Ear, Nose and Throat

Question 1

Define Benign Paroxysmal Positional Vertigo

Answer 1

Peripheral vestibular disorder that manifests as sudden, short-lived episodes of vertigo

elicited by specific head movement

One of the most common causes of vertigo

Question 2

Demographics of Benign Paroxysmal Positional Vertigo

Answer 2

average age of onset is 55 years and it is less common in younger patients.
F>M

It is the most common cause of vertigo, particularly in the elderly due to calcium deposition, cholelithiasis, within the semicircular canals.

Question 3

Features of Benign Paroxysmal Positional Vertigo

Answer 3

Recurrent vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
may be associated with nausea
each episode typically lasts 10-20 seconds
Absence of auditory symptoms
positive Dix-Hallpike manoeuvre:
rapidly lower the patient to the supine position with an extended neck
a positive test recreates the symptoms of benign paroxysmal positional vertigo
rotatory nystagmus

Question 4

What is a positive result of a Dix-Hallpike test for benign paroxysmal positional vertigo?

Answer 4

Rotatory nystagmus

Question 5

What are risk factors for benign paroxysmal positional vertigo?

Answer 5

• Head trauma
• Vestibular neuronitis
• Labyrinthitis
• Migraines
• Inner ear surgery
• Meniere’s disease

Question 6

What can be offered for symptomatic relief of benign paroxysmal positional vertigo?

Answer 6

• Epley manoeuvre (successful in around 80% of cases)
• teaching the patient exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-Daroff exercises

Question 7

What medication if offered for benign paroxysmal positional vertigo?

Answer 7

Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value

Question 8

What is the prognosis for benign paroxysmal positional vertigo?

Answer 8

Around half of people with BPPV will have a recurrence of symptoms 3-5 years after their diagnosis

Question 9

Define Epistaxis

Answer 9

nose bleeds

Question 10

What is the most common site of nosebleeds?

Answer 10

Kiesselbach plexus (Little’s Area- where vessels supplying nasal mucosa anastomose with each other)

Question 11

What are the two types of nosebleeds?

Answer 11

split into anterior and posterior bleeds, whereby the former often has a visible source of bleeding and usually occurs due to an insult to the network of capillaries that form Kiesselbach’s plexus. Posterior haemorrhages, on the other hand, tend to be more profuse and originate from deeper structures. They occur more frequently in older patients and confer a higher risk of aspiration and airway compromise.

Question 12

Common causes of nosebleeds?

Answer 12

Exacerbation factors include:
- nose picking
- nose blowing
- trauma to the nose
- insertion of foreign bodies
bleeding disorders:
- immune thrombocytopenia
- Waldenstrom’s macroglobulinaemia
juvenile angiofibroma:
- Oxygen via nasal cannulae (causes drying and irritation of the nasal mucosa)
- benign tumour that is highly vascularised
- seen in adolescent males
cocaine use:
- the nasal septum may look abraded or atrophied, inquire about drug use. This is because inhaled cocaine
cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum.
- hereditary haemorrhagic telangiectasia
- granulomatosis with polyangiitis (granulomas and inflammation of blood vessels)

Question 13

Management of epistaxis if haemodynamically stable?

Answer 13

Asking the patient to sit with their torso forward and their mouth open
avoid lying down unless they feel faint
this decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth
it also reduces the risk of aspirating blood
Pinch the cartilaginous (soft) area of the nose firmly
this should be done for at least 20 minutes
also ask the patient to breathe through their mouth.

Question 14

Next steps after initial management of epistaxis if successful?

Answer 14

consider using a topical antiseptic such as Naseptin (chlorhexidine and neomycin) to reduce crusting and the risk of vestibulitis
cautions to this include patients that have peanut, soy or neomycin allergies
Mupirocin is a viable alternative
admission and follow up care may be considered in patients under if
a comorbidity (e.g. coronary artery disease, or severe hypertension) is present, an underlying cause is suspected
they are aged under 2 years (as underlying causes such as haemophilia or leukaemia are more likely in this age group)
self-care advice involves reducing the risk of re-bleeding
patients should be informed that blowing or picking the nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks should be avoided

Question 15

If epistaxis does not stop after 10-15 mins what should one do if source of bleed is visible?

Answer 15

Cautery

it is not so well-tolerated in younger children!
ask the patient to blow their nose in order to remove any clots. Be wary that bleeding may resume.
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.
dab the area clean with a cotton bud and apply Naseptin or Muciprocin (topical antiseptic)

Question 16

If epistaxis does not stop after 10-15 mins what should one do if source of bleed is not visible?

Answer 16

Packing

anaesthetise with topical local anaesthetic spray (e.g. Co-phenylcaine) and wait for 3-4 minutes
pack the patient’s nose while they are sitting with their head forward, following the manufacturer’s instructions
pressure on the cartilage around the nostril can cause cosmetic changes and this should be reviewed after inserting the pack.
examine the patient’s mouth and throat for any continuing bleeding, and consider packing the other nostril as this increases pressure on the septum and offending vessel.
patients should be admitted to hospital for observation and review, and to ENT if available

Question 17

What to do if they have epistaxis and they are haemodynamically unstable?

Answer 17

control bleeding with first aid measures in the interim
patients with a bleed from an unknown or posterior source (i.e. the bleeding site cannot be located on speculum, bleeding from both nostrils or profuse) should be admitted to hospital.
Tranexamic acid should be given to all patients with severe bleeding.

Question 18

What to do if epistaxis has failed all emergency treatment?

Answer 18

may require sphenopalatine ligation in theatre

Question 19

What is infectious mononucleosis also known as?

Answer 19

Glandular fever / kissing disease

Question 20

What causes infectious mononucleosis? (glandular fever)

Answer 20

Epstein Barr virus in 90% of cases. Less frequent causes include cytomegalovirus and HHV-6

Question 21

What is the classic triad of symptoms of infectious mononucleosis? (glandular fever)

Answer 21

sore throat
lymphadenopathy: may be present in the anterior and posterior triangles of the neck, in contrast to tonsillitis which typically only results in the upper anterior cervical chain being enlarged
pyrexia

Possible hepatomegaly and/or splenomegaly detected through palpation

Question 22

What are some other features of infectious mononucleosis?

Answer 22

malaise, anorexia, headache
palatal petechiae
splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture
hepatitis, transient rise in ALT
lymphocytosis: presence of 50% lymphocytes with at least 10% atypical lymphocytes
haemolytic anaemia secondary to cold agglutins (IgM)
a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis

The disease tends to cause a milder infection in small children, but can result in a more severe infection in teenagers. One of the most prominent symptoms in this age group is debilitating fatigue that can persist for weeks.

Question 23

How long does it take symptoms to resolve from infectious mononucleosis? (glandular fever)

Answer 23

Symptoms typically resolve after 2-4 weeks.

Question 24

Diagnosis of infectious mononucleosis?

Answer 24

heterophil antibody test (Monospot test / Paul Bunnell test)
NICE guidelines suggest FBC and Monospot in the 2nd week of the illness to confirm a diagnosis of glandular fever.

Question 25

What is the management for infectious mononucleosis?

Answer 25

rest during the early stages, drink plenty of fluid, avoid alcohol
simple analgesia for any aches or pains
consensus guidance in the UK is to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture

Question 26

What investigation may be required for epistaxis if bleeding is significant?

Answer 26

a venous blood gas and FBC should be done to look for anaemia and thrombocytopenia, a clotting screen looking for coagulopathy and a group and save or crossmatch if blood transfusion is required.

Question 27

If due to glandular fever, the spleen has ruptured what would be a tell-tale sign?

Answer 27

Patients may be peritonitic and the pain in the left shoulder is the typical ‘shoulder tip’ referred pain, known as Kehr’s sign, caused by irritation of the diaphragm by intra-abdominal fluid.

Question 28

What is Ménière’s disease?

Answer 28

Meniere’s disease is a condition characterized by the dilation of the endolymphatic spaces of the membranous labyrinth, causing episodes of vertigo lasting for 12-24 hours.

Question 29

What is the epidemiology of Ménière’s disease?

Answer 29

Meniere’s disease typically presents in individuals between the ages of 30 and 60 and predominantly affects only one ear.

Question 30

Aetiology of Ménière’s disease?

Answer 30

The exact cause of Meniere’s disease is unknown, but it is believed to be associated with the dilation of the endolymphatic spaces of the membranous labyrinth. This dilation leads to an increased fluid pressure within the inner ear, causing the characteristic symptoms of the disease.

Question 31

Signs and symptoms of Ménière’s disease?

Answer 31

Sudden attacks of paroxysmal vertigo
Associated deafness
Tinnitus
Attacks often occur in clusters, with periods of remission where function is recovered
The condition can be incredibly disabling, leaving patients bed-bound and suffering from nausea, vomiting, and fluctuating hearing.
episodes last minutes to hours

Question 32

Investigations for Ménière’s disease?

Answer 32

Diagnosis of Meniere’s disease typically relies on clinical evaluation and audiometric testing. Additional imaging or laboratory tests may be needed to rule out other potential causes of the symptoms.
other features include nystagmus and a positive Romberg test

Question 33

Management for Ménière’s disease?

Answer 33

The initial management of Meniere’s disease involves a low-salt diet and diuretics to reduce the volume of endolymphatic fluid. Referral for vestibular rehabilitation, and prescribing an antiemetic for acute attacks would also be appropriate.

Prophylactic use of betahistine to reduce the frequency of attacks
Acute use of Intramuscular or buccal injections of prochlorperazine to manage symptoms during attacks
Diuretics can also be used to reduce endolymphatic fluid, however this is only prescribed by specialists (i.e. ENT clinics)
Surgical approaches are available, but currently lack a strong evidence base.
Low-salt diets can also help prevent attacks, by reducing the volume of endolymphatic fluid.

patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved

Question 34

Natural history of Ménière’s disease?

Answer 34

symptoms resolve in the majority of patients after 5-10 years
the majority of patients will be left with a degree of hearing loss
psychological distress is common

Question 35

Definition of OSA?

Answer 35

Obstructive sleep apnoea (OSA) is a condition where the upper airway becomes completely or partially obstructed during sleep, causing apnoeas (where breathing temporarily stops) or hypopnoeic episodes (decreased airflow during breathing). These episodes cause oxygen desaturations which cause brief arousals from sleep which can be hundreds of times per night. This leads to poor sleep quality which causes symptoms of daytime drowsiness, morning headaches and impaired concentration.

Question 36

Epidemiology of OSA?

Answer 36

OSA is common, affecting an estimated 1.5 million adults in the UK, however around 85% of these are undiagnosed. Around half of people affected are overweight or obese, with 40% of obese people and 77% of morbidly obese people having OSA.

OSA is strongly linked with cardiovascular disease and the metabolic syndrome, and is a significant risk factor for coronary artery disease, type 2 diabetes and stroke.
Daytime sleepiness is an important consideration, especially in patients who drive or whose jobs require vigilance.

Question 37

Aetiology of OSA?

Answer 37

During sleep there is a normal loss of muscle tone in the oropharynx. In most people, there is still sufficient airway patency during sleep so that it does not become obstructed. Patients with OSA, however, require the muscle tone when awake to counteract additional pressures on their airway and so are unable to maintain patency when asleep.

Question 38

Risk factors for OSA?

Answer 38

Obesity
Male sex
Older age
Decreased muscle tone - e.g. alcohol excess, sedative medications, muscular dystrophy or other neuromuscular disorders
Anatomical defects - e.g. retrognathia, macroglossia
Large neck circumference
Adenotonsillar hypertrophy (particularly in children)
Sleeping supine
Down’s syndrome

Question 39

Signs and symptoms of OSA?

Answer 39

Unrefreshing sleep, or frequent waking at night
Daytime sleepiness
Others may witness snoring, apnoeas, gasping or choking during sleep
Difficulty concentrating
Morning headaches
Behavioural problems and hyperactivity in children

On examination, patients may be drowsy and may have some of the risk factors above such as:
Obesity (check BMI)
Large neck circumference (can measure or ask collar size)
Jaw abnormalities (retrognathia or micrognathia)
Mouth breathing or nasal speech (due to nasopharyngeal obstruction, e.g. due to adenotonsillar enlargement)
Also look for signs and symptoms of complications of OSA such as hypertension or arrhythmias.

Question 40

Initial screening for OSA?

Answer 40

STOP-Bang asks about snoring, sleepiness, apnoeas, hypertension, obesity, neck circumference, age and sex and gives a low, medium or high risk of OSA.

The Epworth sleepiness scale focuses on daytime sleepiness and asks how likely the patient would be to fall asleep in a variety of situations (e.g. when watching TV). This gives a result of either normal daytime sleepiness or mild, moderate or severe excessive daytime sleepiness.

Question 41

What is the definitive investigation for OSA?

Answer 41

The definitive investigation is polysomnography (also called a sleep study) which would usually be arranged by a specialist clinic.

Question 42

When should patients be referred urgently for polysomnography with OSA?

Answer 42

Excessive sleepiness is impacting on their safety to work (e.g. professional driver)
They have a related comorbid condition such as treatment resistant hypertension or COPD
They have upcoming major surgery
They are pregnant

Question 43

What does polysomnography show and what are the different categories?

Answer 43

Five or more is diagnostic of OSA and severity is classified as below:
Mild OSA: AHI 5-14 per hour
Moderate OSA: AHI 15-30 per hour
Severe OSA: AHI over 30 per hour
The number of episodes of oxygen desaturation per hour is also measured, with more episodes of desaturation predictive of poorer cardiovascular outcomes.
This test involves monitoring several parameters, including airflow, oxygen saturation, electroencephalogram (EEG) and electromyogram (EMG) activity

Question 44

What is conservative management of OSA?

Answer 44

Patient education, especially concerning driving (see section on driving advice)
Advise to sleep on their side rather than supine where possible (aids such as repositioning pillows may be of help)
Weight loss advice and support (including diet, exercise, medications and surgery)
Reduction in alcohol intake
Smoking cessation

Question 45

What is medical management of OSA?

Answer 45

Continuous Positive Airway Pressure (CPAP) therapy - this is first line in symptomatic OSA and is a long-term treatment.
A mask over the nose or face is used to deliver additional airway pressure that splints open the airways and prevents the collapse seen in OSA.
Education and support are key as tolerance can be a problem and masks need to fit well to be effective.
If patients do not tolerate or respond to CPAP, an intra-oral mandibular advancement device is another option.
These devices pull the mandible forward, opening the airway and preventing obstruction.
Management of comorbidities including hypertension, diabetes and depression is also important.

Question 46

What is the surgical management of OSA?

Answer 46

In cases where there is oropharyngeal obstruction e.g. due to adenotonsillar enlargement, surgery may be considered to relieve this for example a tonsillectomy.

Question 47

What is the driving advice for OSA?

Answer 47

All patients with daytime sleepiness due to OSA should be advised as follows:

If OSA is suspected or mild, advise patients not to drive until symptoms are controlled. If this is not achieved within 3 months, they should inform the DVLA.
If OSA is moderate or severe, patients should inform the DVLA immediately and not drive; this will be reviewed by the DVLA and they may be allowed to drive once symptoms are controlled.

This is the same for group 1 drivers (cars and motorbikes) and group 2 (lorries, buses and coaches), however group 2 drivers returning to driving after symptom control is achieved require annual reviews of this (rather than 3 yearly for group 1 drivers).

Question 47

What are the complications of OSA?

Answer 47

Complications related to daytime sleepiness include:
Road traffic collisions - patients with OSA have a 2.5x increased risk compared to those without the condition
Accidents at home or at work
Deterioration in mental health, including irritability and depression

Cardiovascular and metabolic complications include:
Stroke
Coronary artery disease
Hypertension that may be treatment resistant
Congestive heart failure
Type 2 diabetes

Question 48

Weber test Conductive hearing loss:

Answer 48

Lateralises to affected ear

Question 49

Weber test Sensorineural hearing loss:

Answer 49

Lateralises to unaffected ear

Question 50

Rinne test conductive hearing loss:

Answer 50

• Bone conduction > air conduction in affected ear
• Air conduction > bone conduction in unaffected ear

Question 51

Rinne test sensorineural hearing loss:

Answer 51

• Rinne: Air conduction > bone conduction bilaterally
• Weber: Lateralises to unaffected ear

Question 52

What are the diagnostic features of acute rhinosinusitis?

Answer 52

Sudden onset of symptoms for less than 12 weeks duration including one of:
Nasal blockage/congestion OR nasal discharge
Facial pain/pressure OR loss/reduction of sense of smell

Question 53

definition of rhinosinusitis

Answer 53

Rhinosinusitis is defined as inflammation of the nose and paranasal sinuses.

Question 54

Diagnosis of rhinosinusitis?

Answer 54

The diagnosis requires the presence of at least two symptoms, one of which must be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip).

Question 55

Aetiology of rhinosinusitis?

Answer 55

Rhinosinusitis can be caused by viral, bacterial, or fungal infections, allergies, auto-immune reactions, and deviations or obstructions of the nasal septum.

Question 56

Signs and symptoms of rhinosinusitis?

Answer 56

Nasal blockage/obstruction/congestion
Nasal discharge - Thicker, purulent discharge suggests secondary infection
Facial pain or heaviness - worse when bending forward
Reduced olfaction
Other symptoms may include headache, ear pain, sore throat, and cough (post-nasal drip: may produce chronic cough).

Question 57

Investigations for rhinosinusitis?

Answer 57

Nasal endoscopy: Allows for the visual examination of the internal nasal passages and the sinus openings.
Computed tomography (CT): Provides detailed images of the sinuses and can reveal evidence of sinus inflammation or obstruction.
Cultures: Can be useful when bacterial sinusitis is suspected and previous treatments have failed.

Question 58

Mangement for rhinosinusitis?

Answer 58

Conservative measures: These include nasal saline irrigation, analgesics for pain, and intranasal corticosteroids.
High-dose nasal corticosteroids: If symptoms persist for more than 10 days, a 14-day course of high-dose nasal corticosteroids may be considered.
Antibiotics: These are reserved for severe or persistent cases and are guided by culture results.

Question 59

Predisposing factors for rhinosinusitis?

Answer 59

atopy: hay fever, asthma
nasal obstruction e.g. Septal deviation or nasal polyps
recent local infection e.g. Rhinitis or dental extraction
swimming/diving
smoking

Question 60

Red flag symptoms for rhinosinusitis?

Answer 60

unilateral symptoms
persistent symptoms despite compliance with 3 months of treatment
epistaxis

Question 61

Define tonsillitis?

Answer 61

Tonsillitis is a form of pharyngitis characterized by acute inflammation of the tonsils, often with a purulent exudate present in bacterial tonsillitis.

Question 62

Epidemiology of tonsillitis?

Answer 62

In the UK, tonsillitis is a common condition that predominantly affects children and adolescents, with an estimated 7.4% of GP consultations for children under 15 years involving a sore throat or tonsillitis as the primary reason for the visit.

Question 63

Aetiology of tonsillitis?

Answer 63

The most common causative organism of tonsillitis is Streptococcus pyogenes (group A streptococcus). Epstein-Barr virus (EBV) is another common cause.

Question 64

Signs and symptoms of bacterial tonsillitis?

Answer 64

Bacterial tonsillitis: More often associated with cervical lymphadenopathy.

Question 65

Signs and symptoms of viral tonsillitis?

Answer 65

Viral tonsillitis: More likely to present with headache, apathy, and abdominal pain.

Question 66

What investigation is used for tonsillitis and determine whether its bacterial or viral?

Answer 66

The CENTOR criteria can be used to indicate the likelihood of a sore throat being due to a bacterial infection - Group A streptococcal pharyngitis
There is also the FeverPAIN criteria - (Fever over 38°C, Purulence (pharyngeal/tonsillar exudate), Attend rapidly (3 days or less), Severely Inflamed tonsils, No cough or coryza)

Question 67

Explain the CENTOR criteria?

Answer 67

Each of the CENTOR criteria score 1 point, with a maximum score of 4. A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating Streptococcus. A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating Streptococcus.

Question 68

Treatment for bacteria tonsillitis?

Answer 68

Bacterial tonsillitis with a CENTOR criteria score of 3/4 or evidence of systemic upset/immunosuppression or history of rheumatic fever warrants prescribing antibiotics:
1st line: Penicillin V 500mg PO QDS for 5-10 days
Alternative in penicillin allergy: Clarithromycin/Erythromycin 250-500mg PO BD for 5 days

Question 69

General sign and symptoms of tonsillitis?

Answer 69

Sore throat
Headache
Fever (pyrexia)
Enlarged and tender lymph nodes (lymphadenopathy)

Question 70

What are the 4 signs and symptoms the CENTOR criteria look for?

Answer 70

History of fever
Presence of tonsillar exudates
Absence of cough
Tender anterior cervical lymphadenopathy

Question 71

Complications of tonsillitis

Answer 71

Recurrent Tonsillitis: This is the most common complication. The evidence base for tonsillectomies as a treatment is poor, leading to stricter referral criteria.
Retropharyngeal Abscess: A rare complication characterized by soft tissue swelling, more common in young children. Symptoms include a stiff and extended neck and refusal to eat or drink.
Peritonsillar Abscess (Quinsy): Presents with sore throat, difficulty swallowing, peritonsillar bulge, uvular deviation, trismus, and muffled voice. Treatment has shifted from surgical drainage to antibiotics and aspiration.
Lemierre’s Syndrome: In this rare complication, inflammation leads to pharyngotonsilitis, inflammation within the internal jugular vein, and septic emboli. Treatment may require high-dose benzylpenicillin and debridement.
Otitis media
rheumatic fever and glomerulonephritis very rarely

Question 72

Indications for tonsillectomy?

Answer 72

NICE recommend that surgery should be considered only if the person meets all of the following criteria
sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
the person has 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)
the episodes of sore throat are disabling and prevent normal functioning

Other established indications for a tonsillectomy include
recurrent febrile convulsions secondary to episodes of tonsillitis
obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
peritonsillar abscess (quinsy) if unresponsive to standard treatment

Question 73

What to do if bleeding after a tonsillectomy?

Answer 73

Haemorrhage is one of the most important and concerning complications following tonsillectomy, even in small amounts. Post-tonsillectomy haemorrhages can be categorised as primary (or reactionary, within the first 6-8 hours following surgery), and secondary (between 5-10 days following surgery). This patient’s bleeding started 4 hours after the surgery, indicating they have a primary haemorrhage. Primary haemorrhages are managed by an immediate return to theatre as the risks associated with haemorrhage can be dire, and can be missed as many people, particularly younger patients, can lose a significant amount of blood and compensate before serious problems arise, such as shock.