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Flashcards in ENT II Deck (36):
1

A 15-year-old girl is admitted to hospital with tonsillitis. She also complains of right sided otalgia but examination of her ears is normal.
Which is the nerve causing her otalgia?
(Please select 1 option)
The glossopharyngeal nerve
The second cervical nerve
The third cervical nerve
The trigeminal nerve
The vagus nerve

Secondary or referred otalgia is common in tonsillitis and results from neuralgia of the glossopharyngeal nerve.

Almost any oropharyngeal infection can lead to otalgia by this mechanism including quinsy and pharyngitis.

Tumours of the tongue base can also cause otalgia because of glossopharyngeal neuralgia.

2

Corticol osteoma

The diagnosis is a cortical (ivory) osteoma.

This is a benign bone growth frequently seen in the frontal sinus which only caused problems secondary to obstruction of the sinus.

It is frequently an incidental finding.

3

A mother is concerned as her 2-year-old daughter is not speaking yet. The daughter has a history of otitis media and she has had three grommet insertions.
Her daughter is not responding to her name or any sounds and has a high pitched scream. ENT examination is normal.
What is your next step and the reasoning behind it?
(Please select 1 option)
Ask the mother to observe the child for another month and see if she starts to speak in that time - there is no urgency to address the problem
Prescribe some analgesia for the mother’s headache and reassure her as she is upset and overly anxious
Refer to an audiologist as soon as possible as the child requires urgent assessment of her hearing
Refer to a developmental paediatrician as the child has a developmental delay
Refer to the child’s regular ENT service for further middle ear assessment

Refer to an audiologist as soon as possible as the child requires urgent assessment of her hearing

Delayed language development in a child should be an immediate alert to formally assess hearing.

All aspects of the audiological pathway must be tested - outer, middle and inner ear and a formal audiogram should be obtained.

This should be treated as a 'hearing emergency' as the plasticity of language development pathways declines significantly from around six months of age until around seven years.

The later the detection and initiation of an appropriate management programme, the poorer the outcomes of the intervention.

4

A cochlear implant is a device designed to create an alternative hearing pathway for people of all ages with bilateral, severe to profound sensorineural hearing loss.
Which of the following normal structures of the ear are directly electrically stimulated by the electrodes in a cochlear implant?
(Please select 1 option)
Auditory nerve ganglion cells
Intracochlear hair cells
Ossicles
Oval window
Round window

Auditory nerve ganglion cells

A cochlear implant bypasses the mechanical structures of the normal hearing pathway and provides a direct electrical stimulus to the spiral ganglion cells of the auditory nerve.

Sensorineural hearing loss results from damage to or death of the intracochlear hair cells. These normally are the transducers of the mechanical energy transmitted to the cochlear into the electrical impulse required to initiate an action potential in the auditory nerve.

5

What is the maximum age by which intervention should ideally be in place if a pre-lingually deaf child is to acquire language in a manner as close as possible to a hearing child, in terms of both speed of development and completeness of development?
(Please select 1 option)
6 months
12 months
18 months
24 months
36 months

6months

Studies have shown that if congenital hearing loss is identified, diagnosed and appropriate intervention begun by the age of 6 months, a child's spoken language development will progress in the same way as that of a normal hearing child.

The intervention will consist of hearing aid fitting initially to allow all available sound to be delivered to the child's developing auditory system.

For children with a severe-profound hearing loss, for whom hearing aids are insufficient, cochlear implantation should be considered and, where appropriate, carried out as early as is practicably possible.

6

A 14-year-old boy presents with a high fever, cervical lymphadenopathy and pus on the tonsils.
Which of the following statements regarding diagnosis and management is true?
(Please select 1 option)
Amoxicillin may cause an erythematous rash
Cefotaxime is the treatment of choice
If his CRP is 40, then Group A streptococcal infection is highly likely
If urinary red cells are present then a renal biopsy is indicated
Tonsillectomy is indicated after the acute infection has settled

Amoxicillin may cause an erythematous rash

This is a common problem in paediatrics, general practice and medical admissions, and unfortunately on clinical appearances it is not possible to distinguish bacterial from viral or throat infections with any degree of liability.

Urinary red cells may indicate a secondary post-streptococcal glomerulonephritis, but a renal biopsy is unlikely to be indicated.

A group A streptococcal infection should certainly be considered in this case, and probably covered with oral penicillin-v, but reliable clinical diagnosis is not possible.

If the child has EBV infection, then the administration of Amoxicillin will give an erythematous rash. Non-vomiting patients can be treated with oral penicillin-v.

Cefotaxime, although it would probably be effective, requires IV administrations, which does not seem warranted on the information given.

Tonsillectomy should be reserved for those with recurrent tonsillitis not responding to prophylactic antibiotics.

7

A 19-year old man presents to his dentist with a three day history of pain behind the first molar tooth and a fever. He also complains of pain in his right cheek associated with a right sided nasal blockage and a purulent nasal discharge.

Acute maxillary sinusitis
This man has acute maxillary sinusitis. A tooth abscess has ruptured superiorly and extended into the floor of the maxillary sinus causing infection.

8

A 50-year-old man with bronchiectasis presents to his GP for the eighth time in a year complaining of a horrible taste at the back of his throat. He works in a dusty environment, is a heavy smoker, and has a past medical history of recurrent sinusitis and chronic suppurative otitis media.

Chronic sinusitis
This man has chronic sinusitis. The bronchiectasis and chronic suppurative otitis media suggest that all his respiratory mucosa is diseased (Kartagener's syndrome). This has been exacerbated by his smoking and job.

9

A 28-year-old man presents with a pulsatile swelling in the lower part of the neck at the base of the sternocleidomastoid. On questioning, he gives a history of intermittent claudication particularly when working with his arm above his head.

Subclavian artery aneurysm

Neck swellings are usually classified on their location into:

Anterior triangle swellings (anterior to the sternomastoid muscle) and
Posterior triangle swellings (posterior to sternocleidomastoid).
Typically, swellings in the posterior triangle are lymph nodes.

There are more diverse origins for anterior triangle swellings. Common differentials are lymph nodes and thyroid swellings.

10


A 25-year-old man presents with a lump in the lower neck he noticed on casual palpation. There is no pain associated with the lump. He reports tingling along the inner aspect of his forearm. The lump is situated in the supraclavicular fossa. It is hard, rounded and seems to be attached to the seventh cervical vertebra.

Cervical rib

Swellings could be classified as midline swellings and lateral swellings. There are certain characteristic features associated with certain swellings. For example, thyroid swellings move with deglutition but not with protrusion of tongue.

Other swellings that move with deglutition are:

Thyroglossal cyst
Hyoid bursa and
Median / pyramidal lobe of thyroid.
These also move with protrusion of tongue in contrast to thyroid swellings.

11

A 16-year-old girl presents with a swelling in the lower part of the inferior constrictor. Her mother reports that as an infant the girl was troubled by regurgitation and has always had problems swallowing. This lump in her neck increases after eating and the girl reports that on pressing the swelling she feels food in her throat again. There is cough impulse on examination.

Pharyngeal pouch
Swellings with cough impulse are pharyngeal and laryngeal pouches / diverticula and cystic hygroma. It is true cough impulse in the former conditions while the latter is an ill-defined sac resulting from remnants of an undeveloped lymph sac and the cough impulse is transmitted.

12

A 30-year-old female has noticed a swelling in the front of neck. She has lost significant weight in preparation for her wedding. She does not remember having the lump before. The lump is not painful and is not associated with any other symptoms. On examination, there is a 1.5 cm diameter smooth cystic lump about 2 cm above the thyroid cartilage in the midline. This moves with deglutition and protrusion of tongue.

Thyroglossal cyst

Lymph node swellings are generally found along veins. They are divided into six levels mainly to stage metastatic disease and standardise surgical procedures by the digastric muscle, sternomastoid muscle and hyoid bone.

13

A 40-year-old man is admitted to hospital with an atypical pneumonia. He develops left ear pain on the third day.

Otitis media
Otitis media and bullous myringitis are recognised complications of Mycoplasma pneumonia.

14

A 70-year-old woman presents with right facial palsy and severe pain in the right ear.

Ramsay Hunt syndrome
Ramsay Hunt syndrome. Pain may develop well before the typical vesicles appear. Zoster vesicles may be found around the ear or on the deep meatus. Pain is referred to the ear via the sensory branch of the facial nerve.

15

Abduction of the vocal cords is achieved by contraction of which of the following?
(Please select 1 option)
Cricothyroids
Interarytenoids
Lateral cricoarytenoids
Posterior cricoarytenoids
Thyroarytenoids

The posterior cricoarytenoids are the (only) cord abductors. They are innervated by the recurrent laryngeal nerve.

16

A 12-year-old male presents with a midline cystic swelling. On examination the cyst moves upwards on protruding the tongue.

Thyroglossal cyst
A thyroglossal cyst is an embryological fault. They can occur anywhere along the thyroglossal duct from the lingual foramen caecum to the thyroid isthmus. They are mostly midline and can occur above or below the hyoid body.

The cyst usually presents in childhood or in young adults as a rounded, tense, smooth swelling. The cyst moves upwards on protrusion of the tongue due to the attachment to the hyoid.

17

A 28-year-old female presents with tender lump in the upper neck. On examination the lump protrudes into the anterior triangle of the neck. It is tender, fluctuant and reveals pus-like fluid on aspiration.

Branchial cyst
Branchial cysts develop from persistence of the embryonic branchial clefts (lateral clefts). Incomplete obliteration of the medial clefts results in a deep connection to the nasal or oral pharynx. However, most branchial cysts do not have a deep connection and result from epithelial inclusions within upper deep cervical lymph nodes, which subsequently undergo cystic degeneration.

The diagnosis is confirmed by fine needle aspiration, which reveals pus-like fluid with a characteristic cytology of cell debris and cholesterol crystals.

A branchial fistula may also be present with a discharging point on the anterior border of the sternocleidomastoid low in the neck.

18

A 38-year-old male presents with 2 cm lump on the left side of the neck. On examination the lump is firm and moves with swallowing.

Papillary thyroid carcinoma
Papillary thyroid cancer is the commonest type of thyroid cancer (50-60% of all thyroid cancers). This form is commonest in young adults.

Under the age of 40 years in males and 50 years in females the disease tends to have a very good prognosis. They tend to present as solitary thyroid nodules. Because the lump is intra-thyroid it will move with swallowing.

19

Which one of following is not directly related to the mandible?
(Please select 1 option)
Auriculotemporal nerve
Facial artery
Inferior alveolar nerve
Lingual artery
Lingual nerve

Lingual artery
The facial artery appears at the inferior border of the mandible and grooves the mandible as it hooks around the inferior border.

The lingual nerve descends just anterior to the inferior alveolar nerve near the mandibular foramen.

20

Which of the following statements is correct regarding salivary gland pleomorphic adenomas?
(Please select 1 option)
Are more common in males than in females
Are more common in the sub-mandibular than the parotid gland
Are the most common salivary gland tumour
In the parotid gland most commonly arise medial to the facial nerve
Typically enhance following intravenous contrast injection in CT

Most common salivary gland tumour

Salivary gland pleomorphic adenomas occur most often in women over 40.

Eighty four per cent occur in the parotid gland.

They are the most common salivary gland tumour, representing 70-80% of all benign salivary gland tumours.

Ninety percent of parotid gland pleomorphic adenomas arise lateral to the facial nerve.

Usually they do not enhance.

21

Regarding cleft palate, which of the following statements is correct?
(Please select 1 option)
Carries an increased risk of middle ear infections
Has a recognised association with macrognathia
Is associated with maternal hypertensive therapy
Is associated with subsequent hearing disorders
Is usually repaired before the age of three months

Carries an increased risk of middle ear infections

Hearing impairment and repeated ear infections may occur, as well as other craniofacial abnormalities.

Anti-convulsants have been associated with

Cleft lip and palate
Congenital heart disease
Central nervous system (CNS)
Skeletal abnormalities.
Surgical methods, such as bone grafting one, are carried out in childhood and are most successful in patients under 10 years of age, and as early as 5 to 6 years, as the front incisor teeth are erupting.

Delayed language and articulation development is common.

22

Indications for tonsillectomy include which of the following?
(Please select 1 option)
Five or more episodes of tonsillitis in a year
Peritonsillar abscess
Persistently enlarged tonsils
Recurrent glue ear requiring grommet insertion
Snoring

Five or more episodes of tonsillitis in a year

The indications for tonsillectomy are controversial. Undoubtedly, upper airway obstruction, particularly if associated with hypoxaemia or apnoea, is a clear indication.

In most cases recurrent tonsillitis with pus requiring antibiotic therapy would encourage the surgeon to remove the tonsils. This is particularly the case if there has been a previous abscess.

However, if there is no history of chronic tonsillitis, the chance of a recurrence of quinsy is only about 10%, so isolated incision and drainage with antibiotics is all that is required.

23

Which of the following is true of carcinoma of the parotid gland?
(Please select 1 option)
Has a good prognosis
Is not associated with pleomorphic adenomas
Is typically a squamous carcinoma
Is typically associated with facial paralysis at presentation
Radical en bloc surgery and radiotherapy is the treatment of choice

Radical en bloc surgery and radiotherapy is the treatment of choice

The commonest malignant tumours of the salivary glands are adenoid cystic carcinoma and carcinoma arising in a pleomorphic adenoma.

Squamous cell carcinoma is very rare and aggressive, growing rapidly with 50% having lymph node involvement at presentation. Eighty per cent of tumours are in the parotid gland and 80% of these are benign.

A parotid lump with involvement of the facial nerve is highly suggestive of malignancy. Facial paralysis occurs due to the passage of the nerve through the gland, with

Absence of tone of facial muscles
Asymmetry
Loss of nasolabial fold
Drooping corner of the mouth
and can occur in roughly 25% of cases.

Management of a malignant parotid lump requires radical en bloc resection and radiotherapy. However if a lump thought to be benign, is treated by superficial parotidectomy, and is subsequently found to be malignant, the options include watch and wait, radiotherapy or further surgery.

Prognosis with malignant tumours of the parotid gland is poor with a less than 30% five year survival.

24

Which of the following regarding the anatomy of the larynx is not true?
(Please select 1 option)
The cricothyroid muscles increase the tension in the vocal cords
The internal branch of the superior laryngeal nerve supplies the cricothyroid muscles
The posterior cricoarytenoid muscles abduct the vocal cords
The rima glottidis is the space between the true vocal cords
The ventricle of the larynx is the fossa between the true and false cords

The internal branch of the superior laryngeal nerve supplies the cricothyroid muscles

Regarding the intrinsic muscles of the larynx

The posterior cricoarytenoids abduct the cords
The lateral cricoarytenoids and interarytenoids adduct the cords
The sphincters to the vestibule are the aryepiglottics and the thyroepiglottics.
Vocal cord tension is regulated by the

Cricothyroids (tensors)
Thyroarytenoids (relaxors)
Vocales (fine adjustments).
All the intrinsic muscles of the larynx are supplied by the recurrent laryngeal nerves, except the cricothyroid which is supplied by the external branch of the superior laryngeal nerve (not internal branch).

The rima glottidis is the space between the true vocal cords. The ventricle of the larynx is the fossa between the true and false cords. The part between the inlet and the false vocal cords is the vestibule.

25

Which of the following is true concerning the recurrent laryngeal nerves?
(Please select 1 option)
A neuropraxia causes ipsilateral abduction of the vocal cord
The left originates from the vagus as it crosses the subclavian artery
The left passes under the arch of the aorta
The right is more commonly damaged than the left
They provide motor supply to all of the intrinsic muscles of the larynx

The left passes under the arch of the aorta

A neuropraxia to the recurrent laryngeal nerve results in paralysis of the ipsilateral vocal cord, which causes the vocal cord to adduct (lies near the midline). Complete transection of the nerve results in abduction of the vocal cord.

The left recurrent laryngeal nerve originates from the vagus as it crosses the aortic arch (the right side comes off the vagus as it crosses the subclavian artery) before looping under the aorta.

The left recurrent laryngeal nerve is damaged twice as often as the right, due to its intrathoracic course making it more vulnerable.

The recurrent laryngeal nerves provide the motor supply to all of the intrinsic muscles of the larynx except for the cricothyroid.

26

Which of the following is true regarding the temporomandibular joint?
(Please select 1 option)
Capsule is attached to the articular tubercle superiorly
Cavity is divided into three
Is a synovial ball joint
Lateral collateral ligament is weaker than the medial collateral ligament
Medial collateral ligaments are attached to the medial part of the glenoid cavities

Medial collateral ligaments are attached to the medial part of the glenoid cavities This is the correct answerThis is the correct answer
The temporomandibular joint is situated between the condyle of the mandible below and the mandibular fossa above. It is a type of synovial joint but it is lined by fibrous cartilage, rather than the hyaline cartilage typical of synovial joints.

The joint cavity is divided into two by an articular disc. The capsule surrounding the joint is attached beyond the limits of the articular surfaces.

Superiorly, the capsule is attached to the anterior edge of the squamotympanic fissure. Laterally, the capsule is attached to the articular tubercle, which forms the lateral limit of the articular eminence and the prominent ridge of the bone forms the lateral lip of the glenoid cavity.

Medially, the capsule runs along the suture between the temporal and sphenoid bones and attaches anteriorly to the anterior end of the articular eminence. The capsule is strengthened medially and laterally by the collateral ligaments and the lateral ligaments are much stronger than the medial ligaments.

The medial collateral ligaments are attached to the medial part of the glenoid cavities and the medial poles of the condyle. Superiorly, they attach to the articular tubercles and the lateral margins of the glenoid cavities, and inferiorly run obliquely downwards and backwards to the lateral pole of the condyles. On the mandibular condyle, the capsule is attached below the anterior limit of the articular surface.

27

Infranuclear lesion of the facial nerve does not result in which of the following?
(Please select 1 option)
Corneal ulceration
Hyperacusis
Inability to wrinkle up the forehead
Loss of motor functions of the tongue
Loss of taste sensation in the anterior one third of the tongue

Loss of motor functions of the tongue

Injuries to the facial nerve can be divided into supranuclear and infranuclear lesions.

Supranuclear lesions may result from hemiplegia, usually due to a cerebrovascular accident. In this type of lesion only the muscles below the palpebral fissures are completely paralysed and hence the patient can close the eyelids and wrinkle the forehead.

The commonest cause for infranuclear lesions is the Bell's palsy. In this type of lesion, the ipsilateral upper and lower facial muscles are paralysed which causes inability to wrinkle up the forehead.

Corneal ulceration may result due to the inability to close the eyes.

If the lesion is proximal to the geniculate ganglion, taste is lost in the anterior two-thirds of the tongue. Secretions from the submandibular, sublingual and lacrimal glands are impaired.

Hyperacusis is caused due to paralysis of the stapedius. Motor function to the tongue is not affected since it is supplied by the hypoglossal nerve.

28

A 7-year-old girl complains of a sore throat. She has experienced this symptom on two previous occasions over the past three years.
Her tonsils are large and congested. An incidental heart murmur is noted.
Which of the following statements is correct?

Petechiae on the palate suggest infectious mononucleosis

This question describes a child with an upper respiratory tract infection. This is extremely common and in most cases the cause is viral and treatment is conservative only.

Tonsillectomy is considered in children with a history of recurrent tonsillitis causing them to miss significant time at school. There are no fixed numbers of episodes to justify tonsillectomy but 5 over 2 years would be considered reasonable.

If antibiotics are required to treat a bacterial infection, penicillin is the drug of choice as the usual organism is a group A Streptococcus.

Tetracycline is contraindicated in children, due to the side effects affecting bones and teeth.

Palatal petechiae are often seen in patients with glandular fever.

29

Which of the following is true regarding cleft lip and palate?
(Please select 1 option)
Genetic influence is less significant in combined cleft lip and palate
Has a higher incidence among the black population
Has an incidence of one in 8,000 live births
Isolated cleft palate is less common than isolated cleft lip
Pierre Robin syndrome remains the most common syndrome associated with clefting

Pierre Robin syndrome remains the most common syndrome associated with clefting This is the correct answerThis is the correct answer
The incidence of cleft lip and palate is one in 600 live births, and 1:1000 live births for isolated cleft palate.

The incidence increases in the Oriental groups (1:500) and decreases in the black population (1:2000). The highest incidence reported for cleft lip and palate occurs in the Native American tribes of Montana, USA (1:276).

The typical distribution of cleft types is

Cleft lip alone - 15%
Cleft lip and palate - 45%
Isolated cleft palate - 40%.
Genetic influence is more significant in combined cleft lip and palate than cleft palate alone where environmental factors such as maternal epilepsy and drugs (for example, steroids, diazepam, phenytoin) exert a greater influence.

Although most clefts of the lip and palate occur as an isolated deformity, the Pierre Robin sequence remains the most common syndrome. This syndrome comprises isolated cleft palate, retrognathia and a posteriorly displaced tongue (glossoptosis), which is associated with respiratory and feeding difficulties.

30

Which of the following is true of the thyroid gland?
(Please select 1 option)
Develops from the junction between the anterior one-third and posterior two-thirds of the tongue
Has the recurrent laryngeal nerves running in close proximity to the superior thyroid arteries
Is supplied by branches of the internal carotid artery
Moves upwards along with the larynx during swallowing
Overlies the 5th to 7th tracheal rings

Moves upwards along with the larynx during swallowing

It overlies the second and third tracheal rings.

The recurrent laryngeal nerve crosses either in front of or behind the inferior thyroid artery or it may pass between its branches.

The superior thyroid artery is a branch of the external carotid artery and the inferior thyroid artery is a branch of the thyrocervical trunk.

The thyroid begins to develop during the third week as an endodermal thickening in the midline of the floor of the pharynx between the tuberculum impar and the copula.

The thyroid is surrounded by a pretracheal layer of deep fascia, which attaches the gland to the larynx and trachea. Therefore, the thyroid moves with the larynx during swallowing.

31

Which of the following is true of the submandibular gland?
(Please select 1 option)
Contains sympathetic supply from the facial nerve
Develops as a tubular endodermal outgrowth from the floor of the mouth
Has the facial artery passing over its inferior surface
Is a mainly serous salivary gland
Overlies the glossopharyngeal nerve

Develops as a tubular endodermal outgrowth from the floor of the mouth

The submandibular gland contains the parasympathetic supply from the facial nerve.

It overlies the mylohyoid, the hyoglossus, and the lingual and hypoglossal nerves.

It is composed of a mixture of both serous and mucous acin. This is its embryological origin.

The facial artery is related to the posterior and superior aspects of the superficial part of the gland.

32

Structures derived from the second pharyngeal arch include which of the following?
(Please select 1 option)
Hyoid bone
Maxillary artery
Posterior third of the tongue
Stylohyoid ligament
The incus

Stylohyoid ligament

The incus is not derived from the second pharyngeal arch.

The maxillary artery is not derived from the second pharyngeal arch but the greater palatine branch of the maxillary artery supplies the palate.

The stylohyoid ligament is derived from the second pharyngeal arch.

The hyoid bone is derived from the third pharyngeal arch.

The posterior third of the tongue is formed from the third pharyngeal arch.

33

Which one of the following is associated with macroglossia?
(Please select 1 option)
Down syndrome
Hyperthyroidism
Osler-Weber-Rendu disease
Polycystic ovarian syndrome
Sarcoidosis

Down syndrome

Macroglossia occurs in

Hypothyroidism
Amyloid
Acromegaly
Glycogen storage diseases and
Mucopolysaccharidoses.
OWR is hereditary telangiectasia which may occur on the tongue and is not associated with macroglossia.

In Down syndrome the tongue is protruding and enlarged.

34

Which of the following is correct of the pituitary gland?
(Please select 1 option)
Is located close to the floor of the third ventricle
Lies in the pituitary fossa which is located in the ethmoid bone
Secretion of hormones from the posterior lobe is controlled by hypothalamic inhibitory and releasing factors
The anterior lobe secretes vasopressin and oxytocin
Vasopressin is produced, stored and secreted by the pituitary gland

Is located close to the floor of the third ventricle

The pituitary gland lies in the pituitary fossa which is located in the sphenoid bone and lies close to the floor of the third ventricle. It can be functionally divided into anterior and posterior lobes.

The anterior lobe secretes the following

Growth hormone
Prolactin
Adrenocorticotrophic hormone (ACTH)
Thyrotropin
Lutenising hormone (LH) and
Follicle stimulating hormone (FSH).
The secretion of these hormones is controlled by releasing and inhibitory factors released by the hypothalamus.

Oxytocin and vasopressin are secreted from the posterior lobe (not anterior) of the pituitary.

Vasopressin (antidiuretic hormone) is a neuropeptide which is synthesised in the cell bodies of the supraoptic and paraventricular nuclei (not in the pituitary). It is then transported down their axons to the posterior lobe of the pituitary gland from which it is secreted.

35

Which one of the following is not a feature of fat embolism?
(Please select 1 option)
A petechial rash typically affects the trunk
Fat droplets are identified in the sputum and urine
Hypoxaemia is uncommon
Pulmonary hypertension may occur
Thrombocytopenia is found in 50% of cases

Hypoxaemia is uncommon

The dispersion of fat droplets into the circulation usually follows major trauma, but it can also occur following the insertion of methylmethacrylate cement during orthopaedic procedures on joints.

A rare fat embolism syndrome has been described that typically occurs several days after long bone fractures.

The features include

Hypoxaemia
Haemoptysis
Pulmonary hypertension and oedema leading to acute respiratory distress syndrome
A petechial rash over the trunk, pharynx, and conjunctiva
The appearance of fat droplets in the urine and sputum
Thrombocytopenia in 50% and
Hypocalcaemia.

36

Which one of the following is true of acute otitis media?
(Please select 1 option)
Is infrequently preceded by an upper respiratory tract infection
Severe pain followed by a very sudden improvement in symptoms is a good prognostic sign
Should be treated with grommet insertion
The handle and short process of the malleus often appears less prominent
The tympanic membrane appears congested and bulging

The tympanic membrane appears congested and bulging

The bacteria involved in an upper respiratory tract infection (URTI) can track up the eustachian tubes to cause an infection in the middle ear.

Initially the tympanic membrane usually becomes retracted making the handle and short process of the malleus more prominent.

As pressure builds up in the middle ear the ear drum may become distended and bulge outwards. This sign is usually accompanied by severe otalgia and systemic toxicity and fever and tachycardia.

Severe pain followed by a very sudden improvement is not a good prognostic sign. It suggests that the tympanic membrane has perforated.

The severe pain (often associated with systemic symptoms) is mainly caused by raised pressure within the middle ear. If the tympanic membrane ruptures the pressures will equalise and the pain will fall dramatically.

Treatment does involve broad spectrum antibiotics (to cover Haemophilus and Streptococci), bed rest and analgesia. However, initial treatment certainly does not involve grommet insertion.

Grommets should be considered only if there is a persistent middle ear effusion or recurrent attacks of acute otitis media.