ENT II Flashcards
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
