ENT

Question 1

Is an inferior relation of the pituitary gland

Answer 1

Sphenoid sinus

Question 2

Is a medial relation of the nasolacrimal duct

Answer 2

Inferior concha

Question 3

A posterior relation to the supra ciliary arch

Answer 3

Frontal sinus

Question 4

Is related inferiorly to the molar teeth

Answer 4

Maxillary sinus

Question 5

Is a medial relation of the orbit

Answer 5

Ethmoid sinus
The anatomy of the nose and nasal sinuses are important in both ENT and neurosurgery - particularly pituitary surgery.

The important relations of the pituitary and surgical axis to the pituitary should be understood, together with the relations of the sinuses to the orbit, teeth and their neurovascular contents.

Question 6

A 10-year-old boy presents with hoarseness of voice. On examination of the larynx, there are two pedunculated swellings over the vocal cords. He is otherwise well.

Answer 6

Laryngeal papillomata
Laryngeal papillomata, caused by papilloma virus, occur mainly in children but can also present in adults. They are commonly found over the vocal folds but sometimes may spread throughout the larynx and the tracheo-bronchial tree. These papillomas can be successfully treated by laser surgery.

Question 7

A 42–year-old market trader presents with hoarseness of two months duration. He is a social drinker and smokes 10 cigarettes a day. On examination of the larynx, both cords are slightly red with small swellings on each cord. He is systemically well.

Answer 7

Singer’s nodules
Singer’s nodules are associated with overuse or misuse of voice. Resting the vocal cords is usually adequate to treat small lesions. Larger lesions may require surgical removal.

A 65-year-old known chronic obstructive pulmonary disease patient on steroid inhalers and who smokes 20 cigarettes per day presents with hoarseness of voice of three months duration. On examination, the throat appears inflamed with white patches. In addition, the larynx and vocal cords also appear red and beefy.

Question 8

A 65-year-old known chronic obstructive pulmonary disease patient on steroid inhalers and who smokes 20 cigarettes per day presents with hoarseness of voice of three months duration. On examination, the throat appears inflamed with white patches. In addition, the larynx and vocal cords also appear red and beefy.

Answer 8

Candidiasis of larynx

Candidiasis of the larynx is common in patients using steroid inhalers. Very young or old, diabetics, immuno-suppressed (cytotoxics, steroids, haematological malignancies, AIDS) are at an increased risk. These lesions appear as creamy white patches on the mucosa, surrounded by a thin margin of erythema. Patches are hard to remove and they bleed if scraped. Antifungal agents such as nystatin or amphotericin B are useful to treat this condition, and antibiotics should be withdrawn if possible.

Question 9

A mother is concerned regarding the incessant screaming of her 24-hour-old female infant. On examination, the baby has a temperature of 37.8°C and has an inflamed right tympanic membrane.

Answer 9

Cefotaxime IV
The neonate has features suggestive of otitis media with an inflamed tympanic membrane.

In newborns, Gram negative enteric bacilli, particularly Escherichia coli, and Staphylococcus aureus cause suppurative otitis media. The most appropriate treatment for the neonate is IV cefotaxime to ensure appropriate coverage of these organisms that may be resistant to penicillins.

Question 10

A 12-year-old boy presents with earache following an air journey a week ago. On examination the drum is not inflamed, but fluid is noted in the middle ear.

Answer 10

Analgesia

This boy has features of serous otitis media and requires only simple analgesia with paracetamol.

Question 11

A 3-year-old boy is brought to clinic with a history of tugging at his ear. He has a temperature of 36.7°C, and examination reveals a red inflamed ear canal but the eardrum cannot be observed due to pain.

Answer 11

Analgesia
This child has otitis externa with ear pain and redness of the canal preventing observation of the eardrum.

He needs adequate analgesia, and it may be possible to clean the ear canal with a cotton bud or gentle suction. The ear canal needs to be visualised in order to exclude otitis media, and this should be done before topical antibiotic and/or corticosteroid is used. Risk factors associated with otitis externa include swimming and cleaning the ears with cotton wool buds.

Question 12

A 3-year-old girl presents with a two day history of fever and mild nausea. On examination she has a temperature of 39.5°C and her left tympanic membrane appears red and inflamed with fluid behind it.

Answer 12

Amoxicillin oral
This girl with fever and nausea also has otitis media and should be treated with oral antibiotics. Adequate analgesia will be helpful in improving symptoms and fever, and oral antibiotics can then be trialled in the first instance. Amoxicillin is regarded as the first line treatment for this condition.

Question 13

A 45-year-old male presents with headaches and is diagnosed with acromegaly.

Answer 13

Macroglossia

Acromegaly is associated with enlargement of hands, tongue, feet and typical facial appearance. The condition is also associated with hypertension and diabetes and is due to excess GH secretion from a pituitary tumour.

Other causes of macroglossia include Down’s syndrome and hypothyroidism.

Question 14

A 23-year-old female with a longstanding history of epilepsy for which she takes phenytoin.

Answer 14

Gingival hyperplasia

Phenytoin is associated with gingival hyperplasia as a well recognised side effect. Other causes include calcium antagonists (rarely), cyclosprin and pregnancy.

Question 15

A 45-year-old female presents with tiredness and menorrhagia. She is found to have an iron deficiency anaemia.

Answer 15

Angular stomatitis
Iron deficiency anaemia, like pernicious anaemia, is associated with angular stomatitis.

There is inflammation and erythema of the corners of the mouth.

Other causes are multiple and include inflammatory bowel disease.

Question 16

A 32-year-old male presents with weight loss, fever and fatigue. He is diagnosed with AIDS.

Answer 16

Hairy leukoplakia

AIDS is associated with numerous oral signs including

Oral candidiasis
Oral, gingival regression
Kaposi’s sarcoma
and, like the latter, hairy leukoplakia is classically associated.

Question 17

A 34-year-old man presents with painful ears headache, fever and nasal discharge.

Answer 17

Sphenoid sinusitis
Sphenoid sinusitis. Ear pain is referred via the greater auricular branch of the trigeminal nerve (C2,3). Pain from the teeth may also be similarly referred to the ears.

Question 18

A 5-year-old boy complains of pain in his right ear. he has hearing loss, a low grade fever and has had repeated right middle ear infections. There is a swelling behind his ear.

Answer 18

Mastoiditis complicates partially or untreated otitis media. Classically there is also a swelling behind the affected ear. Treatment is with antibiotics.

Question 19

A 40-year-old business executive presents with painful ears and a hearing loss after disembarking from a transatlantic flight. He had been suffering with a ‘cold’ for one week.

Answer 19

Barotrauma
Barotrauma is due to damage to the tympanic membrane by changes in atmospheric pressure especially in presence of an occluded (Eustachian)tube. Divers and air travellers are most at risk. Clinical features include ear pain, feeling of pressure in ears and conductive deafness.

Question 20

A 72-year-old lady is being treated for myocardial infarction in the coronary care unit. She has been thrombolysed 72 hours ago and is being anticoagulated for a refractory atrial fibrillation. She has developed epistaxis. Her observations are all normal but the nurse has noticed that she bruises very easily.

Answer 20

Drug induced

Splenomegaly in the boy gives the clue to the suggested diagnosis of ITP.

Question 21

An 8-year-old boy presents with epistaxis. He has multiple bruises which according to the parents result from seemingly trivial injuries. He has a cousin with a similar problem who is receiving steroids for it. On examination, he is also found to have splenomegaly.

Answer 21

Idiopathic thrombocytopenic purpura (ITP)
Epistaxis or nasal bleed is a very common condition.

Causes for epistaxis, like most conditions, could be classified into:

Traumatic - fractures of the nasal bones, maxilla, and floor of the cranial cavity or soft tissue injury around the nasal cavity. Nose picking is the most common cause of epistaxis in children.
Neoplastic - include both benign (angiofibroma of nasal cavity) and malignant (maxillary or other paranasal sinus carcinoma, Kaposi sarcoma). Nasal polyps are a common cause of epistaxis but these are generally produced by mucosal hypertrophy rather than true hyperplasia and so are not strictly neoplastic.
Infective - are rare causes of epistaxis. However, severely congested conchae could bleed with very trivial trauma. Orf is one infective cause of infective epistaxis. Ulcers due to sexually transmitted disease are also described.
Systemic illnesses - a variety of systemic illnesses could give rise to nasal bleed. The common ones for a spontaneous epistaxis are hypertension, bleeding diathesis including haematological malignancies.
Miscellaneous - these include medications including anticoagulants.
In the patient with myocardial infarction, epistaxis is probably due to thrombolysis and/or anticoagulation.

Question 22

A 55-year-old carpenter presented to his GP with recurrent episodes of spotty bleeding from his right nostril. He also states that the right nostril seems to be perpetually blocked for the last six months in spite of all the decongestants he has bought off the counter. On examination, right maxillary prominence is noted. Anterior rhinoscopy reveals a fleshy mass obstructing the right nasal cavity. He has associated unilateral diplopia on the right side.

Answer 22

Maxillary adenocarcinoma

The gentleman’s symptoms, his occupation and the examination findings of fleshy mass, maxillary lump and unilateral diplopia point to the obvious cause of his epistaxis.

Question 23

A 12-year-old boy hit his head on a pole on the school playground. His nurse sent him to the emergency department as he had a small nasal bleed that stopped spontaneously. In the intervening two hours, he has noticed a watery discharge from his nose. On examination there is considerable bruising on his nose and forehead.

Answer 23

Ethmoid bone fracture
Epistaxis or nasal bleed is a very common condition.

Causes for epistaxis, like most conditions, could be classified into:

Traumatic - fractures of the nasal bones, maxilla, and floor of the cranial cavity or soft tissue injury around the nasal cavity. Nose picking is the most common cause of epistaxis in children.
Neoplastic - include both benign (angiofibroma of nasal cavity) and malignant (maxillary or other paranasal sinus carcinoma, Kaposi sarcoma). Nasal polyps are a common cause of epistaxis but these are generally produced by mucosal hypertrophy rather than true hyperplasia and so are not strictly neoplastic.
Infective - are rare causes of epistaxis. However severely congested conchae could bleed with very trivial trauma. Orf is one infective cause of infective epistaxis. Ulcers due to sexually transmitted disease are also described.
Systemic illnesses - a variety of systemic illnesses could give rise to nasal bleed. The common ones for a spontaneous epistaxis are hypertension, bleeding diathesis including haematological malignancies.
Miscellaneous - these include medications including anticoagulants.

Ethmoid bone fracture is the only traumatic cause in this list of differentials provided and so is the cause of epistaxis in the boy.

Question 24

An 80-year-old male presents with a history of epistaxis of two hours duration. He states that he feels light headed on occasions and is aware of tiredness. He has otherwise been quite well.

Answer 24

Hypertension

In the absence of any other signs or features in the 80-year-old man who presents with headaches and tiredness, the most likely cause for these symptoms and epistaxis would be hypertension- particularly common in the elderly and usually isolated systolic hypertension - systolic above 140, diastolic below 90.

Question 25

A 36-year-old male presents with bleeding from his right nostril. He has previously been well and is employed as a sheep farmer. On anterior rhinoscopy he is found to have a polyp on the anterior part of his nasal septum.

Answer 25

Orf

Nasal orf acquired from sheep through direct contact may also produce epistaxis.

Question 26

A 42-year-old man presents with episodic epistaxis. He gives a history of excessive crusting, occasional epistaxis and has also noticed a whistling sound on talking and deep inspiration. He is employed in a chrome plating factory. On examination, he has gross septal deviation to the left and crusting over his septum.

Answer 26

Septal perforation

Chromium is an irritant and may cause destructive nasal septum lesions with chronic exposure. This would explain the crusting and deviation.

Question 27

A 65-year-old gentleman with prosthetic heart valve presents with epistaxis. He takes anticoagulation medications but does not remember if he has taken his tablets correctly. He has not seen his general practitioner or the anticoagulation nurse for the last three months.

Answer 27

Anticoagulant overdose

Question 28

A 55-year-old presents with recurrent epistaxis. He says that he has been suffering from a cold and sinusitis that has persisted for the last six weeks. He is employed as a carpenter. No cause for bleeding is apparent on examination. However, anaesthesia of the right cheek is noted.

Answer 28

Carcinoma maxillary antrum

A chronic sinusitis/cold may through repeated nose blowing cause nose bleeds. However, it would not account for the facial anaesthesia which points to a destructive lesion in the right maxilla and involvement of the V nerve and hence a nasopharyngeal carcinoma. Risk factors include wood dust, nickel exposure, smoking, and Epstein-Barr virus (EBV) exposure.

Question 29

A 40-year-old lady is recovering from an anaesthetic after a parathyroidectomy for chronic renal failure. When she wakes up she notices that her voice has become hoarse. One week later there is no improvement.

Answer 29

Recurrent laryngeal nerve palsy
The intrinsic muscles of the larynx are supplied by the recurrent laryngeal nerves. If the nerve is not working the vocal cord cannot be adducted and the voice is hoarse.

Question 30

A 29-year-old singer is referred to an ENT clinic in a worried state as she has noticed her voice has become hoarse recently. Indirect laryngoscopy reveals single small nodules on both vocal cords.

Answer 30

Vocal cord nodules
This lady has vocal cord nodules. Prolonged overuse of the voice may cause keratin nodules to appear on the vocal cords. Smaller nodules disappear with voice rest but larger ones need to be removed surgically.

Question 31

An anxious 18-year-old lady presents to the on-call ENT surgeon with her mother, who states that she suddenly lost her voice the previous night. On examination indirect laryngoscopy shows that the vocal cords fail to adduct when she tries to phonate.

Answer 31

Hysterical aphonia
This patient has hysterical aphonia as illustrated by the failure to adduct the vocal cords. The condition may be a hysterical reaction to some deep-rooted psychological problem and patients need treatment both for their aphonia and their psyche.

Question 32

A 28-year-old primary school teacher attends clinic after losing her voice two days ago. Indirect laryngoscopy reveals oedema of the vocal cords and a small submucosal haematoma.

Answer 32

Laryngeal trauma
This lady's hoarseness is caused by laryngeal trauma. Hoarseness after shouting at an unruly class is due to violent banging together of the vocal cords.

Question 33

A 70-year-old man presents to his GP complaining of a history of deteriorating hoarseness. He smokes 40 cigarettes a day, drinks 40 units of alcohol a week and spends a lot of his time in the bookies shouting at the screens. On examination, the vocal cords appear slightly red.

Answer 33

Chronic laryngitis
This man has chronic laryngitis as suggested by the appearance. His lifestyle has led to chronic inflammation of his larynx causing hoarseness.

Question 34

An 8-year-old boy presents to his GP with a two month history of nasal blockage and a recent torrential nose-bleed.

Answer 34

Juvenile angiofibroma
This boy has a juvenile angiofibroma. It can extend widely into the nose and maxilla. If possible it should be excised; of not radiotherapy is effective but increases the risk of late malignant change.

Question 35

A 70-year-old retired carpenter presents to his GP with a four month history of right sided nasal blockage. Recently he had a blood stained nasal discharge. He also complains of epiphora and that his dentures are now ill-fitting.

Answer 35

Maxillary adenocarcinoma
This man has a maxillary adenocarcinoma caused by longstanding exposure to wood dusts. Spread into the palate has caused a lump with ill-fitting dentures and blockage of the lacrimal duct has caused epiphora.

Question 36

A 25-year-old lady presents to her GP with a two day history of bilateral forehead pain. She recently had an upper respiratory tract infection. On examination the forehead is tender to touch.

Answer 36

Acute frontal sinusitis
This lady has acute frontal sinusitis secondary to an upper respiratory tract infection. This is a worrying condition because infection can easily spread through the posterior wall into the anterior cranial fossa.

Question 37

Which nerve constitutes the afferent (sensory) supply to the piriform fossa?
(Please select 1 option)
	 External laryngeal
	 Glossopharyngeal (IX)
	 Hypoglossal (XII)
	 Internal laryngeal
	 Recurrent laryngeal

Answer 37

The internal laryngeal nerve is afferent from the mucous membrane of the larynx.

The area of mucosa supplied extends from the epiglottis and the back of the tongue down to the vocal folds.

Simulation of the internal laryngeal nerve results in sensations of touch and pain.

The nerve pierces the thyrohyoid membrane above the superior laryngeal artery and divides into terminal branches. A twig is given to the transverse arytenoid muscle, but whether these fibres are motor or proprioceptive is disputed.

The internal laryngeal nerve ends by joining branches of the recurrent laryngeal nerve.

The anastomosis may take place behind or in the substance of the posterior crico-arytenoid and the connection may pierce the inferior constrictor of the pharynx.

Question 38

A 52-year-old man attends the ENT clinic for removal of wax from his external auditory canal. During the procedure he starts to cough.
Of the following which nerve is responsible for this phenomenon?
(Please select 1 option)
	 The auriculotemporal nerve
	 The facial nerve
	 The greater auricular nerve
	 The lesser occipital nerve
	 The vagus nerve

Answer 38

The vagus nerve This is the correct answerThis is the correct answer
The vagus nerve supplies sensation to the inferior external auditory canal and is responsible for the phenomenon of coughing when patients have their ears suctioned.

Question 39

Contraction of which muscle causes vocal cord abduction?
(Please select 1 option)
	 The cricothyroid muscle
	 The lateral cricoarytenoid muscle
	 The posterior cricoarytenoid muscle
	 The thyroarytenoid muscle
	 The transverse arytenoid muscle

Answer 39

The posterior cricoarytenoid muscle is an important muscle as it the only muscle that abducts the vocal cords.

Question 40

The laryngeal prominence is an important surface landmark on the anterior neck.
The structure responsible for the laryngeal prominence is:
(Please select 1 option)
	 Arytenoid cartilage
	 Cricoid cartilage
	 The hyoid bone
	 The tracheal rings
	 Thyroid cartilage

Answer 40

Thyroid cartilage This is the correct answerThis is the correct answer
The angle formed by the laminae of the thyroid cartilage produces the laryngeal prominence. The laryngeal prominence is also known as the thyroid notch.

Identification of the laryngeal prominence and cricoid cartilage is vital for surgical cricothyroidotomy when the airway is entered through the cricothyroid membrane.