Day 4 ENT Flashcards
(160 cards)
1
Q
A 5-year-old boy presents with his mother to the GP surgery with a 5-day history of right-sided otalgia and reduced hearing. On examination, he has a temperature of 38.5ºC and a heart rate of 120 bpm. There is swelling around his right ear and the ear appears to be displaced anteriorly. The canal appears normal however the tympanic membrane is red and bulging.
What is the most appropriate next step in management?
A
This child is unwell and has signs of mastoiditis. He should be referred urgently to ENT for admission and further assessment.
2
Q
A 32-year-old lady presents with episodes of vertigo that come on at random. These ‘dizzy spells’ last for a few minutes to hours, and during this time she also experiences difficulty hearing and ringing in her ear. What is the most likely diagnosis?
A
In Meniere’s disease, vertigo occurs spontaneously. Episodes last for minutes to hours, and are accompanied by unilateral hearing loss and tinnitus
3
Q
A 67-year-old man presents to you with difficulty hearing in his left ear, that has occurred over the past month. He states that recently he has found it difficult to follow telephone conversations and frequently has to increase the volume on his television. He is otherwise well, with no significant past medical history.
Examination reveals a normal oropharynx with no cervical lymphadenopathy. Rinnes test shows bone conduction greater than air conduction left side. Weber’s test lateralises to the left side. Otoscopy shows compacted earwax in the left external canal. Right tympanic membrane and canal appear normal.
Given the diagnosis, what is the appropriate first-line management?
A
Olive oil drops are a commonly used first-line treatment for impacted ear wax
4
Q
A 22-year-old man complains of hearing problems. You perform an examination of his auditory system including Rinne’s and Weber’s test:
Rinne’s test:
- Left ear: bone conduction > air conduction
- Right ear: air conduction > bone conduction
Weber’s test: Lateralises to the left side
What do these tests imply?
A
Left conductive deafness
5
Q
A 19-year-old woman presents with hearing problems for the past six months. She initially thought it was due to wax but her hearing has not improved after ear syringing. You perform an examination of her auditory system including Rinne’s and Weber’s test:
Rinne’s test:
Left ear: air conduction > bone conduction
Right ear: air conduction > bone conduction
Weber’s test:
Lateralises to the left side
What do these tests imply?
A
Right sensorineural deafness
6
Q
A 48-year-old woman is admitted to the acute medical unit with sudden-onset dizziness, which she describes as the room spinning around. The dizziness is persistent and does not settle with rest. It is associated with severe nausea and vomiting. She also complains of hearing loss in her left ear. Other than a recent cough and coryza episode, she has been well with no past medical history.
On examination, Rinne’s test shows air conduction is greater than bone conduction in both ears. Weber’s test lateralises to her right ear. She has a normal range of eye movements with mild horizontal nystagmus on lateral gaze. Her coordination is intact.
What is the most likely diagnosis?
A
Viral labyrinthitis stereotypical history: recently developed an upper respiratory tract infection presents with vertigo and vomiting. Hearing is also affected. The symptoms came on suddenly
7
Q
The parents of a 2-year-old child are concerned after he develops a lump in his neck. On examination there is a swelling in the subcutaneous tissue of the posterior triangle which transilluminates.
A
The correct answer is: Cystic hygroma
This is a classical description. Collection of dilated lymphatic sacs which are fluctuant and brilliantly transilluminable. Recurrence is common.
8
Q
A 10-year-old child presents with enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice peticheal haemorrhages affecting the oropharynx. On systemic examination he is noted to have splenomegaly.
A
Infectious mononucleosis
A combination of pharyngitis and tonsillitis is often seen in glandular fever. Antibiotics containing penicillin may produce a rash when given in this situation, leading to a mistaken label of allergy.
9
Q
A 54-year-old man presents with a 2-day history of sudden onset left-sided hearing loss. On further questioning, there is no history of trauma and he has otherwise been well in himself. He describes some tinnitus in his left ear alongside vertigo.
On examination, he has a moderate amount of ear wax bilaterally. He has no pinna, tragal or mastoid tenderness. The small amount of tympanic membrane you can see bilaterally appears normal. There is evident hearing loss on his left side.
Whilst performing Weber’s test, he localises the sound to his right side. Rinnes test is positive bilaterally (air conduction better than bone).
What is the most appropriate next management step?
A
Acute sensorineural hearing loss is an emergency and requires urgent referral to ENT for audiology assessment and brain MRI
10
Q
A 59-year-old woman presents to the urgent care centre with a 1-day history of facial paralysis. She also complains of some mild ear pain over the last 2 days. On examination, she has a fixed half-smile on the left side of her face. She is unable to raise her left eyelid and has increased sensitivity to sound in her left ear. She denies dizziness or vertigo. The remainder of her cranial nerve examination is normal. ENT examination shows an erythematous left ear canal and vesicles over her soft palate.
Given the likely diagnosis, which of the following is the most appropriate treatment to initiate?
A
Treatment of Ramsay Hunt syndrome consists of oral aciclovir and corticosteroids
11
Q
A 64-year-old woman with a one week history of pain above and lateral to her left eye. On examination she is tender over that area.
A
Temporal arteritis
12
Q
A 70-year-old inpatient on the geriatrics ward who is on warfarin complains of a nosebleed. He is not known to have any nasal pathology or coryzal symptoms.
What is the most likely anatomical origin of the epistaxis?
A
Little’s area in the nasal septum is a common site for epistaxis to originate because it is the confluence of 4 arteries
Little’s area in the anterior nasal septum is the site of Kiesselbach’s plexus, supplied by 4 arteries. Epistaxis therefore most commonly originates from the anterior of the nose.
13
Q
A 51-year-old female with a 3 week history of recurrent attacks of vertigo, right ear tinnitus and the sensation of fullness in her right ear. On testing, there is noted to be right-sided hearing loss affecting low frequencies.
A
Meniere’s disease
14
Q
Mr Zhang, a 56-year-old Mandarin-speaking patient, attends with his daughter, who translates for him. He has had reduced hearing and mild discomfort in his left ear for about two weeks which he attributes to an ear infection, and he is asking for antibiotics. He describes the hearing as being a bit muffled, and he hears clicking and popping at times, especially when swallowing. He says he hasn’t had a cold recently. He is a current smoker. On examination, the right tympanic membrane appears normal, and the left tympanic membrane looks dull and retracted. The oral cavity looks normal and there are no enlarged cervical lymph nodes.
How should you manage Mr Zhang?
What is the likely diagnosis?
A
Unilateral middle ear effusion in an adult can be a presenting symptom of nasopharyngeal cancer, especially in smokers and people of Chinese or South-East Asian origin.
15
Q
Drug ototoxicity examples (3)
A
aminoglycosides (e.g. Gentamicin)
furosemide
aspirin
16
Q
A 19-year-old man has had a sore throat for the past 5 days. Over the past 24 hours he has noticed increasing and severe throbbing pain in the region of his right tonsil. He is pyrexial and on examination is noted to have a swelling around the right tonsillar region
A
Quinsy
Unilateral swelling and fever is usually indicative of quinsy. Surgical drainage usually produces prompt resolution of symptoms.
17
Q
Key features of acoustic neuroma
A
Features can be predicted by the affected cranial nerves
cranial nerve VIII: hearing loss, vertigo, tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy
18
Q
Cause of low frequency hearing loss
A
Otoscleritis
19
Q
What is the Eppley manouvre?
A
The Epley manoeuvre is used to treat BPPV (usually of the posterior canal) once it has been diagnosed by the previously mentioned Dix-Hallpike test.
20
Q
A 64-year-old woman presents to her GP with a five-day history of feeling right earache and feeling generally unwell. In the last day she has developed painful blistering around the ear and her husband has told her that her facial movements appear different. Her past medical history includes hypertension, for which she takes amlodipine.
On examination, a vesicular rash is noted around the right ear and the patient has a visible right-sided facial palsy. Her observations are normal and she is apyrexial.
Given the likely diagnosis, which of the following is the most appropriate treatment plan?
A
Treatment of Ramsay Hunt syndrome consists of oral aciclovir and corticosteroids
21
Q
A 25-year-old lady presents with an swelling located at the anterior border of the sternocleidomastoid muscle. The swelling is intermittent and on examination it is soft and fluctuant.
A
Branchial cyst
Branchial cysts are remnants of the branchial cleft. They may become infected.
22
Q
James, 40, has presented to his GP with weakness of the right side of his face, which examination confirms. James also reveals that he has experienced pain in his ear and otoscopy reveals the presence of vesicles on his tympanic membrane. Which of the following is the likely diagnosis?
A
Ramsay Hunt syndrome, type 2, is a condition where reactivation of pre-existing Varicella Zoster virus occurs in the geniculate ganglion.
23
Q
A 62-year-old woman presents with a two week history of shooting pains across her left cheek. The pain is sometimes triggered by touching her face. She has no past medical history note
A
Trigeminal neuralgia
24
Q
Characteristics of Otoscleritis (4)
A
- Otosclerosis is a genetic condition which is inherited in an autosomal dominant fashion.
- It causes irregular bony formation in the middle ear, causing dysfunction of the ossicular chain.
- This leads to a progressive conductive deafness, which typically presents in middle age.
- Tinnitus and vertigo may also be present, but are less common.
25
What does the audiogram show?
Normal hearing
26
A 33-year-old with coryzal symptoms presents with a one day history of vertigo and nausea. There is no hearing loss on examination
Vestibular neuronitis
27
How do you perform the eppley manouvre?
1. The Epley manoeuvre typically follows on from a positive Dix-Hallpike test, so we will assume the patient is still positioned lying flat, with the head hanging over the end of the bed, turned 45º away from the midline.
2. Turn the patient’s head 90º to the contralateral side, approximately 45º past the midline, still maintaining neck extension over the bed. Keep the patient in this position for 30 seconds.
3. Whilst maintaining the position of the patient’s head, ask the patient to roll onto their shoulder (on the side their head is currently turned towards).
4. Once the patient is on their side, rotate the patient’s head so that they are looking directly towards the floor. Maintain this position for 30 seconds to a minute.
5. Sit the patient up sideways, whilst maintaining head rotation.
6. Once the patient is sitting upright, the head can be re-aligned to the midline and the neck can be flexed so that the patient is facing downwards (chin to chest). Maintain this position for 30 seconds.
28
45-year-old female presents to the general practitioner with a two-week history of progressive paraesthesia of the fingers, toes and peri-oral area, associated with muscle cramps and spasms. She recently underwent a thyroidectomy for Graves' disease but is otherwise well with no drug allergies.
Given the likely diagnosis, what is this patient's ECG likely to show?
Complications of thyroid surgery - damage to parathyroid glands can result in hypocalcaemia
29
A 76-year-old-man was seen by one of your colleagues one month previously complaining of **right ear otalgia and discharge**. He was diagnosed with **otitis externa and started on antibiotic ear drops**.
He was next seen by an out of hours doctor one week ago who prescribed further antibiotic drops and tramadol. He has come to see you reporting that his symptoms are no better and the pain is becoming unbearable.
He has a past medical history of **type-2 diabetes mellitus** and hypertension. His regular m**edicines are metformin, gliclazide, ramipril and atorvastatin**. He has no drug allergies. He has never smoked and rarely drinks alcohol.
**On examination there is debris in the right ear canal** but the tympanic membrane remains visible. There was no erythema of the pinna or mastoid swelling. Examination of the cranial nerves is normal.
Non-resolving otitis externa with worsening pain should be referred urgently to ENT
Long courses of intravenous antibiotics are needed and urgent ENT assessment is required.
30
A 33-year-old male presents to the GP complaining of a 4 month history persistent nasal discharge on his left hand side and facial pressure which is worse on bending forward. He often finds he has to breath through his mouth due to his nose being blocked. He has a past medical history of asthma and is a smoker with a 5 pack-year history.
What is the most appropriate management?
Unilateral symptoms are a red flag for patients with chronic rhinosinusitis
31
A 54-year-old woman presents with a neck swelling. She is systemically well apart from some recent weight loss. On examination she is noted to have a midline, non-tender neck swelling which moves upwards when she swallows.
Goitre
Patients with a goitre are often euthyroid or have minor symptoms. A thyroglossal cyst would be unusual at this age - they typically present in patients \< 20 years old
32
A 78-year-old man complains of difficultly following conversations. His wife says he has the TV turned up too loud. Audiometry shows sensorineural hearing loss at the higher frequencies.
The correct answer is: Presbycusis
* Presbycusis describes age-related sensorineural hearing loss.
* Patients may describe difficulty following conversations
* Audiometry shows bilateral high-frequency hearing loss
33
A 62-year-old male presents with right ear pain and a **longstanding purulent discharge** from his right ear. On examination, you notice he has a **facial nerve palsy**.
Which of the following is the biggest risk factor for malignant otitis externa?
**Malignant otitis externa** is most common in patients with **diabetes**
34
A 78-year-old man is brought to a same-day emergency appointment by his wife. He had a dental extraction 5 days previously but overnight has developed worsening pain and a new fever. He is usually fit and well.
On assessment he is febrile with a temperature of 38.3ºC and a heart rate of 92 bpm but other parameters are normal. He has a tender swelling to the left submandibular region around the site of his dental extraction. He has mild trismus. His tongue is slightly displaced upwards and he is unable to protrude it. He has no stridor or respiratory distress.
What is the diagnosis?
Ludwig’s Angina, a rare infection of the floor of the mouth and soft tissues of the neck.
This is most commonly odontogenic but may also result from any form of soft tissue neck infection.
35
A 28-year-old Bangladeshi woman presents with a three day history of sweats, headache, lethargy and muscle aches. On examination she has bilateral tender swellings in the submandibular region.
Reactive lymph nodes
## Footnote
By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness
36
A 27-year-old male presents to the GP with intense left-sided ear pain which he has had for 24 hours. On examination, you see that the left ear is protruding forward, with a tender, boggy mass behind the ear. The tympanic membrane is bulging and erythematous. He is tachycardic and his temperature is 37.9 ºC.
Urgent treatment of this condition is necessary to prevent which complication?
Mastoiditis is a medical emergency due to the potential risk of meningitis
37
A 67-year-old gentleman comes in to your practice complaining of 'dizziness'. He has a past medical history of hypertension, hypercholesterolaemia and hay fever. He is an ex-smoker with a forty pack-year history.
On closer questioning, he describes a sudden onset of a sensation at 9am this morning - 'like the room is spinning' - accompanied by nausea but no vomiting. The dizziness has persisted and is constant.
On examination he looks well, blood pressure 170/120 mmHg, with other observations in normal range. Cardiac, respiratory and ENT examination is unremarkable. On neurological examination he has normal power, tone, sensation and reflexes throughout both upper and lower limbs bilaterally. There is notable nystagmus on cranial nerve testing. There is also mild past pointing and dysdiadochokinesis.
This gentleman has a history suggestive of vascular disease, and has presented with acute onset of symptoms suggesting a posterior stroke
38
Jamie is a 13-year-old girl who presents to her general practitioner complaining of right ear pain over the last three days, with slightly worse hearing over this time. She also complained of fluid leaking from her ear this morning. Jamie's past medical history includes recurrent otitis media as a child (approximately two episodes per year until the age of 5), and had grommets inserted once at age 4.
On examination, Jamie's blood pressure is 120/80mmHg, heart rate 85/min and temperature 37.4ºC. On otoscopy, the right external auditory canal appears swollen and erythematous. The tympanic membrane is slightly erythematous with no effusion is present. There is no pain on mastoid palpation, however when the GP pulls on the right tragus there is significant tenderness.
Which of the following is the most likely diagnosis?
Otitis externa: pain on palpation of the tragus, itching, discharge and hearing loss
The answer is otitis externa. Classical symptoms of otitis externa include pain on palpation of the tragus, itching, discharge and hearing loss
39
You diagnose a right-sided sudden sensorineural hearing loss (SSNHL) in a normally fit and well 38-year-old woman who has come to see you in your GP clinic. She developed her symptoms over a few hours yesterday and now can not hear at all through her right ear. Her examination shows no obvious external or middle ear causes.
What is your next step?
**Acute sensorineural hearing loss** is an emergency and requires urgent referral to ENT for audiology assessment and brain MRI
40
A 50-year-old man presents with right-sided ear pain and facial weakness. He had flu-like symptoms of fever and headache for three days before the rash appeared.
On examination, there is a right-sided facial nerve palsy. A vesicular rash is seen on otoscopy.
How should this patient be managed?
What is the diagnosis?
Treatment of Ramsay Hunt syndrome consists of oral aciclovir and corticosteroids
herpes zoster oticus
41
A 25-year-old male has come to the emergency department after sustaining an injury in a rugby game earlier that morning. When he was tackled and went to ground, another player's boot impacted his left ear. He did not lose consciousness and only had some ear pain immediately after. In the ensuing minutes the pain worsened and he noticed a persistent ringing. When he felt his ear it was tender and swollen, with other players telling him it looked very red and puffy.
On examination, the patient does not exhibit any neurological deficit or pain other than in his left ear. The ear is ecchymotic and swollen with loss of normal anatomy to the anterosuperior pinna.
What is the diagnosis?
What is the most appropriate next step?
Auricular haematomas are common in rugby players and wrestlers. Prompt treatment is important to avoid the formation of 'cauliflower ear'.
**Auricular haematomas** need same day assessment by ENT
Auricular haematomas occur after direct trauma to the ear and is due to a build up of blood between the cartilage and perichondrium.
This can restrict blood supply and lead to necrosis of the connective tissue. ENT must therefore assess the patient quickly to decide how to manage it. Treatment is usually incision and drainage +/- a draining wick depending on the size.
42
A 61-year-old woman with a history of cardiac problems develops hearing loss after a prolonged admission in hospital. Drug toxicity is suspected.
Furisemide Toxicity
43
What is vestibular neuronitis?
Vestibular neuronitis is a cause of vertigo that often develops following a viral infection.
**Features**
* recurrent vertigo attacks lasting hours or days
* nausea and vomiting may be present
* horizontal nystagmus is usually present
* no hearing loss or tinnitus
44
A 40-year-old female attends your practice complaining of a history of **sudden episodes of dizziness** over the last few weeks. T**he episodes can last several hours and then improve for a few days before recurring again.** She is worried about 'ear cancer' as her mother had suffered from this but she is unsure of any further information.
**On further questioning, she admits the attacks also cause a 'pressure' in her ears**, and, at times, she hears **buzzing noises in both ears**. She has no other past medical history. She is, however, a smoker of 20 pack years.
Meniere's disease
BPPV usually lasts a few seconds and is typically positional. It is not generally associated with tinnitus.
In this case, the most likely diagnosis is Meniere's disease.
Acoustic neuromas tend to present more insidiously with hearing loss and symptoms are generally unilateral. Vertigo is an uncommon symptom, although not entirely impossible.
45
A 23-year-old man presents to his GP with a swollen pinna of the left ear.
On examination, his neurological examination is completely normal. However, the upper half of the left pinna is hot, red, swollen and exquisitely tender to touch. His observations are normal.
What is the most appropriate course of action?
Auricular haematomas need same day assessment by ENT
46
A 64-year-old woman presents to the GP with worsening hearing loss. The GP performs Weber's test and Rinne's test.
**Weber's test** - Sound heard loudest in the left ear
**Rinne's test right ear** - Air sound greater than bone
**Rinne's test left ear** - Bone sound greater than air
In this case, the results test indicate that there is a conductive hearing loss in the left ear.
Exostosis affecting the left ear
47
A 35-year-old woman presents to her GP with hearing loss which has slowly progressed over the last year. She also reports tinnitus that has worsened over the same time period. She is otherwise well and has no significant medical history. Her father also suffered from hearing loss at a young age.
Her neurological examination reveals mild bilateral conductive hearing loss but is otherwise normal. On inspection, the tympanic membrane appears normal.
What is the likely cause of this patient's symptoms?
This presentation (slowly progressive bilateral conductive hearing loss in a young patient with a positive family history) is most consistent with otosclerosis.
Otosclerosis is an autosomal dominant cause of deafness affecting young adults
48
A 32-year-old woman presents with a long history of **chronic ear infections**. She complains of an **offensive discharge** from her right ear with associated **hearing loss for months**. She has had **severe vertigo** for the last 48 hours.
What is the most likely diagnosis?
The past medical history of chronic ear infections and offensive discharge are suggestive of cholesteatoma. A large cholesteatoma can invade the inner ear resulting in sensorineural hearing loss and vertigo, as seen in this case.
49
You see a 3-year-old boy as a follow-up appointment. Two weeks ago he presented with left-sided otalgia associated with a purulent discharge. You prescribed amoxicillin and arranged to see him today. His mum reports that he is much better and says she has managed to keep the ear dry. On examination of the left side a perforation of the tympanic membrane is noted. What is the most appropriate action?
Advise to keep ear dry and see in a further 4 weeks time
50
A 25-year-old woman presents with a slowly enlarging mass on the side of the face. Clinical examination demonstrates that the mass is located in the tail of the parotid gland. There is no evidence of facial nerve involvement. What is the most likely cause?
**Pleomorphic adenomas** are the commonest tumours of the parotid gland and are often slow growing, smooth and mobile.
51
A 34-year-old lady presents with a long standing offensive discharge from the ear and on examination is noted to have a reduction in her hearing of 40 decibels compared to the opposite side.
Cholesteatoma
52
A 37-year-old lady, Mrs Halen is referred to the emergency department by her GP. She reports that when she awoke in the morning her eyes felt like they were moved to one side. Since then, she has felt very dizzy as if the room is spinning and she has been vomiting almost non-stop. She has a dull headache generally around the whole head which came on gradually this morning and is 4/10 severity. She has not experienced photophobia, phonophobia or a rash. She has a history of migraines which present as severe right-sided throbbing head pain but reports that pain to be different from this.
She reports being well prior to this episode, other than a mild cold a week ago. She reports a 3 day history of ringing in her right ear and slight muffling of her hearing. She has not noticed any feeling of pressure in the ear. She says that the ear is not painful. Otoscopy examination is normal.
Mrs Halen is given promethazine which improves her symptoms of vertigo and vomiting.
Which condition is the likely cause of her symptoms?
**Acute viral labrynthitis**: sudden onset horizontal nystagmus, hearing disturbances, nausea, vomiting and vertigo
53
An 18-month-old girl is brought to her general practitioner with a three-day history of poor feeding and pulling at their ears. Her observations are as follows:
* Respiratory rate of 26 breaths/min
* Pulse of 123 beats/min
* Temperature of 37.1ºC
* Blood pressure of 94/58mmHg
* Oxygen saturations of 97%
On examination, you note bulging tympanic membranes with surrounding erythema bilaterally.
What is the appropriate first-line management in this patient?
If antibiotics are required for otitis media, amoxicillin is first-line
54
What are the characteristics of Meniere's disease?
(5)
* recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom
* a sensation of aural fullness or pressure is now recognised as being common
* other features include nystagmus and a positive Romberg test
* episodes last minutes to hours
* typically symptoms are unilateral but bilateral symptoms may develop after a number of years
55
You are working in general practice, a 5-year-old boy is brought in by his mum due to a 3-day history of ear pain. On examination, you suspect a diagnosis of otitis media.
What is the most common cause of bacterial otitis media?
Haemophilus influenzae is a common cause of bacterial otitis media
56
A 37-year-old cello player complains of a three month history of vertigo and hearing loss on the left side. On examination he has an absent corneal reflex on the left eye.
Acoustic neuroma
57
A 25-year-old cat lover presents with symptoms of abdominal pain, lethargy and sweats. These have been present for the past two weeks. On examination she has lymphadenopathy in the posterior triangle.
**Bartonella** infection may occur following a cat scratch. The organism is intracellular. Generalised systemic symptoms may occur for a week or so prior to clinical presentation
58
Where are the parotid glands?
There are 3 main salivary glands:
the parotid glands are anterior and inferior to each ear
the submandibular glands lies below the angle of the jaw
the sublingual glands lie beneath the tongue
59
What is Meniere's disease?
Meniere's disease is a disorder of the inner ear of unknown cause.
It is characterised by excessive pressure and progressive dilation of the endolymphatic system.
60
A 24-year-old patient attends their general practitioner with an earache. They complain of being unable to hear clearly and have had difficulty sleeping due to the pain. They noticed feeling hot at home and recorded a temperature of 38ºC. On examination, the tympanic membrane appears to be bulging and opacified.
Of the following, what is the most likely causative organism of this presentation?
Haemophilus influenzae is a common cause of bacterial otitis media
61
A 6-year-old boy is brought to surgery. His mother says he has been complaining of left sided otalgia for the past three days. Otoscopy demonstrates the following:
Acute otitis media
The bulging nature of the tympanic membrane strongly suggests a diagnosis of otitis media. The colour of the tympanic membrane alone has a low predictive value for otitis media as it may be reddened by coughing, nose blowing, and fever.
62
A 17-year-old female presents to her GP with a sore throat and fevers for the past 3 days. She has no past medical history and takes no regular medication. On examination her throat is red with bilateral tonsillar swelling and bilateral cervical lymphadenopathy. Her pulse rate is 83 bpm and her blood pressure is 124/76 mmHg.
Which of the following features would be suggestive of a diagnosis of bacterial tonsillitis?
The likelihood that a diagnosis of pharyngitis or tonsillitis is due to a bacterial source is decided based on the **Centor** criteria. The criteria are as follows:
• Temperature \>38ºC
• Tender anterior cervical lymphadenopathy
• Absence of a cough
• Exudate present on tonsils
63
A 25-year-old man presents with an acute history of sudden intense vertigo on waking, with loss of balance affecting his right side and pain in the right ear. There is no associated deafness or tinnitus. On examination he has a nystagmus with the rapid component to the right.
Which one of the following is the likely diagnosis?
Sudden and near-complete loss of vestibular function in a young patient is suggestive of vestibular neuronitis, a condition assumed due to a self-limiting viral infection of the vestibular nerve.
Hearing is normal in vestibular neuronitis
64
A 57=year-old male presents in the emergency department with a 12-hour history of sudden onset left-sided hearing loss. His hearing loss is accompanied by new onset tinnitus.
He denies any trauma or exposure to loud sounds and feels well in himself. He denies any weight loss, night sweats, or fever. He has no past medical or surgical history. He does not take any medication regularly apart from an over-the-counter vitamin D supplement.
You perform a full cranial nerve examination and note the below findings for assessment of CN VIII (vestibulocochlear nerve):
* Weber test - Louder in right ear
* Rinne test - Positive
Following urgent referral to ENT, what is the most appropriate next step in management?
Following referral to ENT, patients with sudden-onset sensorineural hearing loss are treated with high-dose oral corticosteroids
65
How is gingevitis treated?
**If a patient presents with acute necrotizing ulcerative gingivitis CKS recommend the following management:**
* refer the patient to a dentist, meanwhile the following is recommended:
* oral metronidazole\* for 3 days
* chlorhexidine (0.12% or 0.2%) or hydrogen peroxide 6% mouth wash
* simple analgesia
66
A 24-year-old woman presents to the emergency department with epistaxis. First-aid measures are commenced and she sits leaning forward with pressure on the upper cartilaginous portion of her nose for 20 minutes. The bleeding does not stop and on examination, the bleeding source is identified on the anterior part of her septum in the left nostril.
What management is most appropriate in this situation?
Epistaxis from an anterior bleeding source that is visualized is treated with **silver nitrate cautery**
67
A 32-year-old woman presents with episodes of sudden onset dizziness, which she describes as 'the room spinning'. These episodes last up to 30 minutes and make her feel nauseous. She denies any hearing loss or tinnitus. These episodes can occur both at rest and during activity, with no specific movements exacerbating the symptoms. Apart from feeling slightly 'run down' a week prior, no other symptoms are reported.
Vestibular neuritis
The absence of ear symptoms such as hearing loss makes an acoustic neuroma unlikely.
There are no signs of active ear infection in this scenario but she has recently felt unwell, likely a viral infection. Therefore, the most likely cause of her vertigo is either vestibular neuritis or labyrinthitis.
68
A 40-year-old woman presents with recurrent episodes of vertigo associated with a feeling or 'fullness' and 'pressure' in her ears. She thinks her hearing is worse during these attacks. Clinical examination is unremarkable. What is the most likely diagnosis?
Meniere's disease
69
A 75-year-old man presents with dysphagia and halitosis. On the left side of the neck is a small, fluctuant swelling which gurgles when palpated.
Pharyngeal pouch
* More common in older men
* Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
* Usually not seen but if large then a midline lump in the neck that gurgles on palpation
* Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough
70
A 4-year-old child is brought to the clinic by his father. They are concerned because the child has been noted to have a small epithelial defect anterior to the left ear and is has been noted to discharge foul smelling material for the past 2 days.
Preauricular sinus
Pre auricular sinuses that a deeper may accumulate secretions and produce foul smelling discharge.
71
A 10-year-old boy comes in to see his GP with a week history of reduced hearing and worsening otalgia.
Weber's test **lateralises to the right ear** and **Rinne's test is negative in the right ear**.
What is the type of hearing loss?
Rinne's test negative
means that bone conduction \> air conduction
thus there is a conductive hearing loss in that ear
72
You are called to do a house visit for a 30-year-old woman who is unable to get to your surgery. She was previously fit and well, apart from having 'a bit if a cold', but this morning she woke up feeling very dizzy with the sensation that the room is spinning, and feels too ill to leave the house. She has vomited twice this morning.
What is the likely diagnosis, how should you manage this patient?
**Prochlorperazine** may be useful in the acute phase of **vestibular neuronitis**, but should be stopped after a few days as it delays recovery by interfering with central compensatory mechanisms
73
A 41-year-old complains of some difficulties with his hearing which have got gradually worse over the past few weeks. An audiogram is arranged:
Right conductive hearing loss
74
A 2-year-old boy is brought in by his mother due to concerns about his hearing and delayed speech. She has noticed problems for the past three months. You can see from the notes that he has had frequent courses of amoxicillin for otitis media in the past. There is no evidence of excessive ear wax on examination.
The correct answer is: Glue ear
Also known as otitis media with effusion
* peaks at 2 years of age
* hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss and elective surgery in childhood)
* secondary problems such as speech and language delay, behavioural or balance problems may also be seen
75
What are Pleomorphic adenomas
Pleomorphic adenomas are the commonest tumours of the parotid gland and are often **slow growing, smooth and mobile**.
* Most common parotid neoplasm (80%)
* Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components
* Slow growing, lobular, and not well encapsulated
76
A 4-year-old is brought to the general practitioner by her mother. She has been distressed with ear pain for the past 14 hours. She is constantly touching and pulling at her ear. Whilst she is sat in the waiting room her mother notices a discharge of foul smelling fluid from the ear, following which the pain resolves.
**Acute suppurative otitis media**
In young children acute suppurative otitis media is a common condition. Rupture of the tympanic membrane is a rare, but recognised complication.
77
You are reviewing a 24-year-old lady who has had episodes of wheeze and shortness-of-breath. She is otherwise fit and well, and has no significant past medical history. Her wheeze improves with her brother's 'blue inhaler'. She also complains of having a blocked nose for years.
Which of the medication is it most important to avoid?
Aspirin
Samter's triad = asthma + aspirin sensitivity + nasal polyposis
78
A 27-year-old woman complains of recurrent ear discharge. Otoscopy is as follows:
Cholesteatoma
'**attic crust**' - seen in the uppermost part of the ear drum
79
A 14-year-old boy present to the emergency department with a severe nose bleed which started 2 hours ago. He has had recurrent nose bleeds since the age of 9. Generally, he can stop the bleed by leaning forward with his mouth open and applying continuous pressure on his nose. However, this has not helped his current bleed.
On examination, it was hard to visualise a point of bleeding.
What is the next most appropriate step in managing this patient?
Anterior packing
Anterior packing is the most suitable management option for epistaxis where the bleed site is difficult to localise
Cautery can only be used if the point of bleeding can be visualised. In this case, since the bleeding point cannot be visualised, this is inappropriate.
80
A 16-year-old boy attends with his mother for an emergency appointment in your duty clinic. The day previously during a rugby match he sustained an injury to his right ear. At the time he did not find it too bothersome and he finished the match. On awaking that morning however he found his right ear was swollen. He denies any otorrhoea or hearing loss. He is systemically well.
On examination he has a sizeable pinna haematoma. Otoscopy is normal with no damage seen to the tympanic membrane. Simple hearing tests are normal.
What is the most appropriate management?
Auricular haematomas need same day assessment by ENT
81
A 24-year-old-man books into your emergency duty clinic. He was seen by one of your colleagues four days previously and diagnosed with right sided otitis externa and started on antibiotic ear drops. He reports that despite these the pain is getting worse. For the last 24 hours he has been unable to apply the drops due to swelling of the canal.
On examination the right external auditory canal is swollen completely shut and you are unable to see any further. Examination is otherwise unremarkable. Observations are within the normal range.
What is the most appropriate management?
Poor response to topical antibiotics should be referred to ENT
82
A 43-year-old lady has undergone a total thyroidectomy for multinodular goitre. You are called to see her because of respiratory distress. On examination she has a marked stridor, her wound seems healthy but there is a swelling within the operative site. What is the most likely explanation for this problem?
In this setting a contained haematoma is the most likely cause. This will impair venous return resulting in laryngeal oedema and respiratory compromise.
83
A 62-year-old male attends your GP surgery complaining of severe dizziness that started earlier this morning. He denies any recent illness. However, since waking this morning, he is finding it difficult to walk in a straight line, which he attributes to the dizziness. He has vomited once. You perform a head impulse test, which is negative. His examination is otherwise normal.
**Cerebellar stroke**
In this scenario, the patient has several symptoms that are concerning for stroke: **ongoing dizziness, headache, and difficulty walking.**
A head impulse test is performed on symptomatic patients to differentiate between peripheral and central causes of vertigo. It is positive in peripheral causes. Other findings that may indicate central causes is bidirectional nystagmus.
84
A 25-year-old woman presents with recurrent attacks of 'dizziness'. These attacks typically last around 30-60 minutes and occur every few days or so. During an attack 'the room seems to be spinning' and the patient often feels sick. These episodes are often accompanied by a 'roaring' sensation in the left ear. Otoscopy is normal but Weber's test localises to the right ear. What is the most likely diagnosis?
In sensorineural hearing loss Weber's test localises to the contralateral ear.
85
A 62-year-old man with a 3 month history of dizziness when he rolls over in bed. Episodes last for about 20 seconds
Benign paroxysmal positional vertigo
86
A 25 year-old man presents with a history of sudden hearing loss on the right side. He had no preceding coryzal illness, fevers, headache or ear pain. On examination his ear canal and tympanic membrane appear normal. Weber testing localises to the left side. What is the appropriate management?
This man has sudden sensorineural hearing loss, which in the vast majority of cases is idiopathic.
There is some evidence that high dose steroids (60mg/day) for seven days improves prognosis
87
A 45-year-old male presents to his GP with a 12-day history of frontal facial pain that is exacerbated by leaning forward. His baseline observations (heart rate, respiratory rate and temperature) are all normal. The patient has no relevant past medical history.
Given the duration of the patient's symptoms, and the absence of any relevant medical history, which of the following drugs may the GP begin today?
What is the likely diagnosis?
**Intranasal steroids** should only be considered for **sinusitis** if symptoms have persisted for 10 days or more
88
A 66-year-old woman comes to the GP surgery complaining of a droop in the left side of her face for the past 3 days. This is associated with dizziness and deafness. She has also noticed that her eyes and mouth are very dry.
On examination, you note a left sided facial droop and red spots in her left ear. Which one of the following is the most likely diagnosis?
Ramsay-Hunt syndrome is shingles affecting the facial nerve. This results in ear pain, vesicles in the external ear canal associated with vertigo and deafness.
89
A 62-year-old man presents 2 days after receiving a punch to his head on the right side. Since the injury, he feels his hearing has been muffled on the right side. On examination there is no bruising. Both his ears are obscured by a thin translucent layer of wax. On the right, Rinne's test demonstrates the tuning fork is easier to hear when pressed on the mastoid bone.
On Weber's test the sound is heard best on the right hand side. What is the most likely diagnosis?
Tympanic membrane perforation is a relatively common complication of trauma to the skull. It is important to distinguish this from sensorineural hearing loss resulting from a base of skull fracture.
90
What is an acoustic neuroma?
Vestibular schwannoma (acoustic neuroma)
The classical history of vestibular schwannoma includes a combination of **vertigo, hearing loss, tinnitus and an absent corneal reflex**. Features can be predicted by the affected cranial nerves:
* **cranial nerve VIII**: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
* **cranial nerve V:** absent corneal reflex
* **cranial nerve VII**: facial palsy
91
What is menniere's disease?
Meniere's disease is a condition of the inner ear which is characterised by attacks of hearing loss, dizziness, and fullness in the ears.
It tends to come in attacks.
92
A 34-year-old woman presents to the emergency department with two days of sudden onset, severe vertigo. She has a productive cough, sore throat, bilateral rhinorrhoea, as well as nausea, vomiting and loss of appetite. Although her hearing is unaffected, she feels generally weak and has passed minimal urine in the past 12 hours.
She has a history of migraines and recurrent urinary tract infections. Three weeks ago, she returned from a holiday in Jamaica.
On examination, she appears generally unwell, has weak peripheral pulses, bilateral cervical lymphadenopathy, and nystagmus.
Basic observations are temperature 38ºC, heart rate 119 beats per minute and respiratory rate 23 breaths per minute.
What is the most likely diagnosis?
Unaffected hearing distinguishes vestibular neuronitis from labyrinthitis
Vestibular neuronitis is the correct option
93
A 32-year-old female is referred urgently to the ear, nose and throat (ENT) specialists with a 1-month-history of severe, unrelenting otalgia, associated with temporal headaches and purulent otorrhoea. She has a past medical history of type one diabetes mellitus and has no allergies. Examination identifies an erythematous external auditory canal and periauricular soft tissue on the left side which is exquisitely tender.
What is the most appropriate antibiotic management for this patient?
Otitis externa in diabetics: treat with ciprofloxacin to cover Pseudomonas
94
A 25-year-old woman with recurrent otitis media presents with chronic left-sided hearing loss. On otoscopy, the doctor sees fluid behind the tympanic membrane. He suspects a left-sided conductive hearing loss. He decides to perform Rinne and Weber tests to investigate further.
Which of the following findings on the Rinne and Weber tests will confirm the doctor's suspicion?
Rinne test shows bone conduction is greater than air conduction in the left ear and air conduction is greater than bone conduction in the right ear. Weber test lateralises to the left
95
A 45-year-old woman with a history of Meniere's disease reports a history of reduced hearing in her right ear. The treating doctor suspects she has **unilateral right-sided sensorineural hearing loss**. He decides to perform a Rinne and Weber test to confirm this.
Which of the following results would confirm the doctor's diagnosis?
Rinne test shows air conduction is greater than bone conduction bilaterally.
Weber test lateralises to left ear
96
A 3-year-old boy is brought to surgery. His mum reports that he has been complaining of a sore left ear for the past 2-3 weeks. This morning she noticed some 'green gunge' on his pillow. On examination his temperature is 37.8ºC. Otoscopy of the right ear is normal. On the left side the tympanic membrane cannot be visualised as the ear canal is full with a yellow-green discharge. What is the most appropriate action?
Amoxicillin + review in 2 weeks
This boy is likely to have had an acute otitis media with perforation.
97
A 56-year-old man presents with episodic facial pain and discomfort whilst eating. He has suffered from halitosis recently and he frequently complains of a dry mouth. He has a smooth swelling underneath his right mandible. What is the most likely underlying diagnosis?
The symptoms are typical for **sialolithiasis**.
The stones most commonly form in the **submandibular gland** and therefore may occlude **Whartons** duct.
*Stensens duct drains the parotid gland.*
98
A 42-year-old man with a 3 month history of chronic cough presents with a persistent headache
This patient has chronic sinusitis. The cough is secondary to a post-nasal drip
99
A 25 year-old lady with no significant past medical history presents with 2 days of right ear discomfort, discharge and reduced hearing. She is systemically well and has not had a recent cold. On examination the auditory canal appears inflamed and there is a small amount of debris, but you can still see the tympanic membrane. What is the best management?
This lady likely has acute otitis externa.
Start a combination topical antibiotic and steroid
100
A **1-year-old boy** is brought to the GP as his mother has noticed an **unusual lump on his neck.** She is not sure how long it has been there for. It is located in the anterior triangle just in front of the sternocleidomastoid muscle and is soft in texture. The lump **does not transilluminate** but is **mobile**.
A biopsy is performed and reveals cholesterol crystals in the fluid extracted.
What is the most likely underlying diagnosis?
Branchial cysts characteristically contain cholesterol crystals
101
A newborn baby is noted to have a large swelling on the left-side of the neck. On examination a soft, fluctuant and highly transilluminable lump is noted just beneath the skin.
**Cystic hygroma**
* A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
* Most are evident at birth, around 90% present before 2 years of age
102
A 30-year-old man presents to his GP with bilateral hearing loss that has developed over the last three hours associated with episodes of vertigo and vomiting. He also reports having an upper respiratory tract infection about a week ago.
On examination, he has visible horizontal nystagmus and veers to the right when asked to walk.
What is the most likely diagnosis?
Viral labyrinthitis typically presents with **sudden vertigo** and h**earing can be affected**.
A viral infection often precedes its presentation
103
A 50-year-old lady presents with symptoms of a dry mouth that has been present for the past few months. She also has a sensation of grittiness in her eyes. On examination she has a diffuse swelling of her parotid gland. There is no evidence of facial nerve palsy.
Sjogren's syndrome
104
A 27-year-old female presents to her GP with dizziness, nausea, and unilateral hearing loss which has been consistent for the past 2 days. Upon questioning, she denies having ever experienced symptoms like this before. She reports no tinnitus, otalgia or otorrhoea.
Upon examination, she is afebrile and does not appear to be in pain. Examination of her ears shows no abnormalities.
What is the most likely diagnosis?
Unaffected hearing distinguishes vestibular neuronitis from labyrinthitis
This patient has presented with symptoms of n**ausea, dizziness, and hearing loss**. The likely diagnosis is **labyrinthitis** due to hearing loss.
Labyrinthitis is inflammation of the labyrinth of the inner ear and presents with these symptoms and a sensorineural hearing loss.
105
A 54-year-old woman attends the GP with a one-day history of hearing loss in her right ear. There is no discharge or pain. She has no history of dizziness or tinnitus.
Assessment by otoscopy shows wax in the right ear with no other obvious changes to the external auditory meatus or tympanic membranes bilaterally. Weber test lateralises to the left side. Rinne test shows air conduction louder than bone conduction bilaterally.
What is the most appropriate next step?
Acute sensorineural hearing loss is an emergency and requires urgent referral to ENT for audiology assessment and brain MRI
106
A 64-year-old woman presents to her general practitioner with dizziness. When she rolls over in bed in the morning, she experiences sudden onset dizziness associated with nausea, which spontaneously resolves after around 20 seconds if she keeps her head still. After these episodes, the patient feels light-headed and unbalanced for several hours. She has suffered recurrent otitis media in the past and her family history is significant for otosclerosis.
What is the most important immediate investigation?
What is the likely diagnosis?
BPPV
Dix-Hallpike manoeuvre is diagnostic
Epley manoeuvre is for treatment
107
A 5-year-old boy is brought to the office due to ear pain. Two days ago he developed low-grade fever and pain in the left ear, which his parents note he tugs. For the past week, he has also had a runny nose and cough, which developed after a flight from a family vacation. This morning, yellow stain was noted on his pillow. He has no history of ear infection and is up to date with vaccinations. He is allergic to penicillin, and has no other medical history. Temperature is 37.9 degrees Celsius. Nasal mucosa appears boggy, and postnasal drip is present.
What is the best course of treatment?
Erythromycin
108
You diagnose an older man with a left-sided sudden-onset sensorineural hearing loss that started 12 hours ago during your joint clinic with a medical student and refer directly to ENT who diagnose an idiopathic sudden-onset sensorineural hearing loss and begin treatment. Your medical student asks what will happen next for the patient.
What is the most appropriate drug treatment?
Following referral to ENT, patients with sudden-onset sensorineural hearing loss are treated with high-dose oral corticosteroids
109
A 5-year-old boy presents with a 5 day history of right sided otalgia and reduced hearing after returning from holiday in Tenerife. On examination, he has a temperature of 37.3ºC and the tympanic membrane is not visible due to debris in the canal. What treatment should be initiated?
This child has classic symptoms of otitis externa likely caused after swimming on holiday. Topical combination steroid and antibiotic drops should be initiated
110
Which drugs cause Gingival hyperplasia?
Gingival hyperplasia: phenytoin, ciclosporin, calcium channel blockers and AML
111
A 23-year-old male swimmer presents to his GP with left ear pain, discharge, and mild hearing loss for the past two days. Otoscopy reveals swollen external auditory meatus and normal appearance of the tympanic membrane.
What is the first line treatment for his condition?
Topical antibiotics with or without steroid are first line treatment in otitis externa
112
A patient presents due to a 'brown coating' on his tongue. He is 34-years-old and has no significant medical history. The coating has been present for the past few weeks. He is asymptomatic other than a slight 'tickling' sensation on his tongue.
Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae. Despite the name the tongue may be brown, green, pink or another colour.
113
What is Samter's triad?
Samter's triad = asthma + aspirin sensitivity + nasal polyposis
In patients with asthma, aspirin and other NSAIDs should be avoided as these may precipitate an asthma exacerbation. The combination of asthma, aspirin sensitivity and nasal polyps is known as Samter's triad.
114
A 46-year-old female presents to the emergency department after a syncopal episode. She has recently had thyroid surgery for a follicular carcinoma of her thyroid. On examination, she is noted to have paresthesia periorally. In her ECG, the waveform timings recorded are as follows:
* 'Ventricular rate: 70 bpm
* PR interval: 161 ms
* QRS duration: 94 ms
* Corrected QT interval: 530 ms'
What electrolyte disturbance is the most likely cause for the abnormality in ECG timing?
Complications of thyroid surgery - damage to parathyroid glands can result in hypocalcaemia
115
What is Otosclerosis (3)
Otosclerosis describes the replacement of normal bone by vascular spongy bone.
It causes a progressive conductive deafness due to fixation of the stapes at the oval window.
Otosclerosis is autosomal dominant and typically affects young adults
116
A 32-year-old lady is referred to the clinic with recurrent infections and abscesses in the neck. On examination she has a midline defect with an overlying scab, which moves upwards on tongue protrusion.
The correct answer is: Thyroglossal cyst
Thyroglossal cyst is always located in the midline as it is this route that the thyroid takes during its embryological descent. Its connection with the foramen caecum means it will move on tongue protrusion.
117
When is Otitis media treated?
Otitis media is a common presentation you will see in general practice. It is more common in children and often only requires analgesia. The most common bacterial causes of otitis media are Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis.
**Antibiotics should be prescribed immediately if:**
* Symptoms lasting more than 4 days or not improving
* Systemically unwell but not requiring admission
* Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
* Younger than 2 years with bilateral otitis media
* Otitis media with perforation and/or discharge in the canal
118
What is Prochlorperazine?
prochlorperazine or antihistamines may help reduce the sensation of dizziness in vestibular neuritis and labrinthitis
119
What is Ludwig's angina?
Immunocompromised patients with poor dentition can develop airway compromise from cellulitis at the floor of the mouth known as Ludwig's angina.
120
CENTOR criteria (4)
The criteria are:
* Tonsillar exudate
* Tender anterior lymphadenopathy or lymphadenitis
* History of fever
* Absence of cough
121
During a routine cranial nerve examination the following findings are observed:
Rinne's test: Air conduction \> bone conduction in both ears
Weber's test: Localises to the right side
What do these tests imply?
In Weber's test if there is a sensorineural problem the sound is localised to the unaffected side (right) indicating a problem on the left side
122
A **74-year-old man** presents with an **8-week history of right sided otalgia**. This is associated with a **sore throat and odynophagia**. He smokes 20 cigarettes every day and is known to be a heavy drinker. On examination of the ear, there are no abnormalities noted.
What is the most likely cause of the otalgia?
Referred pain from nasopharyngeal carcinoma
123
A 80-year-old lady presents with a 5 day history painful left sided neck swelling below the angle of the jaw. She also complains of a foul taste in her mouth. On examination, she has a temperature of 37.8ºC and a 4x5cm submandibular mass which is tender to palpation. There is associated tender lymphadenopathy. What is the most likely diagnosis?
This lady has **sialadenitis** - inflammation of the salivary gland likely **secondary to obstruction by a stone** impacted in the duct. The duct from the submandibular gland drain into the floor of the mouth and purulent discharge from this duct causes a foul taste in the mouth.
124
A 62-year-old woman presents with a four-month history of painless, malodorous discharge from the left ear. There are no other symptoms of note. She saw one of your colleagues one month previously who prescribed a course of gentamicin/hydrocortisone ear drops, unfortunately these did not improve her symptoms.
Examination of the ears shows some wax in the attic of the left ear but is otherwise unremarkable. Cranial nerve examination is normal.
What is the diagnosis?
125
A 19-year-old man presents with a swelling on the left side of his neck. On examination he has a smooth swelling in between the sternocleidomastoid muscle and the pharynx. It is fluctuant but doesn't transilluminate or move during swallowing.
Branchial cysts often present during intercurrent upper respiratory tract infection
126
A 7-year-old girl is brought to surgery due to a sore throat. She has a temperature of 39.2ºC and is not eating due to the pain, although she is tolerating fluids. She has had no other related symptoms such as a cough or a rash. Her heart rate is 120/min and auscultation of the chest is unremarkable. The tonsils are covered in exudate bilaterally. Examination of the ears is unremarkable. Other than supportive treatment, what is the most appropriate management?
This girl has marked systemic upset and should be treated with antibiotics. A 7 or 10 day course of antibiotics is appropriate to ensure eradication of possible Streptococcus infection.
Phenoxymethylpenicillin is the first-line antibiotic choice in the BNF
127
You are seeing a 38-year-old female patient in your morning clinic who complains of persistent vertigo associated with some nausea, but no vomiting.
This started 16 days ago following a 'nasty cold' and seems fairly constant. She has not noticed any other symptoms. She had spoken to a pharmacist who gave her 3 days of prochlorperazine. Unfortunately, her symptoms have not improved.
What would be the most appropriate next step?
Vestibular rehabilitation exercises are the preferred treatment for **vestibular neuronitis**
128
What does the audiogram show?
Right sensorineural hearing loss
129
What is vestibular neuronitis?
**Vestibular neuronitis is an inflammation of the eighth cranial nerve** and presents similarly to labyrinthitis, however, it can be distinguished from the condition by the fact that **vestibular neuronitis does not cause hearing loss.**
130
A 40-year-old female presents with a painless neck lump. There is a mass noted beneath the sternocleidomastoid muscle. There is a long history and somewhat unkindly her husband remarked on her rather noticeable halitosis.
Pharyngeal pouch
Usual history of regurgitation of undigested food or coughing at night. Associated with halitosis and throat infections.
131
A 38-year-old lady presents with a mass in the midline of the neck immediately below the hyoid bone. It moves upwards on tongue protrusion.
Thyroglossal cyst
Thyroglossal cysts are usually located in the midline and are linked to the foramen caecum and will thus move upwards on tongue protrusion.
132
What kind of hearing loss does presbycusis present with?
Presbycusis presents with **bilateral high-frequency hearing loss**
133
What is Sarcoidosis? (4)
**Sarcoidosis is a multisystem disorder of unknown aetiology** characterised by **non-caseating granulomas**. It is more common in young adults and in people of **African descent**
**Features**
* acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia
* insidious: dyspnoea, non-productive cough, malaise, weight loss
* skin: lupus pernio
* hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)
134
Jane is an 85-year-old woman who presents to her GP with ringing in her ears. This has been going on for some months now and is affecting her sleep. There is no associated headache and no focal neurology. On examination, both tympanic membranes appear normal.
Which medications could be contributing to her symptoms?
**Aspirin** and other **NSAIDs** taken in high doses can cause tinnitus
135
A 23-year-old man is diagnosed as having nasal polyps. Sensitivity to which medication is associated with this condition?
aspirin sensitivity
136
Key features of Meniere's disease (4)
**More common in middle-aged adults**
* recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom
* a sensation of aural fullness or pressure is now recognised as being common
* other features include nystagmus and a positive Romberg test
* episodes last minutes to hours
137
A 17-year-old male presents to the Ear Nose and Throat clinic to discuss the results from the fine needle aspirate taken from a smooth, fluctuant, non-tender, non-translucent mass located anterior to his left sternocleidomastoid muscle. It does not move on tongue protrusion. The aspirate reveals an acellular fluid with cholesterol crystals.
Based on the clinical and pathological information, what is the mass most likely to be?
Branchial cyst
138
A 36-year-old man presents with recurrent episodes of right-sided tinnitus, hearing loss and vertigo.
These episodes typically last between 10-30 minutes.
He also describes a 'full' sensation in his right ear. Otoscopy is unremarkable and the cranial nerve examination is normal.
Meniere's disease
139
A 31-year-old man presents with bilateral hearing loss and tinnitus. There is a family history of similar problems. Examination of the tympanic membranes is unremarkable. Audiometry shows bilateral conductive hearing loss.
**Otosclerosis**
Otosclerosis describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window. **Otosclerosis** is **autosomal dominant** and typically affects young adults
**Onset is usually at 20-40 years - features include:**
* conductive deafness
* tinnitus
* normal tympanic membrane\*
* positive family history
**Management**
* hearing aid
* stapedectomy
140
A 60 year-old man presents with a two month history of nasal blockage on the right side, which is now beginning to disrupt his sleep. He has not noticed any bleeding but has had postnasal drip. On examination you see a polyp on the right side and an inflamed mucosa bilaterally. What is the most appropriate management?
Refer to ENT76%
Unilateral polyps are a red flag symptom
Polyps due to rhinosinusitis are usually bilateral so it is important to refer this gentleman to be seen by an ENT doctor to exclude malignancy.
141
What is Presbycusis?
Presbycusis is a type of sensorineural hearing loss that affects elderly individuals.
Typically, high-frequency hearing is affected bilaterally, which can lead to conversational difficulties, particularly in noisy environments.
Presbycusis progresses slowly, as sensory hair cells and neurons in the cochlea atrophy over time.
Although certain factors are associated with presbycusis, it is distinct from noise-related hearing loss.
**Causes**
* Arteriosclerosis: May cause diminished perfusion and oxygenation of the cochlea, resulting in damage to inner ear structures
* Diabetes: Acceleration of arteriosclerosis
142
A 42-year-old man presents to his general practitioner 6 weeks after developing a cold. Whilst all of his other symptoms have now resolved, the patient is experiencing persistent blockage of his left nostril associated with rhinorrhoea and sneezing. He is otherwise well.
On examination, a large polyp is seen in the left nostril. Examination of the right nostril is unremarkable.
What is the most appropriate next step in management?
Unilateral polyps are a red flag symptom
143
A 77-year-old man presents to his GP with a painful rash around his ear. He first noticed pain in his left ear 3 days ago and is now also complaining of vertigo and tinnitus. On examination, you note a vesicular rash around his left ear.
Given the most likely diagnosis, what is the most appropriate treatment for this patient?
Treatment of Ramsay Hunt syndrome consists of oral aciclovir and corticosteroids
144
Rinne's Test - LeftAir \> Bone
Rinne's Test - RightAir \> Bone
Weber's TestLocalises to left
Following your referral, how should this patient be managed?
Following referral to ENT, patients with sudden-onset sensorineural hearing loss are treated with high-dose oral corticosteroids
145
A 57-year-old gentleman presents to the general practitioner. His wife has noticed that **his voice has become increasingly hoarse over the last 4 weeks**. He has not had a sore throat or any coryzal or chest symptoms which he thinks could account for this, however, he has noticed some discomfort in his neck on swallowing. He has an 80-pack-year history of smoking and admits to drinking roughly 20 units of alcohol per week for most of his life.
Persistent unexplained hoarseness in a patient aged \>45 years old: consider urgent referral to ENT
Hence he meets the criteria for referring patients down the suspected cancer pathway to investigate for laryngeal cancer.
146
A 50-year-old woman presents with a 2-week history of vertigo. The doctor suspects benign paroxysmal positional vertigo (BPPV) and decides to perform a Dix-Hallpike manoeuvre to confirm his diagnosis.
Which of the following findings on the performance of the manoeuvre would suggest his diagnosis is correct?
Rotatory nystagmus is indicative of a positive Dix-Hallpike manoeuvre
147
A 3-year-old child presents with his mother with a 3-day **history of fever, irritability and rubbing his left ear a lot**. This stopped dramatically this morning and was followed by **oozing discharge** from his left ear. On examination, his right ear looks normal, however, the **tympanic membrane of his left ear is perforated**.
What is the correct management of this child?
Oral antibiotics should be given in acute otitis media with perforation
148
Which medication is most useful for helping to prevent attacks of Meniere's disease?
betahistine
149
What is the most likely diagnosis?
Cholesteatoma is a non-cancerous growth of squamous epithelium that is 'trapped' within the skull base causing local destruction. It is most common in patients aged 10-20 years. Being born with a cleft palate increases the risk of cholesteatoma around 100 fold.
150
A 55-year-old man from Hong Kong presents with left sided otalgia and recurrent episodes of epistaxis. On examination his pharynx appears normal. Examination of his neck reveals left sided cervical lymphadenopathy. What is the most likely underlying diagnosis?
Given this man's ethnic origin and presenting features a nasopharyngeal carcinoma is the most likely underlying diagnosis.
* Squamous cell carcinoma of the nasopharynx
* Rare in most parts of the world, apart from individuals from Southern China
* Associated with Epstein Barr virus infection
151
A 49-year-old Caucasian male presents with a 12 week history of pus-like discharge from his ear. You decide to perform otoscopy. What is the most important part of the tympanic membrane to visualise?
In patients with chronic or recurrent ear discharge, ensure the attic is visualised to exclude cholesteatoma
152
A 26-year-old man books an urgent appointment in your duty clinic. He reports a two-week history of **left sided facial pain and malaise**. He tells you that his symptoms initially were improving after seven days however they then worsened again and he is now feeling worse than he did initially. He is normally fit and well.
On examination he has a **low grade pyrexia of 37.9** degrees but other observations are within normal limits. **Anterior rhinoscopy** shows a **purulent discharge** coming from the left middle meatus. There is no abnormalities of the eyes or periorbital tissues.
What is the most likely diagnosis?
'Double-sickening' suggests bacterial sinusitis - an initial period of recovery followed by a sudden worsening of symptoms.
153
A 50-year-old female presents with bilateral parotid gland swelling and symptoms of a dry mouth. On examination she has bilateral facial nerve palsies. This improved following steroid treatment.
Sarcoidosis
154
What is the Dix Hallpike manouvre
The Dix-Hallpike test is a diagnostic manoeuvre used to identify benign paroxysmal positional vertigo (BPPV).
155
How would you perform a Dix-Hallpike test?
1. Ask the patient to sit upright on the examination couch.
2. Adjust the patient’s position so that when supine, their head will hang over the edge of the bed, allowing for head extension below the horizontal plane.
3. Position yourself standing behind the patient.
4. Turn the patient’s head 45º to one side.
5. Whilst supporting the neck, move the patient from their sitting position to a supine position in one brisk smooth motion, ensuring their head hangs over the bed 30º below the horizontal plane. Ask the patient to keep their eyes open throughout this process.
6. Inspect the patient’s eyes carefully for evidence of nystagmus for at least 30 seconds.
7. If no nystagmus is observed, the test is then complete for that side and you should carefully help the patient sit back up.
8. After a short break, the test should be repeated on the other side, turning the patient’s head in the opposite direction during step 4.
156
What is Ecchymosis?
Ecchymosis is the medical term for the common bruise
157
A **43-year-old woman** who has been experiencing continuous **bilateral 'runny nose'** with a sensation of facial pressure for **4 months continuously** comes to see you for help.
She has already tried a 14 day course of high-dose nasal corticosteroids and found it didn't help very much.
What is an appropriate treatment option for her condition?
Nasal irrigation with saline solution is a treatment option for chronic rhinosinusitis
158
A 46-year-old lady presents with a 2 week history of a worsening sore throat, and is complaining of painful swallowing. On examination you notice that her uvula is deviated to the left. What is the most likely diagnosis?
Peritonsillar abscess
In tonsillitis, uvular deviation may indicate development of a peritonsillar abscess (quinsy)
159
A 10-year-old boy presents to the general practitioner (GP) with a **sore throa**t. On examination, he has **tonsillitis** with **exudate** and **cervical lymphadenopathy**. The patient's **temperature is 38.1°C**, respiratory rate is 24 breaths/min, and his heart rate is 104 beats/min. Auscultation of the chest is clear. The patient denies having a cough and there is no history of allergies.
How should this patient be managed?
What is the most likely Diagnosis?
The child has tonsillar exudate, cervical lymphadenopathy, a raised temperature, and no cough and therefore has a **Centor score of 4**; increasing the likelihood of group A beta-haemolytic streptococcus (GABHS) infection.
Furthermore, this infection is more likely in the 5-15-year-old age group. Antibiotic treatment should be considered in this patient (source: SIGN and NICE)
160
An 8-year-old child presents with enlarged tonsils that meet in the midline and are covered with a white film that bleeds when you attempt to remove it. He is pyrexial but otherwise well
Acute bacterial tonsillitis
In acute tonsillitis the tonsils will often meet in the midline and may be covered with a membrane. Individuals who are systemically well are unlikely to have diptheria.
