ENT

Question 1

Persistent sore throat in a patient with smoking history

Answer 1

2ww ENT if >4weeks

Question 2

mouth ulcer >3 weeks

Answer 2

2ww

Question 3

conductive hearing loss, tinnitus and positive family history

Answer 3

otosclerosis

Question 4

macupapular rash starting on trunk post antibiotics

Answer 4

amoxicillin

Question 5

Gingival hyperplasia

Answer 5

phenytoin, ciclosporin, calcium channel blockers and AML

Question 6

Examination of the nostrils reveals a bilateral red swelling arising from the midline, which is slightly boggy.

Answer 6

urgent ENT review for ?nasal septal haematoma

If untreated irreversible septal necrosis may develop within 3-4 days. This is thought to be due to pressure-related ischaemia of the cartilage resulting in necrosis. This may result in a ‘saddle-nose’ deformity

Question 7

management septal haematoma

Answer 7

surgical drainage
IV Abx

Question 8

bilateral acoustic neuroma/ vestibular schwannoma -associated with

Answer 8

Neurofibormatosis type 2

Question 9

bilateral acoustic neuroma cranial nerve impact

Answer 9

cranial nerve VIII: hearing loss, vertigo, tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy

Question 10

when to refer for tonsillectomy

Answer 10

7 episodes per year for one year, 5 per year for 2 years, or 3 per year for 3 years, and for whom there is no other explanation for the recurrent symptoms

Question 10

Sore throat FeverPAIN

Answer 10

Fever over 38°C.
Purulence (pharyngeal/tonsillar exudate).
Attend rapidly (3 days or less)
Severely Inflamed tonsils
No cough or coryza

5-10 day course of antibiotics is appropriate to ensure eradication of possible Streptococcus infection. Phenoxymethylpenicillin is the first-line antibiotic choice in the BNF

Question 11

complications of tonsillectomy

Answer 11

primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain

secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain

Question 11

sudden sensorineural hearing loss, idiopathic

Answer 11

steroids and refer ENT urgent

Question 12

Treatment of Ramsay Hunt syndrome

Answer 12

acyclovir and prednisolone

Question 13

Parathyroid surgery -> damage to parathyroid = which electrolyte abnormality?

Answer 13

Hypocalcaemia

isolated QT elongation

Question 14

thyroid surgery complications

Answer 14

recurrent laryngeal nerve damage
bleeding
damage to parathyroid glands (hypocalacemia)

Question 15

juvenile angiofibroma

Answer 15

benign tumour that is highly vascularised
seen in adolescent males

Question 16

how to stop nose bleeding if holding nose has failed

Answer 16

1- Cautery OR packing

Cautery= if bleeding point visible

ask pt to blow nose
use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect
identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation.

packing = If can’t visualise

Question 17

v bad nosebleed that has failed all other management (cautery/packing)

Answer 17

may require sphenopalatine ligation in theatre

Question 18

when to admit those with nose bleed

Answer 18

if haemodynamically unstable or from unknown/posterior source (i.e. bleeding from both nostrils)

Question 19

acute onset vertigo following a viral illness NO auditory Sx

Answer 19

vestibular neuronitis

Question 20

Neck lumps:
local infection or generalised viral illness

Answer 20

reactive lymphadenopathy

Question 21

Neck lumps:
rubbery, painless lymphadenopathy
night sweats and splenomegaly

Answer 21

thyroid swelling

Question 22

Neck lumps:
<20 years old
midline
between isthmus of thyroid and hyoid bone
moves upwards with tongue
may be painful if infected

Answer 22

throglossal cyst

Question 23

Neck lumps: older man gurgles on palpation dysphagia, regurigitaiton, aspiration, chronic cough

Answer 23

pharyngeal pouch

Question 24

Neck lump> congenital lymphatic lesion L side neck evident at birth

Answer 24

cystic hygroma

Question 25

neck lump: oval mobile cystic mass between sternocleidomastoid muscle and pharynx develop due to failure of obliteration of the second branchial cleft in embryonic development Usually present in early adulthood can present during intercurrent URTI

Answer 25

branchial cyst

Question 26

neck lump: Pulsatile lateral neck mass which doesn't move on swallowing

Answer 26

carried aneurysm

Question 27

neck lump: midline non tender swelling that moves upwards when swallows

Answer 27

goitre

Question 28

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.

Answer 28

cystic hygroma

Question 29

what is postnasal drip

Answer 29

excess mucus by nasal mucosa --> chronic cough + bad breath

Question 30

Ramsay Hunt: which cranial nerve?

Answer 30

CN 7 (facial)

Question 31

Ramsay Hunt: features?

Answer 31

auricular pain facial nerve palsy vesicular rash vertigo/ tinnitus Oral aciclovir + corticosteroids

Question 32

Mastoiditis: 1st line management?

Answer 32

IV Abx (then CT head)

Question 33

Mastoiditis: complications

Answer 33

facial nerve palsy hearing loss meningitis

Question 34

T wave inversion, QTc prolongation and visible U waves

Answer 34

hypokalaemia

Question 35

tall, peaked T waves, QTc shortening and ST-segment depression

Answer 35

hyperkaemia

Question 36

Recurrent otitis externa following numerous antibiotic treatment and curd-like discharge

Answer 36

Candida (fungal)

Question 37

Unexplained, unilateral ear ache for more than 4 weeks with unremarkable otoscopy how to manage?

Answer 37

2WW

Question 38

when to give in sinusitis? - intranasal steroids - Abx?

Answer 38

- when >10 days (give steroids for 14 days - Abx (phenoxymethylpenicillin) if systematically unwell or Sx of serious complications OR "double sickening" (getting worse later due to bacterial infection)

Question 39

Haemorrhage 5-10 days after tonsillectomy

Answer 39

wound infection --> ABX

Question 40

Ménière's disease PREVENTION

Answer 40

Betahistine AND vestibular rehabilitation

Question 41

when can you drive with Meniers disease?

Answer 41

need to inform DVLA and shouldn't drive until symptoms under control

Question 42

acute attacks meniers

Answer 42

prochlorperazine (used short term as delays recovery by interfering with central compensatory mechanisms)

Question 43

ototoxic drugs (4)

Answer 43

gentamicin, quinine, furosemide, aspirin and some chemotherapy agents.

Question 44

Otitis externa management

Answer 44

TOPICAL aminoglycaside (if bacterial) +/- corticosteroid if don't respond to topical --> REFER TO ENT second line: - consider contact dermatitis secondary to neomycin - oral antibiotics (flucloxacillin) if the infection is spreading - taking a swab inside the ear canal - empirical use of an antifungal agent

Question 45

diabetic + otitis externa?

Answer 45

Malignant otitis externa is more common in elderly diabetics. In this condition, there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal. Intravenous antibiotics may be required.

Question 46

vertigo, tinnitus (often described as a 'roaring' sensation), and sensorineural hearing loss.

Answer 46

Menieres (lasts 20mins-hours)

Question 47

Samters triad

Answer 47

aspirin sensitivity, asthma and nasal polyps Aspirin can exacerbate respiratory symptoms by inhibiting the cyclooxygenase pathway of arachidonic acid metabolism, leading to an overproduction of leukotrienes. This causes bronchoconstriction and inflammation in sensitive individuals.

Question 48

nasal polyps

Answer 48

asthma (particularly late-onset asthma) aspirin sensitivity infective sinusitis cystic fibrosis Kartagener's syndrome Churg-Strauss syndrome

Question 49

Glue ear RF

Answer 49

male sex siblings with glue ear higher incidence in Winter and Spring bottle feeding day care attendance parental smoking

Question 50

glue ear treatment

Answer 50

active observation: the management for a child with a first presentation of otitis media with effusion is active observation for 3 months - no intervention is required grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube. The majority stop functioning after about 10 months adenoidectomy children should be observed for 6-12 weeks as symptoms are normally self-limiting and referral should be reserved if symptoms persist beyond this period. but refer earlier if: Sx affecting hearing/ development/ education

Question 51

immediate referral for otitis media with effusion if:

Answer 51

Downs syndrome/ cleft palate

Question 52

Otitis externa in diabetics: what are you concerned about? (1) investigations? (1) treatment (1)

Answer 52

malignant otitis externa (necrotising otitis externa) CT scan Pseudomonas - CIPROFLOXACN

Question 53

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.

Answer 53

cystic hygroma

Question 54

Neck lump: difference between thyroglossal cyst and thyroid swelling? (movement) (2)

Answer 54

Thyroglossal cyst --> between isthmus of the thread and hyoid bone. moves upwards with protrusion of TONGUE Thyroid swelling --> moves upwards on swallowing.

Question 55

when to refer sinusitis to ENT

Answer 55

Unilateral symptoms (consider urgent referral as this increases suspicion of neoplasia). Persistent symptoms despite compliance with 3 months of treatment. Nasal polyps complicating assessment or treatment, particularly if present in children. Recurrent episodes of otitis media and pneumonia in a child. Unusual opportunistic infections. Symptoms that significantly interfere with functioning and quality of life. Allergic or immunologic risk factors that need investigating. RED FLAGS: unilateral symptoms persistent symptoms despite compliance with 3 months of treatment epistaxis

Question 56

sinusitis management

Answer 56

avoid allergen intranasal corticosteroids nasal irrigation with saline solution

Question 57

haloperidol vs risperidone

Answer 57

HALI = 1st gen (TYPICAL) Risperidone = 2nd gen (ATYPICAL)

Question 58

parotid tumor - most common

Answer 58

pleomorphic= most common middle age slow growing, painless lump superficial parotidectomy; risk = CN VII damage

Question 59

warthins vs pleomorphic tumor

Answer 59

warthins softer, more mobile and fluctuant (although difficult to differentiate)

Question 60

sailvrAY GLAND stones - which gland is most common

Answer 60

recurrent unilateral pain & swelling on eating may become infected → Ludwig's angina 80% are submandibular plain x-rays; sialography surgical removal

Question 61

causes of salivary gland enlargement

Answer 61

cancer stones acute viral infection e.g. mumps acute bacterial infection e.g. 2nd to dehydration diabetes sicca syndrome and Sjogren's (e.g. RA)

Question 62

refer to 2nday Care for otitis media

Answer 62

meningitis, mastoiditis, or facial nerve paralysis

Question 63

when to give Abx for otitis media

Answer 63

>4 days unwell immunocompromised / high risk e.g. heart/lung disease <2 years old with bilateral otitis media perforted and/or discharge ---> 5-7 day course

Question 64

NICE indications for antibiotics sore throat

Answer 64

features of marked systemic upset secondary to the acute sore throat unilateral peritonsillitis a history of rheumatic fever an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency) patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present

Question 64

centor

Answer 64

presence of tonsillar exudate tender anterior cervical lymphadenopathy or lymphadenitis history of fever absence of cough (feverPAIN : Fever over 38°C. Purulence (pharyngeal/tonsillar exudate). Attend rapidly (3 days or less) Severely Inflamed tonsils No cough or coryza)

Question 65

Unexplained, unilateral ear ache for more than 4 weeks with unremarkable otoscopy

Answer 65

2WW ENT

Question 66

oral cancer 2ww

Answer 66

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either: unexplained ulceration in the oral cavity lasting for more than 3 weeks or a persistent and unexplained lump in the neck. Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either: a lump on the lip or in the oral cavity or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Question 67

glue ear management

Answer 67

--> hearing test This child has otitis media with effusion (glue ear). Following the revised NICE guidelines in 2011, children should be observed for 6-12 weeks as symptoms are normally self-limiting and referral should be reserved if symptoms persist beyond this period. However, referral should be earlier if: Symptoms are significantly affecting hearing, development or education Immediate referral in children with Downs syndrome or cleft palate

Question 68

presbycusis: Patients typically present with a chronic, slowly progressing history of:

Answer 68

Speech becoming difficult to understand Need for increased volume on the television or radio Difficulty using the telephone Loss of directionality of sound Worsening of symptoms in noisy environments Hyperacusis: Heightened sensitivity to certain frequencies of sound (Less common) Tinnitus (Uncommon)

Question 69

irregularly shaped red, smooth and sometimes slightly raised patches on the tongue surface. The lesions often have a white or light-coloured border.. erythematous areas with a white-grey border (the irregular, smooth red areas are said to look like the outline of a map) some patients report burning after eating certain food

Answer 69

Geographic tongue. This condition, also known as benign migratory glossitis,

Question 70

This chronic inflammatory condition affects the mucous membranes inside your mouth. May appear as white, lacy patches; red, swollen tissues; or open sores. These lesions may cause burning, pain or other discomfort.

Answer 70

oral lichen planus

Question 71

thickened white patches that form on the gums, inside of the cheeks and/or under the tongue. These patches cannot be scraped off easily and this condition does not match with our patient's presentation either.

Answer 71

oral leukoplakia

Question 72

acute sinusitis= when to give steroids

Answer 72

if >10 days