1 . Vertigo:
i) The main feature of vertigo is a feeling of dizziness FALSE
ii) May complicate otitis externa FALSE
iii) If a diagnosis of benign paroxysmal positional vertigo is made the patient is likely to be cured by performing the Epley manouvers TRUE
iv) If associated with chronic tinnitus and hearing loss the most likely diagnosis is acute labyrithitis FALSE
v) Is a condition to be expected with ageing FALSE
Explanations
i) Vertigo: The main feature of vertigo is a feeling of dizziness (FALSE)
Many patients experience dizziness; this is not vertigo. Vertigo is characterised by a feeling or illusion of movement relative to the patient's surroundings. It is a severely disabling condition that often results in severe nausea and vomiting.
ii) Vertigo: May complicate otitis externa (FALSE)
Inflammation of the outer ear canal alone will not cause vertigo. However, middle ear disease can cause vertigo.
iii) Vertigo: If a diagnosis of benign paroxysmal positional vertigo is made the patient is likely to be cured by performing the Epley manouvers (TRUE)
Benign paroxysmal positional vertigo is a condition caused by solid particles residing in the semi circular canals; a position where they should not be. The Epley manouvers is a series of movements of the head that works by moving the particles out of the semicircular canals and thus curing the vertigo. IF it fails to cure the vertigo in the first attempt a second attempt is tried. If done properly there is a greater than 90% success rate.
iv) Vertigo: If associated with chronic tinnitus and hearing loss the most likely diagnosis is acute labyrithitis (FALSE)
This is false; the triad of vertigo, tinnitus and hearing loss is the characteristic presentation of Merniere's disease
v) Vertigo: Is a condition to be expected with ageing (FALSE)
Vertigo is not a condition to be expected with ageing. Ageing often causes dizziness and balance disorders due to cardiovascular problems, impaired eyesight and reduced proprioception; but this results in dizziness, not vertigo.
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2 . A patient presents with a painful ear but no obvious pathology affecting his ear. The pain may be referred from:
i) Sinusitis TRUE
ii) Dental disease TRUE
iii) Cervical spondylosis TRUE
iv) Oesophageal malignancy TRUE
v) Lanrangeal malignancy TRUE
Explanations
i) A patient presents with a painful ear but no obvious pathology affecting his ear. The pain may be referred from: Sinusitis (TRUE)
Sinusitis may cause referred otalgia
ii) A patient presents with a painful ear but no obvious pathology affecting his ear. The pain may be referred from: Dental disease (TRUE)
Dental disease may cause referred otalgia.
iii) A patient presents with a painful ear but no obvious pathology affecting his ear. The pain may be referred from: Cervical spondylosis (TRUE)
Cervical spondylosis may cause referred otalgia.
iv) A patient presents with a painful ear but no obvious pathology affecting his ear. The pain may be referred from: Oesophageal malignancy (TRUE)
Oesophageal pathology may cause referred otalgia and malignancy is an important diagnosis not to miss.
v) A patient presents with a painful ear but no obvious pathology affecting his ear. The pain may be referred from: Lanrangeal malignancy (TRUE)
Larangeal pathology may cause referred otalgia and malignancy is an important diagnosis not to miss.
Further notes:
In many ways this is a bad question as it tests a very specific area of knowledge, however it is an important one to get right as otalgia may result from larangeal or oesophageal malignancy.
When working out what structures could cause referred otalgia it is important to consider the sensory nerve supply of the ear. The nerves that innervate the ear are the trigeminal, glossopharangeal, vagus and the posterior roots of the 2nd and 3rd cervical nerves. Thus any structure supplied by these nerves may cause referred otalgia:
TRIGEMINAL (CN V):
- Nose and sinuses
- Teeth
- Parotid gland
- Temporomandibular joint
- Toungue
GLOSSOPHARYNGEAL (IX):
- Oropharynx
VAGUS (X):
- Hypopharynx
- Larynx
- Oesophagus
C1 AND C2 (CERVICAL NERVES)
- Cervical spine
This wide range of structures that can cause referred otalgia means that a patient with no obvious otological pathology requires a thorough history and examination of the head, neck, upper respiratory tract and oesophagus.
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3 . Acute otitis media:
i) Is often associated with a preceeding upper respiratory tract infection TRUE
ii) The tympanic membrane usually becomes retracted leaving the handle and short process of the malleus more prominent TRUE
iii) The tympnaic membrane may become congested and bulge TRUE
iv) Severe pain followed by a very sudden improvement in symptoms is a good prognostic sign FALSE
v) Should be treated with broad spectrum antibiotics and grommit insertion. FALSE
Explanations
i) Acute otitis media: Is often associated with a preceeding upper respiratory tract infection (TRUE)
The bacteria involved in an upper respiratory tract infection (URTI) can track up the eustachian tubes to cause an infection in the middle ear.
ii) Acute otitis media: The tympanic membrane usually becomes retracted leaving the handle and short process of the malleus more prominent (TRUE)
Initially the tympanic membrane usually becomes retracted making the handle and short process of the malleus more prominent.
iii) Acute otitis media: The tympnaic membrane may become congested and bulge (TRUE)
As pressure builds up in the middle ear the ear drum may become distended and bulge outwards. This sign is usually accompanied by severe otalgia and systemic toxicity and fever and tachycardia.
iv) Acute otitis media: Severe pain followed by a very sudden improvement in symptoms is a good prognostic sign (FALSE)
Severe pain followed by a very sudden improvement is not a good prognostic sign. It suggests that the tympanic membrane has perforated. The severe pain (often associated with systemic symptoms) is mainly caused by raised pressure within the middle ear. If the tympnaic membrane ruptures the pressures will equalise and the pain will fall dramatically.
v) Acute otitis media: Should be treated with broad spectrum antibiotics and grommit insertion. (FALSE)
Treatment does involve broad spectrum antibiotics (to cover haemophilus and streptococci), bed rest and analgesia. However, initial treatment certainly does not involve grommit insertion. Grommits should only be considered if there is a persistent middle ear effusion or recurrent attacks of acute otitis media.
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4. Acute otitis externa:
i) Often has an allergic aetiology FALSE
ii) Is more common in patients who use cotton wool buds to remove ear wax TRUE
iii) Is more common in patients with eczematous ear canals TRUE
iv) Is more common in people who fail to remove water from their ears adequately TRUE
v) The first line treatment of choice is steroid ear drops alone FALSE
Explanations
i) Acute otitis externa: Often has an allergic aetiology (FALSE)
This is false; otitis externa usually a result of bacterial infection and occasionally a result of fungal infection. The bacteria most commonly involved include: streptococci, staphylococci and pseudomonas. Aspergillus is the most commonly implicated fungus.
ii) Acute otitis externa: Is more common in patients who use cotton wool buds to remove ear wax (TRUE)
The use of cotton wool buds to remove ear wax may cause local trauma and thus predispose to bacterial infection.
iii) Acute otitis externa: Is more common in patients with eczematous ear canals (TRUE)
The damaged skin allows bacteria to colonise and infect the ear canal more easily
iv) Acute otitis externa: Is more common in people who fail to remove water from their ears adequately (TRUE)
Moist, humid environments predispose to bacterial infection.
v) Acute otitis externa: The first line treatment of choice is steroid ear drops alone (FALSE)
This is false. Acute otitis externa is usually bacterial and thus antibiotics +/- steroids are the first line treatment of choice (unless the infection is obviously fungal).
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5 . Nasal polyps:
i) The majority of cases are associated with allergic or intrinsic rhinitis. TRUE
ii) Are usually unilateral FALSE
iii) Are usually bright red and bleed readily FALSE
iv) Predispose to sinusitis TRUE
v) Polyps of all sizes can usually be treated effectively by topical steroids. FALSE
Explanations
i) Nasal polyps: The majority of cases are associated with allergic or intrinsic rhinitis. (TRUE)
Only about 25% of patients will have a positive skin prick test, but most will have a history indicative of allergic or intrinsic rhinitis.
ii) Nasal polyps: Are usually unilateral (FALSE)
This is false; nasal polyps are almost always bilateral. Unilateral lesions are strongly suggestive of malignancy and require urgent investigation.
iii) Nasal polyps: Are usually bright red and bleed readily (FALSE)
Nasal polyps are usually grey, insensitive to palpation and do not bleed easily. A lesion that bleeds easily, espescially if unilateral, is suggestive of malignancy and requires urgent biopsy.
iv) Nasal polyps: Predispose to sinusitis (TRUE)
Some patients with nasal polyps will suffer from recurrent episodes of sinusitis because the polyps block the sinuses.
v) Nasal polyps: Polyps of all sizes can usually be treated effectively by topical steroids. (FALSE)
Small polyps may regress on steroid therapy, however larger polyps usually require surgery in the form of polypectomy.
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6 . Tuning fork tests for hearing:
i) Are not as good as whisper or voice tests for checking hearing in the consultation room. FALSE
ii) A patient with normal hearing will hear air conduction of sound from the tuning fork louder than bone conduction of sound. TRUE
iii) On examination with the Weber test, a patient hears the sound loudest in their right ear; this result is consistent with a diagnosis of right sided glue ear. TRUE
iv) On examination with the Weber test, a patient hears the sound loudest in their right ear; this result is consistent with a diagnosis of right sided acoustic neuroma. FALSE
v) On examination a pateint is Rinne positive in their left ear and Rinne negative in their right ear. The Weber test is heard loudest in their left ear. This is consistent with a diagnosis of comlete right sided sensorineural deafness. TRUE
Explanations
i) Tuning fork tests for hearing: Are not as good as whisper or voice tests for checking hearing in the consultation room. (FALSE)
Tuning fork tests are much more sensitive than whisper and voice tests. In fact, whisper and voice tests are relatively useless unless performed in a quiet room with sound pressure level meters.
ii) Tuning fork tests for hearing: A patient with normal hearing will hear air conduction of sound from the tuning fork louder than bone conduction of sound. (TRUE)
The Rinnie test is used to compare air conduction of sound and bone conduction of sound. A normal patient will hear the tuning fork better by air conduction rather than bone conduction. This result is known as Rinne positive.
iii) Tuning fork tests for hearing: On examination with the Weber test, a patient hears the sound loudest in their right ear; this result is consistent with a diagnosis of right sided glue ear. (TRUE)
A patient with right sided glue ear will have a conductive hearing loss in their right ear. Thus the patient will have heightened bone conduction hearing on their right side and the Weber test will be heard loudest on that side.
iv) Tuning fork tests for hearing: On examination with the Weber test, a patient hears the sound loudest in their right ear; this result is consistent with a diagnosis of right sided acoustic neuroma. (FALSE)
An acoustic neuroma damages the vestibulo cochlear nerve resulting in a unilateral sensorineural hearing loss. With a unilateral sensorineural hearing loss the Weber test will sound loudest in the unaffected ear; in the case the left ear. The answer is therefore false.
v) Tuning fork tests for hearing: On examination a pateint is Rinne positive in their left ear and Rinne negative in their right ear. The Weber test is heard loudest in their left ear. This is consistent with a diagnosis of comlete right sided sensorineural deafness. (TRUE)
This is the most difficult question from this set as it demands a good appreciation of both the Rinne and Weber tests. Furthermore the fact that the patient is Rinne negative in their right ear may appear consistent with a conductive hearing loss rather than a sensorineural hearing loss, however this is not the case:
A severe, unilateral sensorineural hearing loss will result in the contralateral ear picking up sound better than the affected ear during the Rinne test. Sound transmition to the contralateral ear will be greatest through bone as the sound will be transmitted through the skull, sound transmission through the air to the contralateral side will be minimal; thus pateints with severe or complete sensorineural hearing loss will be Rinne negative in the affected ear. In an examination such patients should be re-tested with appropriate sound masking in the contralateral ear (using a noise emitter), this masking should correct the Rinne test and nothing is likely to be heard in the affected ear at all.
Further notes:
This is a tricky question. The first branches are relatively easy but get progressively harder as you go through the question with branches 3 and 4 testing your knowledge of both the Weber test and the causes of sensorineural and conductive deafness. The last branch is particularly tricky and demands a good appreciation of both tests in a complex presentation.
If you have not done well on this question I strongly suggest you revise tuning fork tests as these tests come up often in clinical examinations and OSCEs. To summarise the tests:
CONDUCTIVE DEAFNESS:
- Rinne negative in affected ear (bone conduction louder than air conduction).
- Weber heard loudest in affected ear
SENSORINEURAL DEAFNESS:
- Rinne positive in affected ear
- Weber heard loudest in the unaffected ear (or the ear with the greatest cochlear function)
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7 . Acute sinusitis:
i) Usually starts with a viral infection of the nose and sinuses TRUE
ii) Facial swelling is seen in most cases of acute sinusitis FALSE
iii) Inflammation and swelling of the skin around the eye is a common feature of sinusitis in children FALSE
iv) Is usually self limiting and is therefore often left to clear on its own without medical intervention. FALSE
v) Involvement of the frontal sinus is worrying as it may lead to meningitis TRUE
Explanations
i) Acute sinusitis: Usually starts with a viral infection of the nose and sinuses (TRUE)
Sinusitis usually begins with a viral infection causing local inflammation, blockage of the sinus ostia and paralysis of the mucociliary clearance system. The blocked sinus then usually becomes superinfected with local, resident bacteria.
ii) Acute sinusitis: Facial swelling is seen in most cases of acute sinusitis (FALSE)
Facial swelling is not usually seen; its presence suggests that complications of the infection have occured and the patient needs a more thorough investigation
iii) Acute sinusitis: Inflammation and swelling of the skin around the eye is a common feature of sinusitis in children (FALSE)
Involvement of the skin around the eye is not normal and is a worrying sign as it is suggestive of orbital abcess, a condition that can complicate ethmoiditis. Orbital abscess can result in permenant blindness and has a significant mortality rate if left untreated so it is important to recognise it early and treat with antibiotics and surgical drainage if required.
iv) Acute sinusitis: Is usually self limiting and is therefore often left to clear on its own without medical intervention. (FALSE)
Sinusitis can have serious complications and is extremely painful so is always treated with a combination of broad spectrum antibiotics, analgesics (such as paracetemol or codine) and often with nasal decongestants such as ephidrine.
v) Acute sinusitis: Involvement of the frontal sinus is worrying as it may lead to meningitis (TRUE)
Frontal sinusitis has many serious complications including:
- Osteomyelitis
- Extradural abscess
- Subdural abscess
- Frontal lobe abscess
- Meningitis
- Encephalitis
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8 . A 32 year old woman presents to her GP with a 2 week history of a hoarse voice.
i) If her hoarsness does not resolve within the following 5 weeks she should then be referred to a specialist FALSE F
ii) The most common cause of hoarsness is acute laryngitis TRUE
iii) If acute laryngitis is diagnosed she should be treated with broad spectrum antibiotics FALSE
iv) The patient also has signs of hypothyroidism: if this diagnosis is confirmed it could explain the hoarseness. TRUE
v) A Vagus nerve palsy would not cause hoarseness. FALSE
Explanations
i) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. If her hoarsness does not resolve within the following 5 weeks she should then be referred to a specialist (FALSE)
This is false; if a patient remains hoarse for over a month they should then be referred urgently to a specialist: 7 weeks (NB: symptoms present for 2 weeks before presentation) is far too long to wait before referring because dysphonia is an important sign of neoplasia.
ii) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. The most common cause of hoarsness is acute laryngitis (TRUE)
Acute laryngitis is very common and often causes dysphonia. The aetiology of acute laryngitis may be:
- Infective (associated with upper respiratory tract infections)
- Traumatic (Eg: following shouting)
- Chemical (Eg: smoking, inhalation of chemicals)
iii) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. If acute laryngitis is diagnosed she should be treated with broad spectrum antibiotics (FALSE)
Acute layngitis usually has a viral aetiology and resolves spontaneously. Antibiotics are unlikely to have much effect on clinical outcome, even if the infection is bacterial as by the time the antibiotic is becoming effective, the body will usually have mounted a good immune response.
iv) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. The patient also has signs of hypothyroidism: if this diagnosis is confirmed it could explain the hoarseness. (TRUE)
Hypothyroidism can cause oedema of the vocal cords and a resulting hoarse voice. A deepening and hoarsness of the voice is a well recognised symptom of hypothyroidism.
v) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. A Vagus nerve palsy would not cause hoarseness. (FALSE)
The vocal cords are innervated by both the vagus and recurrent laryngeal nerves; damage to either of these nerves can cause hoarsness,
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9 . During surgery on the submandibular gland
i) an incision directly over the lower border of the mandible is safe FALSE
ii) the submandibular gland is seen to wrap around the posterior border of the mylohyoid muscle TRUE
iii) the facial artery and vein are divided as they course through the deep part of the gland FALSE
iv) the hypoglossal nerve is seen to loop under the submandibular duct FALSE
v) damage to the lingual nerve will cause loss of sensation to the posterior third of the tongue FALSE
Explanations
i) During surgery on the submandibular gland an incision directly over the lower border of the mandible is safe (FALSE)
The incision should be made 2cm below the lower border of the mandible to avoid damage to marginal mandibular branch of the facial nerve
ii) During surgery on the submandibular gland the submandibular gland is seen to wrap around the posterior border of the mylohyoid muscle (TRUE)
The submandibular gland has superfical and deep parts that are connected at the posterior border of the mylohyoid muscle
iii) During surgery on the submandibular gland the facial artery and vein are divided as they course through the deep part of the gland (FALSE)
The facial artery and vein pass through the superfical part of the gland. They invariably need to be divided as they both enter and leave the gland
iv) During surgery on the submandibular gland the hypoglossal nerve is seen to loop under the submandibular duct (FALSE)
The lingual nerve is seen to loop under the submandibular duct
v) During surgery on the submandibular gland damage to the lingual nerve will cause loss of sensation to the posterior third of the tongue (FALSE)
The lingual nerve supplies sensation to the anterior two-thirds of the tongue. The glossopharyngeal nerve supplies sensation to the posterior one-third of the tongue
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10 .
The following conditions may complicate otitis media:
i) Acute mastoiditis TRUE
ii) Thrombosis of the lateral venous sinus TRUE
iii) Facial paralysis TRUE
iv) Reactive arthritis FALSE
v) Labyrinthitis TRUE
Explanations
i) The following conditions may complicate otitis media: Acute mastoiditis (TRUE)
Mastoiditis is probably the most common complication of otitis media and is seen predominantly in children.
Mastoiditis is associated with severe pain and an oedematous posterior ear canal wall. This condition is serious and should be treated by prompt administration of IV antibiotics, occasionally surgery may be required in the form of cortical mastoidectomy.
ii) The following conditions may complicate otitis media: Thrombosis of the lateral venous sinus (TRUE)
This may occur following mastoiditis with suppuration extending into the sinus leading to clot formation and vessel occlusion. The patient will often develop rigours and fever, but these symptoms may be masked by previous antibiotics
iii) The following conditions may complicate otitis media: Facial paralysis (TRUE)
The facial nerve may become damaged as it passess through the ear. The paralysis is caused by the local inflammatory reaction and is usually temporary.
iv) The following conditions may complicate otitis media: Reactive arthritis (FALSE)
Reactive arthritis does not complicate otitis media
v) The following conditions may complicate otitis media: Labyrinthitis (TRUE)
The infection may spread into the inner ear to cause labyrinthitis, a condition that is associated with vertigo, nausea, vomiting amd often sensorineural hearing loss.
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