Post exam 1

Question 1

Overdose, dilated pupils with widened QRS. Patient refuses to disclose what medication was overdosed. What was the agent?

Answer 1

Amitriptyline

Question 2

History of atopy, with pollen being the trigger. Now spring and both eyes are watery, red and sore. – allergic conjunctivitis. Treatment?

Answer 2

Anti-histamine eye drops

Question 3

House fire inhaled. Patient needs increased ventilatory pressures, what is the reason?

Answer 3

Surfactory deficiency

Question 4

Medial epicondyle

Answer 4

Flex the wrist

Question 5

Lateral epicondyle

Answer 5

Extends the wrist

Question 6

Patient due for colonic resection surgery, when do you give prophylactic antibiotics?

Answer 6

8-12 hours?????

Question 7

histology results of: glandular cells with cellular atypia, something about nuclei and something else.

Answer 7

Adenocarcinoma of the lung

Question 8

Went on holiday and swam in the ocean, now pain when pressing on tragus and canal looks macerated. Nothing wrong with tympanic membrane. What’s the treatment?

Answer 8

??

Question 9

Long thoracic nerve innervates which muscle

Answer 9

Serratus anterior

Question 10

Radio femoral delay - which condition?

Answer 10

Coarctation of the aorta

Question 11

Dermatomyositis antibody

Answer 11

Anti-Jo1

Question 12

Treatment of chronic rhinosinusitis?

Answer 12

Topical corticosteroid

Question 13

Ix for TMJ?

Answer 13

MRI

Question 14

 Necrotising otitis externa mx?

Answer 14

urgent ENT referral; ix: CT head;
Ciprofloxacin

Question 14

 Acute otitis media with perforation

Answer 14

• Oral amoxicillin, 5 days
• Review in 6 weeks (should heal in 6-8 weeks – if not, refer to ENT  myringoplasty)

Question 14

o Management (acute otitis externa):

Answer 14

 Topical antibiotics (‘sofradex’) ± topical steroid  oral ABx (flucloxacillin)
 Wicking and removal of debris

Question 15

 Acute otitis media without perforation:
* Immediate prescription indications?

Answer 15

• Symptoms lasting more than 4 days (normally ~3 days) or not improving
• Systemically unwell but not requiring admission
• Immunocompromise or high risk (heart, lung, kidney, liver, or NM disease)
• Younger than 2 years with bilateral otitis media
• Otitis media with perforation and/or discharge in the canal
• Otherwise  delayed script / no prescription (amoxicillin, PO, 5 days)

Question 16

s/s cholesteatoma?

Answer 16

• Signs & symptoms  98% = ear discharge OR conductive hearing loss: 10-20yo

Question 17

Mx cholesteatoma?

Answer 17

Surgery

Question 18

o Unilateral tinnitus?

Answer 18

acoustic neuroma/vestibular schwannoma.

Question 19

Vestibular schwannomas (also called acoustic neuromas) associated with what?

Answer 19

Neurofibromatosis 2

Question 20

Meniere’s disease

Answer 20

Tinnitus, vertigo, hearing loss, sensation of fullness

Question 21

Vestibular neuronitis?

Answer 21

No hearing loss

Question 22

Acoustic neuroma signs?

Answer 22

Unilateral hearing loss, loss of corneal reflex, neurofibromatosis 2

Question 23

Mx of vestibular neuronitis?

Answer 23

o Management:
 Acute phase:
* Severe  buccal / IM prochlorperazine
* Less severe  PO cyclizine or prochlorperazine (stopped after few days – can delay recovery)
 Chronic  vestibular rehabilitation exercises [referral to balance specialist – 2ww]

Question 24

Otosclerosis:

Answer 24

AD condition
* Bilateral conductive deafness + tinnitus
* HL improves with noise (“Willis’ paracousis”)
* HL worsens with pregnancy, menstruation, menopause
 Ix: PTA (dip at 2kHz – “Cahart’s notch”)
Hearing aid and implant

Question 25

Mx of allergic rhinosinusitis?

Answer 25

o Mild-moderate intermittent symptoms; mild persistent symptoms:
 1st line: PRN oral antihistamine (cetirizine, loratadine) or PRN intranasal antihistamine (azelastine)
 2nd line: PRN intranasal sodium cromoglicate

o Moderate-severe persistent symptoms; initial treatment ineffective:
 Main issue (nasal blockage / polyps)  intranasal corticosteroid (beclomethasone), nasal irrigation
 Main issue (sneezing / discharge)  intranasal corticosteroid or oral antihistamine

Question 26

Sinusitis is where?

Answer 26

Maxillary sinuses

Question 27

Red flags (urgent ENT referral) of sinusitis?

Answer 27

unilateral S/S, persistent >3m S/S despite tx, epistaxis

Question 28

Mx of sinusitis?

Answer 28

o Symptoms lasting >10 days:
 High-dose nasal corticosteroid for 14 days (if >12yo, e.g. mometasone)
* May improve symptoms but unlikely to affect duration of illness
* Could cause systemic side-effects

 ABx not indicated (as per guidelines) but can give back up prescription (if given, only use if symptoms don’t get better in 7 days or if symptoms get rapidly worse):
* 1st line: phenoxymethylpenicillin (clarithromycin if penicillin-allergic)
* 2nd line: co-amoxiclav

Question 29

o Samter’s/ASA triad?

Answer 29

Nasal polyps, asthma, aspirin hypersensitivity

Question 30

o Single, unilateral polyp

Answer 30

may be a sign of a rare but sinister pathology…  ix: CT, histology

Question 31

• Management of polyps?

Answer 31

o Routine referral to ENT for examination (do medical therapy in the meantime)
o Medical (topical steroids (betamethasone drops) 4-6w  short course of oral steroids)
o Surgical (endoscopic polypectomy)

Question 32

When to manage nose fracture?

Answer 32

o Immediate, before swelling  reduce immediately
o Swelling  re-examine after 1 week (↓ swelling)  EUA ± MUA reduction + post-op splinting (<2 weeks)

Question 33

Treatment of epistaxis?

Answer 33

 1st  remove clots  gauze (soaked in vasoconstrictor + local anaesthetic)  ix: rhinoscopy
 Bleeding visualised  silver nitrate cautery (3-10 seconds, dab clean, add naseptin/muciprocin)
 Bleeding cannot be visualised  packing (anterior or posterior and anterior packing)
* Anterior pack (pack as per instructions)
* Posterior pack (18G foley to nasopharynx, inflate, pull back until lodging)
* Admit for up to 48 hours ± ENT review; examine patient’s mouth and throat for bleeding
 Continue bleeding  NBM and refer to ENT (? ligation of sphenopalatine artery)

Question 34

Tonsilitis?

Answer 34

“Centor Score” determines likelihood of bacterial over viral (only used if ≤3 days of pharyngitis):
o +1 = Exudate/swelling on tonsils
o +1 = Tender/swollen anterior cervical lymph nodes
o +1 = Temperature >38C (at any point)
o +1 = Cough absent

0, 1, 2 = 3-17% chance GAS, no ABx
3, 4 = 32-56% chance GAS, ABx + rapid strep test

Question 35

Tonsilitis causes?

Answer 35

o Group A β-haemolytic streptococcus (GAS) – N.B. rare under 3yo or ≥45yo, common 3-14yo
o EBV (i.e. bacterial or viral) – no amoxicillin treatment (as you can get a generalised maculopapular eruption)

Question 36

Glandular fever?

Answer 36

S/S: sore throat, fever, malaise, lymphadenopathy, pharyngitis, petechiae on soft palate, splenomegaly

Question 37

If persistent (>3w) change in voice, refer for what?

Answer 37

laryngoscopy

Question 38

o Specific cases to watch out for (take urgent FBC): tonsilitis?

Answer 38

 DMARDs – could cause immunodeficiency
 Carbimazole – idiosyncratic neutropoenia

Question 39

‘web’/pseudomembrane at back of throat

Answer 39

Diptheria
; tx: penicillin + anti-toxin

Question 40

Bleed post-tonsillectomy

Answer 40

Post-op delayed bleed  same-day ENT assessment
Post-op <24 hours bleed  immediate return to theatre

Question 41

• Tonsillar SCC rf?

Answer 41

HPV infection

Question 42

s/s of ramsay hunt syndrome?

Answer 42

o S/S: otalgia, facial nerve palsy, vesicular rash around ear (incl. inside ear), vertigo, tinnitus

Question 43

Warthin tumour

Answer 43

M > F (the only one)
60-80yo
most common bilateral benign neoplasm
Lymphocytic infiltrate, cystic epithelial proliferation

Question 44

Benign pleomorphic adenoma

Answer 44

80% of parotid neoplasms, young patient
Slow-growing, lobular, poorly encapsulated
Mx: superficial parathyroidectomy

Question 45

Haemangioma

Answer 45

90% of parotid tumours in child <1yo
Hypervascular imaging
Spontaneous regression may occur

Question 46

Monomorphic adenoma

Answer 46

Slow growing
One morphological cell type (i.e. basal cell adenoma)

Question 47

Mucoepidermoid carcinoma

Answer 47

30% of all parotid malignancies
Low potential for local invasion
Slow growing (low grade) OR high grade (fast)

Question 48

Adenoid cystic carcinoma

Answer 48

Unpredictable growth + tendency for perineural spread
Distant metastasis common

5-year survival at 35%

Question 49

Adenocarcinoma

Answer 49

Develops from secretory portions of the gland
5-year survival depends on the stage at presentation

Question 50

• Pinna haematoma mx?

Answer 50

o Mx: incision + drainage

Question 51

• TM perforation:

Answer 51

o Mx: watch & wait for 6-8 weeks (if not healed, refer to ENT)

Question 52

• Nasopharyngeal carcinoma:

Answer 52

Associated with EBV
 Cervical lymphadenopathy Unilateral serous otitis media
 Otalgia Nasal obstruction, discharge or epistaxis
 Cranial nerve palsies

Question 53

Mx of nasopharyngeal carcinoma?

Answer 53

o Ix: combined CT/MRI
o Mx: radiotherapy

Question 54

• Ludwig’s angina:

Answer 54

o Aetiology: a rare infection of the floor of the mouth and soft tissue of the neck
 RFs: dental surgery
o S/S: neck swelling, dysphagia, fever
o Ix: clinical
o Mx: urgent admission + airway management + IV ABx