ENT

Question 1

What’s apnea-hypopnea index (AHI)

Answer 1

Average that represents the combined number of apneas and hypopneas that occur per hour of sleep.

Question 2

How does allergic rhinitis occur

Answer 2

By allergens that trigger a local hypersensitivity reaction. Specific IgE antibodies triggers a cascade of inflammatory mediators.
Nasal terminates appear pale and boggy ( rather than red and inflamed as in infected rhinitis)
Avoidance measures alone are often ineffective
Symptom relief- antihistamines and intranasal corticosteroids

Question 3

Vasomotor rhinitis

Answer 3

It’s a non allergic rhinitis
Secondary to a hyperactive nerve in the nasal canal.
It activates in response to a chronic allergy, chronic inflammation, structural issues .
When nerve is hyperactive it overstimulates terbinates to swell and secrete excessively.
Can try a trial of ipratropium bromide ( also there’s a new method of cryotherapy done to the nerve to reduce the hyperactivity. Done in opd setting)

Question 4

What’s rhinitis medicamentosa

Answer 4

That’s a recurrence of nasal congestion due to overuse of topical nasal decongestants

Question 5

What’s hay fever

Answer 5

The Common name for Allergic rhinitis produced by seasonal aeroallergens
Symptoms- nasal congestion, rhinorrhea, sneezing and itching of nose and eyes.
Medical treatments are antihistamines( treats allergen induced sneezing,nasal itching and rhinorrhea ) , leukotriene receptor modulators and topical glucocorticoids

Question 6

Role of antigen immunotherapy in severe allergic rhinitis

Answer 6

Specific antigen must be identified before commencing the allergy shot
Duration less than a year is ineffective, normally 3-5 year course is completed

Immunotherapy could be beneficial for asthma but not commonly used
There’s NO evidence that immunotherapy against bacterial pathogens decrease incidence of sinusitis of respiratory infections

Question 7

What’s the midline upper neck cystic mass which moves with swallowing

Answer 7

Thyroglossal cyst

Question 8

How to manage pleomorphic adenoma

Answer 8

It’s a benign tumor (no chemo or radiotherapy needed)
Tx of choice is superficial parotidectomy
Recurrence with simple enucleation is 20-45%, but less than 5% in S.Parotidectomy.
Commonly total parotidectomy (more extensive) doesn’t reduce risk of recurrence and is associated with high risk of facial nerve dysfunction and other complications.
Total parotidectomy is done for benign tumors that holds deep lobe and high grade malignant parotid tumors.

Question 9

6yo girl, unwell for 1 week with URTI + L/S earache, L ear tympanic membrane perforation of 1-2mm noted and some dry blood in ear canal. What’s the next step

Answer 9

Scenario suggestive of Acute otitis media with TM perforation
1st line is Amoxicillin for 1 week duration and review in 1 week to asses resolution of symptoms
ENT surgical referral is not needed as TM heals by itself in AOM

Question 10

What’s the first line med for severe allergic rhinoconjunctivitis

Answer 10

Intranasal corticosteroids

Question 11

Chronic rhino sinusitis symptoms

Answer 11

Following symptoms for more than 12 weeks
1.Nasal blockage( obstruction or congestion)
2.Mucopurulent nasal discharge( anterior of posterior drip)
3.Facial pain or pressure
4.Reduction of sense of smell

Question 12

How to treat chronic rhino sinusitis ?

Answer 12

1. topical steroids and nasal irrigation for 8 weeks
2. Antibiotics - acute rhino sinusitis that do not improve in 7 days or worsens over time.
   (Amoxicillin is first line )
3. If symptoms doesn’t improve with amoxicillin therapy within 6 weeks- start respiratory fluoroquinolone ( levofloxacin or Moxifloxacin )

Question 13

Management of active epistaxis

Answer 13

1. Position sitting forward to prevent blood dripping down the throat
2. Compress the little’s area for about 10mins without interrupting
3. If not effective apply local anesthesia and pack the nose with ribbon gauze

Question 14

What are the possible tumor sites related to metastatic nodes

Answer 14

1. Posterior triangle- nasopharyngeal carcinoma
2. Upper jugular chain- oral cavity, oropharynx and larynx
3. Isolated supraclavicular nodes- tracheobronchial, distal esophageal or stomach carcinoma

Question 15

Disadvantages of uss

Answer 15

1.Operator dependency
2.Sound wave not transmitted via bone and air. So can’t visualize structures behind bone and air

Question 16

What are the mechanisms of stroke due to chronic OSA

Answer 16

1.Large swings in BP
2.Increased coagulopathy
3.Development of atrial fibrillation
4.Local vibrational damage to carotid artery bifurcation
5.Paradoxical emboli through asymptomatic patent foramen ovals opening during transient sleep related hypoxia with pulmonary hypertension

Hyperlipidemia is not a mechanism

Question 17

Commonest cause of epistaxis

Answer 17

Local incidental trauma

Then facial trauma, foreign bodies, nasal or sinus infection , prolonged inhalation of dry air

Hypertension is rarely the direct cause of nasal bleeding

Rarely NSAIDs or hay fever may cause epistaxis

Question 18

Features of chronic suppurative otitis media

Answer 18

CSOM is the infection of middle ear with perforated tympanic membrane

Very common in preschool children
Hx of cold symptoms months ago
Profuse yellow discharge from an ear for few weeks
Ear drum could be perforated

Question 19

Treatment of CSOM

Answer 19

Ear toilet with providing idone solution , followed by dry mopping with rolled toilet papers. Can be done 2 to 3 times a day

Ciprofloxacin ear drops also can be used secondly

Question 20

Features of nasopharyngeal carcinoma Mets to the lymph nodes

Answer 20

Nasopharyngeal ca has tendency to spread to LN without exhibiting any systemic symptoms. It is seen that about 20% nasopharyngeal ca , initial mode of presentation is multiple BL nodes in posterior triangle of neck

Question 21

What’s sternocleidomastoid tumor

Answer 21

A benign swelling within the sternocleidomastoid muscle, which joins the base of the skull to the collar bone
In anterior triangle of the neck

In some babies this muscle is shorter than the other. So at birth they come with tilted head which results in birth trauma and breech deliveries

Question 22

Bronchial cysts

Answer 22

Congenital epithelial cysts
Arise from lateral part of the neck due to failure of obliteration of the Second branchial cleft in embryonic development
Usually soft non tender and in anterior triangle

Question 23

What’s tuberculous lymphadenitis

Answer 23

In posterior triangle of the neck
Painless and long standing

Question 24

Carotid body tumor

Answer 24

Slowly growing painless swelling of anterior triangle of the neck

Question 25

RF of obs sleep apnea

Answer 25

1.Obesity 2.Myotonic dystrophy 3.Ehlers- Danlos syndrome 4.Smoking 5.Hypothyroidism 6.Acromegaly

Question 26

What’s central sleep apnea and what are the RF

Answer 26

Lack of drive to breathe during sleep , resulting in repetitive periods of insufficient ventilation and compromised gas exchange RF are congestive heart failure and stroke

Question 27

Features of OSA

Answer 27

1.Daytime sleepiness 2.Narcolepsy 3.Impaired vigilance 4.Hypertension 5.Fatigue 6.Snoring at night 7.Choking or gasping while sleep 8.Morning headaches 9.Moodiness,irritability, depression Must be referred to a respiratory specialist for confirmation of diagnosis Sleep maintenance insomnia ( many people experience a lot of awakenings during the night or one long wakeful period . If the awakenings are long and associated with daytime tiredness that’s called sleep maintenance insomnia ) is seen in central sleep apnea

Question 28

What’s narcolepsy

Answer 28

It’s a chronic neurological disorder that affects brain’s ability to control sleep-wake cycles Patients may experience uneven or interrupted sleep that may involve waking up frequently during the night They may cause sudden attacks of sleep, sudden loss of muscle tone, hallucinations (like day dreaming)

Question 29

Fever,ear ache, cough for last four days. Otoscope shows red and bulging TM

Answer 29

AOM Without perforation of TM

Question 30

In chronic supportive otitis media with TM perforation, is surgery mandatory

Answer 30

No surgical repair is elective and not mandatory

Question 31

In COM with perforation 1.A dry central perforation 2.Continuous discharging central perforation 3.Perforation associated with cholesteoma

Answer 31

Dry central perforation will not progress to complications , even if it doesn’t heal.surgical repaid is elective Other types of perforations are not safe and need special attention Continuously discharging central or marginal perforation indicates granulation and osteitis and bone destruction Cholesteoma is not a neoplasm but a cystic lesion that contains amorphous debris. It’s formed through chronic infection and perforation of eardrum with ingrowth of squamous epithelium forming a nest which becomes cystic. By progressive enlargement cholesteatoma can erode the ossicles, labyrinth and adjacent bone and carries the risk of cerebral abscess formation and meningitis

Question 32

Painless swelling with associated facial nerve involvement

Answer 32

Most likely parotid gland carcinoma ( facial nerve palsy never presents with a benign condition like pleomorphic adenoma)

Question 33

What’s warthin tumor

Answer 33

Second commonest benign parotid tumor Primarily in 60-70y patients Usually at the tail of parotid gland near the angle of mandible Only tumor virtually restricted to the parotid gland

Question 34

High risk patient of oral cancer how often should screen

Answer 34

Every 12 monthly should be screened

Question 35

Explain acute labrynthitis

Answer 35

Acute vertigo , nausea ,vomiting , tinnitus and hearing loss. Change in head position provokes vertigo( lasts for few seconds to minutes) History of preceding viral URTI in 50% patients

Question 36

What’s Ménière’s disease

Answer 36

Acute onset vertigo, tinnitus and hearing loss, ear fullness ( due to increased endolymph pressure in labyrinth) Associated positive family history+ Much less common compared to labyrinthitis

Question 37

What’s vestibular neuronitis

Answer 37

Inflammation of vestibular nerve often by viral infection (preceding viral URTI or herpes zoster) Acute onset Vertigo ,imbalanceness nausea and vomiting are present. but NO HEARING LOSS OR TINNITUS favors either BPPV or vestibular neuronitis. But caloric test and horizontal nystagmus with fast part towards unaffected side suggests vestibular neuronitis. Symptoms worsens with head positioning

Question 38

What is acoustic neuroma

Answer 38

AKA Vestibular schwannomas Intracranial tumors arise from the Schwann cell sheath of either vestibular or cochlear nerve. As acoustic neuromas increase in size they eventually occupies a large portion of the cerebellopontine angle. Usually unilateral, B/L tumors almost always suggest neurofibomatosis type2. Prominent feature is the unilateral GRADUAL hearing loss. Tinnitus , imbalanceness, contralateral sensory disturbances. Vertigo is NOT SEEN ( bcos as the tumor grows gradually there’s enough time for compensation) and facial nerve involvement seen due to compression in CPA Produce hearing loss through two mechanisms- Direct injury to cochlear nerve( occurs more chronically) Interruption to cochlear nerve blood supply ( occurs much faster but seen in about 15%)

Question 39

What’s lateral medullary syndrome

Answer 39

AKA Wallenberg syndrome , AKA Posterior inferior cerebella artery (PICA) syndrome Has vertigo, hearing loss, tinnitus Cross body sensory impairment Horner’s syndrome, dysphagia, dysarthria, dysphonia

Question 40

What’s pure tone audiometry

Answer 40

Standard test to assess hearing loss in adults It helps to assess conductive hearing loss(CHL)( air conduction) And sensorineural hearing loss(SNHL) (bone conduction)

Question 41

Rinne and Weber test

Answer 41

Done for provisional assessment of hearing loss In a normal person air conduction(AC) is better than bone conduction(BC), so when BC is better than AC conductive hearing loss(CHL) is suspected. Not reliable as pure audiometry

Question 42

What speech discrimination test

Answer 42

A part of formal audiometry Assess the patients ability to hear words correctly and it’s a good indication of integrity of cochlear nerve

Question 43

What’s electrocochleography

Answer 43

Measurement of electrical potentials generated in inner ear as a result of sound stimulations. This is often used to determine if the cochlear has excessive amount of fluid pressure. ( excess fluid pressure can can cause symptoms such as hearing loss, ear fullness, tinnitus, dizziness)

Question 44

What’s acute mastoiditis(AM)

Answer 44

Rare but the commonest suppurative complication of acute otitis media(AOM) and maybe associated with intracranial complications It’s always a clinical diagnosis with following findings 1. History of AOM 2. Post auricular inflammation signs like erythema, edema, tenderness 3. Protruding auricle or external auditory canal edema Mainstay of treatment is IV Flucloxacillin + a third generation cephalosporin (But before antibiotics should take a sample form ear discharge for microscopy) Then if TM is intact tympanocentesis or Myringotomy should do to obtain samples and to relieve middle ear pressure( by and ENT consultant) CT has to be done later to evaluate the extent of the complications of mastoiditis. Audiometry maybe later used after treatment to assess hearing status and medicolegal issues.

Question 45

Recurrent epistaxis with CPAP use and BL crusting and excoriation on nasal septum,but not active bleeding on examination

Answer 45

After starting CPAP many patients develop dryness, obstruction, epistaxis due to mucosal damage caused by cold , dry and pressurized air from CPAP machine. On examination nasal mucosa is dry and erythematous with crusting. Treatment- Warming and humidifying air through CPAP machine Nasal saline irrigation (to moisturize the nasal mucosa and to clear dry secretions) If excoriation is associated with recurrent epistaxis ,a focal lesion and crusting with excoriations - biopsy is indicated to exclude malignancies. Corticosteroids are effective in allergic rhinitis but here no place for them bcos that may further thin the walls which could worsen the epistaxis Oxymetazoline ( topical vasoconstrictor) can be used in acute epistaxis where direct pressure doesn’t stop the bleeding. But it can’t be used as a preventive drug for epistaxis

Question 46

What’s the pathogenesis of cholesteatoma

Answer 46

Presentation- Persistant otorrhea, conductive hearing loss,on examination pearly white mass behind intact tympanic membrane Development of retraction pockets in TM due to chronic middle ear infections or recurrent AOM or tympanostomy tube placement. These pouches traps squamous epithelial cells and debris , leading to otorrhea if infected or conductive hearing loss if growth expands to the nearby ossicles. In examination pearly white mass on anterosupirior quadrant of TM or a visible retraction pocket with draining debris is seen Treatment is surgical excision

Question 47

Otitis externa is characterized by

Answer 47

Maceration and inflammation in the external ear canal

Question 48

Painful swelling under the jaw, more painful and prominent after eating. Bimanual shows slightly tender mass on the region

Answer 48

Chronic sialadinitis. Most commonly Due to duct obstruction by a salivary duct calculi. Postprandial pain and swelling commonly seen On palpation gland is enlarged , maybe tender. Manipulation should be minimized to avoid the calculi from pushing further into the gland which makes it harder to do the transoral excision. Common in submandibular gland- long tortuous duct, mixed mucus and serous composition, draining against gravity Intraoral plain X-ray is most commonly used. Then USS(duct dilatation,to identify stones as small as 1mm) and sialogram( size, location) are also used

Question 49

What’s Orthopantomogram(OPG)

Answer 49

Panoramic dental X-ray of upper and lower jaws Has no role is salivary gland diseases

Question 50

Painless form and mobile preauricular mass with ipailateral facial nerve involvement. What’s the work up

Answer 50

Most important to consider malignant parotid tumor that invaded facial nerve. When a salivary gland tumor is suspected imaging starts with CT and MRI of head and neck ( to assess location, local extensions and invasion, detect nodal and systemic Mets ) FNAC is used after that for confirmation of diagnosis and before surgery Chest X-ray and CT of chest and abdomen are done for staging later.

Question 51

Painless, firm and mobile neck mass for 6 months, FNAC is inconclusive , what’s the next best step

Answer 51

Painless lateral neck/collarbone lumps in adults are malignant until proven otherwise. After history and examination best to perform FNAC and CT scan. How ever if FNAC is inconclusive CT scan is preformed and then excision biopsy is performed. Red flags for hard and neck ca- 1. Mass present for >2 weeks 2. Recent change in the voice 3. Dysphagia or odynophagia 4. LOA, LOW 5. Ipsilateral otalgia, nasal obstruction or epistaxis RF for head and neck ca- 1. Smoking 2. Alcohol use 3. Age>40y 4. Hx of head and neck malignancy 5. Hx of head and neck cutaneous lesions

Question 52

BPPV

Answer 52

Usually wake up with the condition and notice while trying to sit up properly Physical examination is unremarkable

Question 53

What are the most contributing factors for SCC in head and neck

Answer 53

Smoking and alcohol

Question 54

Commonest RF for nasopharyngeal ca

Answer 54

Commonest is Epstein Barr virus ( EBV). Others are HPV infection and genetically.

Question 55

What’s the second most common cause for tonsillar lump

Answer 55

Lymphoma

Question 56

What’s a CI for silogram

Answer 56

Active infection( bcos it can exacerbate the extent of the infection)

Question 57

Acute siladenitis

Answer 57

Unilateral erythema and tender swelling over aubmandibular gland highly suggestive of above. 80% calculi are radio opaque( most parotid gland calculi are radiolucent) X-ray is the first ix, then CT or USS are done.