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NB: ENT was only examined in about 6% of our questions last year. For comparison, there were three times as many O&G questions, and twice as many Psych, Paeds or Haem questions. I would recommend focusing on those topics more than ENT if you’re tight for time, then focusing on the ENT conditions listed in the MLA content map. Q1 A 3-year-old girl is brought to the general practitioner. She has been distressed with otalgia, pulling her left ear for 12 hours. Just before arriving at the practice, the mother notices a smelly fluid discharge from her daughter’s left ear. Since then, her otalgia has resolved. What is the most likely diagnosis? 1. Acute otitis media 2. Otitis media with effusion a. Presents similarly, but onset less acute 3. Cholesteatoma a. Tends to affect teenagers 4. Otitis externa a. Wouldn’t get resolution of otalgia after fluid discharge 5. Malignant otitis externa a. Condition of elderly diabetics. Q2 A 5-year-old-boy presents with a persistent hearing loss. His mother reports concerns from his teachers that he does not seem to pay attention in class. She reports he often turns up the volume of the television while at home. On examination, the left eardrum is retracted and there is loss of the light reflex. He presented to your colleague 12 weeks previously with similar symptoms, and audiometry showed moderate hearing loss, particularly at low frequencies. What is the next most appropriate management in primary care? 1. Prescribe a 5 day course of antibiotics and review symptoms following the treatment course a. AOM treatment 2. Refer to an ear, nose and throat (ENT) specialist for further management a. Glue ear 3. Reassure the patient that most cases of otitis media with effusion spontaneously resolve, and arrange routine follow-up in 2-3 months with a repeat audiogram a. Delay may lead to complications 4. Prescribe a 2 week course of decongestants and review symptoms following the treatment course a. Non-allergic sinusitis 5. Arrange a hearing aid for the child, and review in 2-3 months a. Mainly used for sensorineural hearing loss in elderly patients. b. Don’t get confused with cochlear implants which are for profound hearing loss once all other therapies have been exhausted. Q3 A 4-year-old girl, an avid swimmer, attends the GP practice with her mother complaining of discharge from her right ear. She states that the ear is painful and has been for the last 2 days. On examination there is a creamy discharge which partially occludes the external auditory meatus. The canal is red and inflamed and the tympanic membrane is intact. What is the most appropriate treatment option? 1. Oral antibiotics for 5-7 days a. Systemic treatment not required. 2. Microsuction, discharge and give analgesia 3. 2% acetic acid drops a. Use for mild otitis externa 4. Urgent referral to ENT is required 5. Advise not to go swimming and topical antibiotic/steroid drops a. Best is to avoid precipitants and RF: recent swimming, tropical climate Q4 A 33 year old woman presents to her GP complaining of an episode of what she described as “the world rotating,” which has since resolved. She says that the vertigo has made her vomit, though she currently denies nausea. Upon further questioning, she reveals that she has experienced three similar episodes in the last week, and that they are associated with “difficulty hearing” and “ringing in the ears”. Neurological examination shows no physical abnormalities. What is the most likely diagnosis? 1. Viral labyrinthitis a. Split into conditions that cause hearing loss, conditions that cause vertigo, and conditions that cause both. 2. Vestibular neuritis a. Only the vestibular function is affected. 3. Vestibular migraine a. Generally associated with identifiable triggers. 4. Meniere’s disease a. Aural fullness, recurs at random points throughout the week. Always ask about driving. 5. Acoustic neuroma a. Vestibular schwannoma.Q5 A 72 year old woman presents with progressively worsening deafness in her right ear. She first noticed that she had difficulty hearing the doorbell, however she now finds it difficult to follow conversations. She does not report any problems with the left ear. She reports she occasionally gets attacks of tinnitus in her right ear which have worsened over the past 3 months. She does not report any problems with balance nor the presence of a headache. What is the single most appropriate investigation? 1. MRI head a. Likely Acoustic neuroma 2. Clinical diagnosis a. True for meniere’s but would want to rule out acoustic neuroma first for this lady. 3. Auditory brainstem response test 4. Audiometry a. May still be performed and will show sensorineural hearing loss 5. Otoacoustic emission testing a. Newborn Hearing Screening Programme. Q6 A 70-year-old woman presents with vertigo and vomiting. On examination she has gaze evoked nystagmus with no other obvious clinical signs. A head impulse test is normal. What is the most appropriate next step? Correction to question: The vertigo is persistent, no corrective saccade (oscillations of the eye due to fast head movements in order to refocus on the target). 1. Perform dix - hallpike manoeuvre a. There is never a situation in which you would perform both the Dix hallpike and head thrust examination. https://www.youtube.com/watch?v=9fQlnDLVeCE b. Indications for HiNTS exam: i. Persistent vertigo over hours or days ii. Nystagmus iii. A normal full neurological exam 2. Give prochlorperazine and review in 4-6 weeks a. Yes if persistent vertigo alone – need to find underlying cause first though 3. Perform Epley manoeuvre 4. Refer to A&E a. HiNTs exam helps to identify the cause of vertigo – peripheral (vestibular function), or central (posterior circulation stroke). The head impulse test assesses whether the vestibulo-ocular reflex (VOR) is intact. b. Central cause if gaze-evoked nystagmus, or any DANISH symptoms. Gaze-evoked nystagmus is due to a deficiency of neural positional integrator 5. Advise Brandt Daroff exercises Q7 A 75 year old gentleman presents to his GP with sudden attack of dizziness. During these episodes, he feels that the room is spinning around him. These episodes occur for approximately 30 seconds. There are no signs of any focal neurology. Which of the following options is the most appropriate next step? 1. Perform Epley manoeuvre 2. Perform Dix-hallpike manoeuvre a. BPPV is the most common cause of vertigo - affects approximately 1 in 50 adults in their lifetime. However, 15% of patients who present to the ED with vertigo have a life-threatening cause. 3. Advise Brandt Daroff exercises 4. Give prochlorperazine and review in 4-6 weeks 5. Refer to A&E Q8 A 54-year-old man presents with a 2-day history of sudden onset left-sided hearing loss. On further questioning, there is no history of trauma and he has otherwise been well in himself. He describes some tinnitus in his left ear alongside vertigo. On examination, he has a moderate amount of ear wax bilaterally. He has no pinna, tragal or mastoid tenderness. The small amount of tympanic membrane you can see bilaterally appears normal. There is evident hearing loss on his left side. Whilst performing Weber's test, he localises the sound to his right side. Rinnes test is positive bilaterally (air conduction better than bone). What is the most appropriate next management step? 1. Ear irrigation a. Always exclude conductive causes (Eg. ear wax, otitis externa) before arranging audiological assessment. ENT will perform irrigation. 2. Intranasal corticosteroids a. Indicated if there is eustachian tube dysfunction. 3. Routine referral to ENT 4. Trial of prochlorperazine a. Indicated if there is vertigo 5. Urgent referral to ENT a. Sudden-onset sensorineural hearing loss always requires an immediate referral to ENT (seen within 24 hours) - defined by NICE as sudden onset (over a period of 3 days or less), and episode occurred within the last 30 days. b. If the episode occurred more than 30 days ago, you do an urgent referral (seen within 2 weeks). c. So immediate referral if sudden onset + <30 days ago/ assoc. facial droop/ immunocompromised. Q9 An 11-year-old boy attends the emergency department with his mother because of a nosebleed. He is leaning forward while pinching his nose and he appears calm. The nosebleed started 30 minutes ago, and he has been pinching his nose ever since. He tends to pick his nose and suffers from recurrent nosebleeds. Nil past medical history. He is haemodynamically stable. On examination, he is mouth breathing and there is no coughing or choking. There is blood dripping from his right nostril when he takes his hand away. On closer examination, you can see a bleeding site on his right septum. What is the next most appropriate management step? 1. Further direct compression for 10-15 minutes 2. Nasal packing 3. Transnasal endoscopy with direct cautery 4. Nasal cautery a. Method of choice if obvious bleeding site 5. Nasal balloon catheter Q10 A 20-year-old gentleman presents to the GP with pain in his forehead and cheeks as well as nasal discharge for the past 3 days following a cold. Which is the most appropriate treatment for this patient? 1. Paracetamol, nasal saline irrigation and decongestants a. Acute sinusitis 2. Paracetamol, nasal saline irrigation, decongestants and amoxicillin a. Abx if the patient is seriously unwell or immunocompromised - beware of double sickening. 3. Paracetamol, nasal saline irrigation, decongestants and intranasal steroids a. Intranasal steroids if the symptoms have been present for more than 10 days. 4. Paracetamol, nasal saline irrigation decongestants and ceftriaxone a. Penicillin V or co-amoxiclav are the first line options 5. Subcutaneous sumatriptan a. Some migraines present with pain in the forehead but the nasal discharge and preceding cold make sinusitis more likely. Q11 A 29-year-old man presents to the emergency department after being hit in the face by a ball whilst playing rugby. The patient reports some nasal pain but feels otherwise well. On examination, the left nasal septum is swollen and soft to the touch, and there is epistaxis from the right nostril. Externally, the nose appears aligned. What is the best management step? 1. Anterior nasal packing and cautery of the right nostril a. Applicable if there is a clear bleeding site 2. Leave for 7-14 days and then attempt septal reduction a. Complications of septal haematomas include septal perforation and saddle nose deformity 3. Apply local anaesthetic and aspirate left nostril 4. Nasal packing then routine ENT referral 5. Nasal packing and urgent ENT referral Q12 A 7 year old boy attends A&E with a lego block stuck in his nose. You have been unable to retrieve the foreign body using the parent’s kiss technique and a wax hook. The child is crying and feels unable to nasal breathe. SpO2 94% on room air. What is the next most appropriate action to take? 1. Book for EUA nose + removal of foreign body by tomorrow morning a. Two methods have already been tried without success which suggests that the foreign body is firmly lodged and requires more definitive management. Still want to do it as soon as you can. 2. Refer to ENT for immediate removal of foreign body a. Immediate removal is indicated for batteries (especially button batteries which can leak alkali material into the nose and erode the mucosa), or magnets. 3. Attempt removal with suction catheter 4. Advise that it will fall out by itself and follow up in 4-6 weeks 5. Give oxygen and bleep anaesthetics Q13 A 15 year old male presents to his GP with an ongoing sore throat and widespread maculopapular rash that developed over the past day. He recently recovered from a flu-like illness and sore throat 1 week ago, for which he was given a course of antibiotics. His tonsils are swollen with creamy exudate. Which is the most likely cause of this patient's rash? 1. Anaphylaxis 2. Steven-johnson syndrome a. Dermatological reaction to mild infections or medications which also involves the mucosa. It is thought to be on a spectrum with erythema multiforme and toxic epidermal necrolysis 3. Jarisch-herxheimer reaction a. Transient dermatological reaction to antibiotics in patients who have had certain infections called spirochete infections eg. syphilis, lyme disease 4. EBV a. Glandular fever 5. Group A streptococcus a. This patient was treated as though they had Group A strep with abx, but this was the wrong diagnosis. Q14 A 7 year old is brought to his GP by his parents complaining of a sore throat and a hoarse voice lasting 3 days. He has no cough and no problems breathing but complains of pain on swallowing. His parents report that he was previously pyrexial at 39.2. On examination his tonsils appear red and swollen with an overlying white exudate. There is no palpable lymphadenopathy. What is the most appropriate management of this patient? 1. 10 day course of oral amoxicillin a. Not first line 2. 10 day course of oral penicillin V a. This is tonsillitis or quinsy. Use FeverPAIN score or CENTOR criteria. 3. Admit to hospital for IV amoxicillin 4. Admit to hospital for IV penicillin V a. May be indicated if systemically unwell 5. Reassure and discharge home with no antibiotics Q15 An 18-year-old girl is seen in the GP clinic with a 2-day history of sore throat. She has had 5 episodes of tonsillitis in the past year. Mum says it started off with coughing followed by a sore throat. She is currently struggling to eat or drink due to the pain. She has a temperature of 38.5 and lymphadenopathy is seen on the right side at level II. On examination, the patient is having some difficulty fully opening her mouth, but you can see an erythematous swollen soft palate on the right side, and the uvula is deviated towards the left. Which of the following is the best next step in the management of this patient? 1. Treat tonsillitis and request routine referral to ENT for tonsillectomy a. Indications for tonsillectomy are 7 in 1 year. She is still in the acute phase so tonsillectomy may not be the safest option. 2. Prescribe STAT dose of steroids, antibiotics, and difflam spray 3. Send home with analgesia and reassurance 4. Prescribe 10 day course of phenoxymethylpenicillin and review in 2 weeks 5. Send to hospital immediately a. This is quinsy with trismus. She has lymphadenopathy of the upper jugular nodes by the upper third of her sternocleidomastoid. b. Complications include airway compromise and spread of infection. Q16 A 62-year-old man presents to his GP with a persistently hoarse voice following a bout of sore throat 3 weeks ago. He requests some antibiotics as it is now starting to affect his work (he is a football commentator). When you examine his throat, you note that there is no pus or exudate on his tonsils, he doesn’t have a cough, and he doesn’t have any obvious lymphadenopathy. Given this man's presentation, what is the best approach to take? 1. Prescribe antibiotics and paracetamol 2. Refer to OT for vocal rehabilitation exercises a. Considered once sinister causes ruled out 3. Prescribe antibiotics and paracetamol and refer him non-urgently to have a neck ultrasound 4. Review the man in 3 days to assess the need for antibiotics 5. Refer on the 2-week wait cancer pathway a. Laryngeal cancer b. Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with: i. persistent unexplained hoarseness or ii. an unexplained lump in the neck He requires an X-ray to rule out apical lung lesions that could be affecting the recurrent laryngeal nerves https://cks.nice.org.uk/topics/head-neck-cancers-recognition-referral/ Q17 A 48-year-old man presents to her GP complaining of extreme tiredness during the day. He explains that this has been ongoing for months but that recently he has been falling asleep at work and is finding it increasingly difficult to concentrate. His wife says that he snores very loudly. He has a BMI of 36kg/m² and a past medical history of hypertension and type 2 diabetes for which she takes no medication. A recent comprehensive set of blood tests returned normal. On examination, his adenoids appeared enlarged. What is the most appropriate next step in this patient's management? 1. Continuous positive airway pressure (CPAP) a. Treatment once diagnosis confirmed 2. Keep a pulse oximetry diary for a minimum of 2 weeks 3. Routine referral to ENT for adenoidectomy 4. Arrange formal polysomnography assessment a. OSA formal diagnosis required. 5. Advise weight loss and lifestyle modification then review in 4-6 weeks Q18 A 50 year old woman presents with slowly worsening diffuse swelling in the region of her right parotid gland together with facial pain. On examination she has a right sided facial nerve palsy. She has no significant past medical history of note. The remainder of her neurological examination is intact and blood tests are normal. What is the single most likely diagnosis? 1. Warthin's tumour a. Tends to be bilateral in older women. 2. Sarcoidosis a. In Mikulicz syndrome there is enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma 3. Sjogren's syndrome a. Associated with systemic dryness4. Benign pleomorphic adenoma a. This is the most common, but is benign 5. Adenoid cystic carcinoma a. This is a parotid gland malignancy that has invaded her facial nerve. b. Diagnostic evaluation i. Plain x-rays may be used to exclude calculi ii. Sialography may be used to delineate ductal anatomy iii. FNAC is used in most cases Superficial parotidectomy may be either diagnostic of therapeutic depending upon the nature of the lesion. Where malignancy is suspected the primary approach should be definitive resection rather than excisional biopsy iv. CT/ MRI may be used in cases of malignancy for staging primary disease