer: Order an overnight polysomnographic study

      Explanation:

      Childhood Obstructive Sleep Apnoea: Diagnosis and Treatment Options

      Childhood obstructive sleep apnoea (OSA) is a pathological condition that requires proper diagnosis and treatment. A polysomnographic study should be performed before any intervention is undertaken, even though adenotonsillectomy is the treatment of choice for childhood OSA. Childhood OSA is characterised by disordered breathing during sleep, which includes both apnoea and hypopnoea. Symptoms such as mouth breathing, abnormal breathing during sleep, poor sleep with frequent awakening or restlessness, nocturnal enuresis, nightmares, difficulty awakening, excessive daytime sleepiness or hyperactivity and behavioural problems are typically observed.

      It is important to reassure parents that snoring loudly is normal in children of this age, and their child’s behaviour pattern will improve as they mature. Elective adenotonsillectomy as a day procedure is an option, but a polysomnographic study should be performed first to confirm the diagnosis.

      While dental splints have a small role to play in OSA, they are not the ideal treatment option. Intranasal budesonide is an option for mild to moderate OSA, but it is only a temporising measure and not a proven effective long-term treatment. Therefore, it is important to consider all available treatment options and choose the most appropriate one for each individual case.

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  • Question 5 - A 52-year-old woman with a history of intermittent ringing sound in her left...

    Correct

    • A 52-year-old woman with a history of intermittent ringing sound in her left ear for the last six months presents to the Ear, Nose and Throat (ENT) Outpatient Department. She describes the ringing sound to be pulsatile in nature. She has no history of fever, hearing loss, trauma or any recent ear infections. Her past medical history includes a diagnosis of multiple sclerosis under remission for the past two years. Clinical examination of the head and neck is unremarkable.
      Which is the most appropriate investigation which will help to reach a final diagnosis in this patient?

      Your Answer: Computerised tomography (CT) (contrast-enhanced) scan of the temporal bone

      Explanation:

      Investigating Pulsatile Tinnitus in a Patient with Multiple Sclerosis

      Pulsatile tinnitus, a constant ringing or humming sound perceived in the absence of actual sound, can be psychologically debilitating to the patient. In a patient with multiple sclerosis, pulsatile tinnitus may be caused by spontaneous spasm of middle ear muscles. The National Institute for Health and Care Excellence (NICE) recommends imaging for all patients with pulsatile tinnitus to identify the underlying cause. In this case, contrast-enhanced CT scanning of the temporal bone is the best investigation to identify middle ear/osseous pathology. Tympanometry and otoscopy can also be valuable initial investigations for suspected middle ear pathologies. Magnetic resonance angiography is not the best investigation in this scenario as the patient’s history suggests a muscular cause of pulsatile tinnitus. Weber’s test is not relevant in this case as the patient does not report any hearing loss.

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  • Question 6 - A 56-year-old woman presents to the clinic with a complaint of feeling like...

    Incorrect

    • A 56-year-old woman presents to the clinic with a complaint of feeling like there is a lump in her throat. She reports an itching sensation, but no pain. The symptoms are intermittent and not related to swallowing solids or liquids, and there is no persistent hoarseness. She also reports feeling anxious and tired. There is no significant family history. She was a heavy smoker between the ages of 22-32 but has since quit smoking and drinking. Her blood profile and thyroid function tests show the following results:
      - Haemoglobin: 98 g/l (normal range: 115-165 g/l)
      - Mean corpuscular value: 75 fl (normal range: 80-100 fl)
      - Thyroid stimulating hormone: 2.2 mU/L (normal range: 0.45-4.1 mU/L)

      What is the most appropriate initial investigation for this patient?

      Your Answer: Ultrasound neck

      Correct Answer: Naso-endoscopy

      Explanation:

      The patient is experiencing globus sensation, but before being discharged, it is important to rule out any serious conditions. Given the patient’s history of smoking and anemia, a naso-endoscopy should be performed as an initial investigation. If the results are clear, the patient can be reassured and discharged. A CT neck is not necessary at this time unless the endoscopy results are inconclusive. A barium swallow would only be appropriate if a tumor was suspected, making it a second-line investigation. An ultrasound of the neck would only be necessary if a specific mass or thyroid issue was suspected, which is not the case here. Globus sensation can typically be diagnosed through a clinical examination and a ridged endoscopy. Overall, the initial investigation should focus on ruling out any serious conditions before considering further tests.

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  • Question 7 - A 38-year-old man presents with a one-month history of feeling a lump in...

    Incorrect

    • A 38-year-old man presents with a one-month history of feeling a lump in his throat. The feeling comes and goes and has not progressed. He has no difficulty swallowing food or liquids; in fact, eating and drinking help to relieve the symptoms. He has not lost weight. He is a non-smoker. He was recently diagnosed with gastro-oesophageal reflux disease (GORD) and is taking a proton pump inhibitor. He also has chronic sinusitis, for which he takes a steroid nasal spray.
      Examination is normal, without cervical lymphadenopathy.
      What is the most likely diagnosis in this case?

      Your Answer: Laryngeal squamous cell carcinoma

      Correct Answer: Globus pharyngeus

      Explanation:

      Globus pharyngeus is a condition where patients feel a painless lump at the back of their throat. The cause of this condition is unknown, but it is often attributed to anxiety, pharyngeal spasm, reflux disease, or hiatus hernia. However, it is important to rule out more serious conditions such as thyroid disorders or cancer before diagnosing globus pharyngeus. An oesophageal ring is a benign structure at the lower end of the oesophagus that can cause swallowing difficulties. While not always symptomatic, patients may experience regurgitation and food obstruction. A diagnosis is confirmed through upper gastrointestinal endoscopy to rule out more serious causes such as oesophageal cancer. Achalasia is a disorder of the oesophagus where the lower oesophageal sphincter fails to relax, causing difficulty swallowing and regurgitation. A barium swallow and manometry can confirm the diagnosis. Eosinophilic oesophagitis is an allergic reaction that causes pain and heartburn upon swallowing, as well as vomiting and loss of appetite. Laryngeal squamous cell carcinoma is a type of head and neck cancer associated with smoking and other carcinogens. Symptoms include hoarseness, coughing, difficulty swallowing, and systemic signs of distant metastases. However, the patient in question had no warning signs or risk factors for this type of cancer.

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  • Question 8 - A 6-year-old asylum seeker from Africa presents to the Surgical Outpatient Clinic with...

    Incorrect

    • A 6-year-old asylum seeker from Africa presents to the Surgical Outpatient Clinic with a mass on the right side of his neck that has been growing in size. On examination, a mass is found on the side of the neck, behind the sternocleidomastoid muscle, which transilluminates brightly. What is the most probable diagnosis?

      Your Answer: Branchial cyst

      Correct Answer: Cystic hygroma

      Explanation:

      Differentiating Neck Abnormalities: Cystic Hygroma, Laryngocoele, Cervical Rib, Branchial Cyst, and Enlarged Lymph Node

      Neck abnormalities can be challenging to differentiate, but understanding their characteristics can aid in proper diagnosis. Cystic hygromas are lymphatic abnormalities that are commonly found in the posterior triangle of the neck and transilluminate. They may not be noticeable at birth but typically grow as the child grows. Laryngoceles are abnormal cystic dilatations of the saccule or appendix of the laryngeal ventricle, which communicate with the lumen of the larynx and are filled with air. They are usually benign but can cause airway obstruction. Cervical ribs are extra ribs that arise from the seventh cervical vertebra and are located above the first rib. They do not transilluminate. Branchial cysts are remnants of the second branchial cleft and occur along the anterior border of the sternocleidomastoid, most commonly at the junction of the lower and middle thirds of the muscle. They do not transilluminate. Enlarged lymph nodes are usually secondary to an infection and settle to normal size after six to eight weeks. Understanding the characteristics of these neck abnormalities can aid in proper diagnosis and treatment.

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  • Question 9 - The patient in the picture has a slow-growing facial lump and has been...

    Incorrect

    • The patient in the picture has a slow-growing facial lump and has been referred to the Ear, Nose and Throat (ENT) Outpatient Clinic. He denies any other symptoms and is in good health. Radiology confirms a parotid swelling. What is the most likely pathology he has?

      Your Answer: Adenocarcinoma of the parotid

      Correct Answer: Pleomorphic adenoma

      Explanation:

      Possible Parotid Gland Conditions and Their Characteristics

      The parotid gland is a salivary gland located in front of the ear. It can be affected by various conditions, including pleomorphic adenoma, lymphoma, parotid adenitis, parotid abscess, and adenocarcinoma.

      Pleomorphic adenoma is the most common tumour of the parotid gland. It is a slow-growing, mixed benign tumour that can potentially become malignant and has a high chance of recurrence. Surgical removal through a parotidectomy is the current treatment approach.

      Lymphoma is a possibility in the parotid gland, but it is less common than pleomorphic adenoma. Patients with lymphoma may have constitutional symptoms, such as night sweats, weight loss, and fever.

      Parotid adenitis is inflammation of the parotid gland, which can occur for various reasons. It may be unilateral or bilateral, as seen in mumps. Inflammatory conditions typically cause more tenderness than swelling.

      Parotid abscess is a collection of pus in the parotid gland. However, the unusual shape of the gland in combination with normal overlying skin is not typical of abscesses or inflammation.

      Adenocarcinoma of the parotid gland is a malignant tumour that can involve the facial nerve. However, the lack of facial nerve involvement and the relative size of the tumour make adenocarcinoma unlikely in this case.

      In summary, the characteristics of each condition can help differentiate between them, and a proper diagnosis is crucial for appropriate treatment.

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  • Question 10 - A 68-year-old woman presents to her General Practitioner with her husband who has...

    Incorrect

    • A 68-year-old woman presents to her General Practitioner with her husband who has noticed a gradual decrease in hearing on her left side over the past six months. She also reports difficulty walking and a tendency to lean towards the left side. Upon referral to the ENT Department, the Consultant observes nystagmus and dysdiadochokinesia, as well as sensorineural loss in her left ear. What is the most suitable diagnostic test for this patient?

      Your Answer: Vestibular colorimetric test

      Correct Answer: Magnetic resonance imaging (MRI)

      Explanation:

      Diagnostic Tests for Acoustic Neuroma: An Overview

      Acoustic neuroma is a type of tumor that affects the vestibular nerve and can cause symptoms such as unilateral hearing loss and unsteady gait. To diagnose this condition, several diagnostic tests are available.

      Magnetic resonance imaging (MRI) is the most reliable test for detecting acoustic neuroma, as it can detect tumors as small as 1-1.3 mm. MRI with gadolinium contrast is recommended in cases where brainstem testing is abnormal or there is a high suspicion of vestibular schwannoma.

      Plain computerized tomography (CT) scan can provide prognostic information on post-operative hearing loss, but it cannot detect all cases of acoustic neuroma. Otoscopy is of limited or no value in cases of sensorineural deafness.

      Pure tone audiometry (PTA) is the best initial screening test for acoustic neuroma, as only 5% of patients will have a normal test. Brainstem-evoked response audiometry can be used as a further screening measure in patients with unexplained asymmetries on standard audiometric testing.

      Vestibular testing has limited utility as a screening test for acoustic neuroma, but a decreased or absent caloric response on the affected side may be seen in some cases. Overall, a combination of these tests can help diagnose acoustic neuroma and guide treatment decisions.

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SESSION STATS - PERFORMANCE PER SPECIALTY

ENT (3/10) 30%
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