Surgical Specialties A - ENT Year 4 Assessment Questions

Question 1

QUESTION 1 - 73 year old man with epistaxis

Answer 1

External pressure to the nose for 20 minutes and ice would be the initial management of epistaxis

Question 2

QUESTION 1 - 73 year old man with epistaxis

Answer 2

After trying pressure and ice Clot removal e.g. suction or nose blowing Apply a cotton soaked ball - adrenaline to cause vasoconstriction and lidocaine for analgesia Cauterise using silver nitrate Rhino pack if bleeding continues Endoscopic ligation of sphenopalatine artery Ligation of the external carotid artery Embolisation - can cause stroke - LAST LINE

Question 3

QUESTION 1 - 73 year old man with epistaxis

Answer 3

Anterior ethmoidal artery, Posterior ethmoidal artery, Sphenopalatine artery, Greater palatine artery, and the Septal branch of the superior labial artery. (branch of the facial artery)

Question 4

QUESTION 1 - 73 year old man with epistaxis

Answer 4

Continued bleeding Visual disturbance CSF leak

Question 5

QUESTION 1 - 73 year old man with epistaxis

Answer 5

Principal region supplied by the sphenopalatine artery is the lateral wall of the nasal cavity

Question 6

27 year old woman with runny, blocked nose and snoring

Answer 6

Exposure to animals Drinking alcohol Seasonal (worse in hayfever season)

Question 7

27 year old woman with runny, blocked nose and snoring

Answer 7

Allergic rhinitis

Question 8

27 year old woman with runny, blocked nose and snoring

Answer 8

Skin prick test would be 1st line to identify the allergic RAST - radioallergosorbent test would be next - looks for specific IgE

Question 9

27 year old woman with runny, blocked nose and snoring Which of the types of hypersensitivity is involved in allergic rhinitis? Which type of antibody is found in allergic rhinitis?

Answer 9

Allergic rhinitis - immediated hypersensitivity Type 1 Type 1 - IgE

Question 10

What are the treatment steps for allergic rhinitis? ( up to oral steroids)

Answer 10

Allergen avoidance is step one Then antihistamines eg loratadine If symptoms persist - intranasal corticosteroids Can try leukotrienes after this eg montelukast Oral steroids only short course for rapid relief of symptoms

Question 11

Why would oral steroids be used?

Answer 11

Oral steroids only short course for rapid relief of severe symptoms ie exams

Question 12

27 year old woman with runny, blocked nose and snoring State in order of treatment for allergic rhinitis

Answer 12

Corticosteroid mechanism of action used in allergy - binding to receptors within the cell which cause the nucelus to down regulate the production of inflmmatory mediators

Question 13

QUESTION 3

Answer 13

ALL OF THE ABOVE

Question 14

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Answer 14

FBC and Chest Xray

Question 15

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Answer 15

Inform the patient of the results and state they are worrying and though they will be seen in ENT, you are going to ask the resp clinic to see them. Mention it may bea cancer.

Question 16

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Answer 16

Give smoking cessation advice or refferal Refer to SALT Refer to ENT for a further opinion on hoarseness Arrange for community dietician Ask macmillan nurse to visit

Question 17

QUESTION 4

Answer 17

Recurrent acute otitis media Chronic OME Otitis externa Cholesteatoma

Question 18

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Answer 18

Recurrent otalgia Recurrent ear discharge Hearing loss All could happen with chronic OME

Question 19

How many months must symptoms be persistent for a diagnosis of OME?

Answer 19

3 months

Question 20

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Answer 20

Retracted and dull - the negative pressure in the eustachian tube would be pulling the membrane back

Question 21

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Answer 21

* O - right ear air conduction * X - left ear air conduction * Triangle - bone conduction ANSWER _ Bilateral conductive hearing loss, worse left side * Bone conduction higher than air hear * Shows that when using a bone vibration patient can hear better than when just using air - this means there is a conductive hearing loss as there is a problem with the passage of sound to the inner ear

Question 22

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Answer 22

Type B - a flat tracing on tympanogram ususally shows either fluid filled ear or a perforation

Question 23

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Answer 23

Option B - no, permission is needed from parents

Question 24

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Answer 24

ALl of them

Question 25

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Answer 25

FBC and electrolytes CT scan of neck, chest and liver LFTs FNA cytology of neck node Biopsy of tonsil mass

Question 26

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Answer 26

Refer to head and neck MDT Panendoscopy and biopsies under GA (A panendoscopy is the examination of the upper aerodigestive tract (pharynx, larynx, upper trachea and oesophagus). It may also involve the removal or biopsy of any abnormal tissue found.)

Question 27

Apart from smoking, alcohol and rarer occupational exposures what other aetiological factor is now recognised as important in head and neck cancer?

Answer 27

HPV

Question 28

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Answer 28

ALL THE QUESTIONS

Question 29

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Answer 29

Meniere’s disease Aural fullness Last hours NO POSITIONAL TRIGGER

Question 30

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Answer 30

O - air conduction right ear X - air conduction left ear Triangle - bone conduction [ - masking to prevent non-test ear from affecting test results Low frequency conductive hearing loss is seen on this audiogram

Question 31

Would this audiogram be consistent with a diagnosis of Ménière’s Disease? Is Ménière’s Disease a common cause for vertigo? Which of the vestibular conditions below causes brief episodes of rotatory vertigo? * • Vestibular neuronitits * • Benign positional paroxysmal vertigo * • Menieres Disease * • Vestibular Schwannoma *

Answer 31

No because Menieres causes a SNHL Not common BPPV causes brief episodes of otatory vertigo

Question 32

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Answer 32

Laterality of sore throat Voice change

Question 33

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Answer 33

Infectious mononculeiosus Tonsilitis

Question 34

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Answer 34

Lymphocytosis on blood film

Question 35

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Answer 35

Liver enzymes

Question 36

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Answer 36

Phenoxymethylpenicillin first line if patient can swallow If not then Benzylpenicilllin

Question 37

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Answer 37

Anti-EBV IgG absent, anti-EBV IgM present IgG measures past disease IGM measures active disease

Question 38

What is the manageemnt of quinsy? What if pen allergic?

Answer 38

Peritonsilar abscesss Benzylpenicillin IV or Penicillin V oral Total duration IV/PO: 10 days Penicillin allergy: Clindamycin oral (10 days) If unable to swallow IV Clindamycin If not resolving at 48 hours consider adding metronidazole to penicillin. for anaerobic cover (Cindamycin gives adequate anaerobic cover

Question 39

What are the components of the centor criteria for differentiating between viral and bacterial tonsilitis?

Answer 39

Centor criteria absence of Cough tonsilar Exudate cervical Node enlargement Temp Fever - approx 38

Question 40

What extra does the modified centor criteria contain?

Answer 40

If the child is less than 15 then add a point If over 45 then deduct a point

Question 41

A new score FEVERPain has been introduced to also help diagnose tonsiltiis How does this scoring system work? What score recommends use of antibitoics by NICE and Antibitoic man NHS?

Answer 41

The FeverPAIN criteria are: score 1 point for each (maximum score of 5) - consider ABx if score >/=4 Fever over 38°C. Purulence (pharyngeal/tonsillar exudate). Attend rapidly (3 days or less) Inflamed tonsils (severe) No cough or coryza