DOHNS APRIL 2008

MANNED STATIONS:

History:
Anosmia
UPSIT (Uni of Pennsylvanian Smell ID Test)
Ammonia cos its trigeminal
<5 malingering
Precaution methane alarm/ fire alarm/ smoke alary
Convert gas to electricity
Food: keep sell by date
Examination:
FNE for hoarse patient
-Explain
-perform on manikin,
-look at picture of larynx - draw picture (from photo) and label
Examination:
Ear examination (not including vertigo) – instruments provided – headlight, otoscope, tuning forks
Explanation:
Man admitted with severe epistaxis. Explain to relative causes and treatment including surgical Mx (patient has agreed to
discussion)
Explanation:
Explain Dx of BPPV – discuss management options + Epley’s manourve (ask if they have arthritis in neck – if they do – don’t do it)

UNMANNED STATIONS:

Op note – 3 yo who you Pt details: names/ DOB/ HN

have performed bilateral Surgeon/ anaesthetist/ scrub nurse
grommets and Date
adenoidectomy on. The Op
anaesthetist is happy for Indication: Recurrent tonsillitis
patient to be discharged Findings: Grade 2 tonsils
the same day
Procedure:
Op note - tonsillectomy standard drapes
boyle davis gag and draffin rods
bilateral cold steel dissection
2.0 silk ties to both lower poles
diathermy haemostasis (12w)
PNS suctioned
swab count correct
Teeth/ TMJ

Post op:
Monitor airway, pulse, bp, O2 sats, signs of swallowing,
Regular analgesia, encourage E+D
Doctor to review prior to D/C
Home late if well
2 pictures of TMs: -label the pictures right and left
L ?retraction
R ?OME -draw the tympanograms for the ears shown
normal tympanogram peak at just after 0 on x axis and 0.5mls on y axis and a flat tympanogram.
X axis – dPA
Y axis – compliance (mls)

-what Sx would patient most likely complain of

hearing loss, sensation of blocked ear, tinnitus
-Dx for each picture
 -if person was of Southern Chinese origin, what other Ix would you want to do
examine post nasal space either with rigid nasoendoscope or with a fibreoptic flexible nasoendoscope

Video of L vocal cord -3 most common causes

palsy Iatrogenic- post thyroid surgery, post carotid enartrectomy, medistinal surgery
Malignancy such as lung cancer, thyroid carcinoma
Traumatic
Idiopathic
Viral infection

-2 Sx this pt is most likely to complain of

hoarse voice, inadequate voice projection, breathy quality to voice, difficulty swallowing, loss of vocal
pitch, noisy breathing

-What is the principle of surgical treatment in this condition

to medialize affected vocal cord for approximation of vocal cords

-what is the length of time you would wait before undertaking surgery
??

CT sinuses with ? -what is the view

opacification L maxillary Axial CT scan of sinuses
sinus
-what Ix is this
CT scan

-describe the abnormality shown

opacification of left maxillary sinus

-what artery causes increased intro-occular pressure if damaged

Ethmoidal artery

-what structures in this region can be damaged during surgery

optic nerve, medial rectus muscle for orbit, base of skull, nasolacrimal duct injury

Photo of tonsillitis -list 2 DDx

acute tonsillitis, glandular fever

-what are the causative organisms for these

Group A beta haemolytic streptococcus and Ebstein Barr Virus

-what are the 4 principles of treatment

Analgesia
Antibiotics avoiding amoxicillin
Fluid rehydration
Throat relief with difflam mouth wash ?

-what 2 serological tests would be useful in dx

Monospot test
Full blood count

CT temporal bone with -what is this Ix

arrow to right sided # Axial CT scan of temporal bone
PTA with normal L side,
dead ear on the R What is the Dx
Transverse fracture of right temporal bone

-describe in words the PTA

Normal hearing on left side
 Profound sensorineural hearing loss on right side

-what other Sx might this pt have

Dizziness, facial nerve palsy, headaches, CSF otorrhoea, CSF rhinorrhoea, unilateral loss of taste

-the pt wants to know if his hearing will recover and if a BTE HA will help. What will you tell him
hearing is unlikely to recover. BTE would not help as patient has profound SNHL. However, there are
other hearing aids which may be useful such as bone conduction hearing aids. Either bone aid which is
held by a headband or a bone anchored hearing aid.

Ba swallow pharyngeal -what is this Ix

pouch Barium swallow

-Dx
pharyngeal pouch

-What is the anatomical defect that causes this

Weakness in the inferior constrictor muscle at Killian’s Dehiscence between the cricopharyngeus and
thyropharyngeus muscle.

-list 3 Sx this might cause

regurgitation of old food
halitosis
aspiration
recurrent aspiration pneumonia
dysphagia
neck lump

-name most common surgical procedure and the structure it divides

endoscopic pharyngeal pouch stapling.
It involves stapling the bar of tissue dividing the pouch and the oesophagus.

Photo – attic -what is the dx

cholesteatoma Attic Cholesteatoma

What type(s) of deafness can this cause and why

Conductive hearing loss as it may erode and discontinue the ossicular chain
Mixed hearing loss – erosion into the labyrinth or inner ear and the ossicles but the cholesteatoma
itself is in contact with the inner ear to transmit sound.

-list 2 sx this might cause except from deadness (excluding complications)

hearing loss
dizziness

-if this was a 6 yo ear what would be the treatment

-list 4 complications of surgery
meningitis
facial nerve palsy
dizziness
hearing loss
bleeding

Skull base with various -name 2 muscles that attach to ‘A’ (mastoid)
pins in situ (viewed from sternocleidomastoid muscle
inferiorly not posterior belly of diagastrci muscle
intracranially)
-name 1 muscle and 1 ligament that attach to ‘B’ (styloid process)
styloglossus muscle, stylohyoid muscle, stylopharyngeus muscle
stylohyoid ligament
 -what runs through ‘C’ (stylomastoid foramen)
facial nerve

-what runs through ‘D’ (foramen lacerum)

greater pertrosal nerve

-what 4 things run through ‘E’ and what is the name of the foramen (jugular foramen)
sigmoid sinus which then forms the internal jugular vein
glossopharyngeal nerve
vagus nerve
accessory nerve

PTA with normal hearing -draw symbol for right unmasked AC

on L and SNHL (worse O
with higher frequencies)
on R -draw symbol for left unmasked AC
X

-draw symbol for unmasked BC

triangle

-describe in words the PTA

Normal hearing in left ear.
Right ear has high frequency SNHL.

-what is the DDx in a 6 yo

congenital hearing loss as part of syndrome eg: Waardenburg syndrome, CHARGE syndrome, NF2
intrauterine infectioncs TORCHS
neonatal/childhood infection eg meningitis
Maternal drug/alcohol abuse during pregnancy
Ototoxic drugs during childhood

Photo: neck swelling ? -which triangle is the swelling

branchial cyst anterior triangle

-what is the most likely Dx

branchial cyst

-list 3 DDx
lymphadenopathy
parotid swelling
submandibular gland swelling
carotid body tumour
sebaceous cyst
lipoma

-what Ix would you next perform in clinic

FNA

-assuming the lesion is cystic what could be 3 findings

aspiration of turbid fluid
??

-describe at least 2 Mx options

conservative – observation for frequency of infections and if the lump is enlarging. Treat infections with
antibiotics
surgical – excision of branchial cyst
Photo: septal perforation -what is the Dx
septal perf

-what is the main cause

trauma
untreated septal haematoma
granulomatous disease – sarcoidosis, Wegener’s granulomatosis
infective – TB, syphyllis
drugs
iatrogenic – post septoplasty

-what Ix could you arrange

FBC, UE, LFT, cANCA, ANA, ESR, TB screen, syphllis screen

-what Sx may this pt complain of

whistling
crusting
nasal obstruction
epistaxis

-what Tx options are there

conservative
medical – regular naseptin cream to avoid crusting, nasal douching
surgical – insertion of septal button, surgical closure with a flap/graft

Table of instruments -what is the full name of object ‘A’ (BIPP)

(cophenylcaine spray, bismuth iodoform paraffin paste
cautery stick, rigid
oesophagoscope, rigid -what object would you use to remove FB from lower
bronchoscope, foley trachea
catheter, crocodile bronchoscope
forceps, BIPP)
-which object would you use with pt with epistaxis and vessels in Little’s area
silver nitrate cautery stick

-Which object would you put in a TOF

blom singer valve

-In a pt with dislodged Blom Singer valve, which object could you insert instead
foley catheter

-which object would you use to insert a wick in a patient with otitis externa
crocodile forceps
-which 4 objects could you use in a patient with a significant posterior epistaxis
tilley’s nasal dressing forceps
bismuth iodoform paraffin paste
LA spray
Foley catheter

Photo: right tongue -what is the likely histology of this lesion

lesion SCC

-list 5 risk factors for this condition

alcohol
smoking
HPV infection subtype 6,11
Betel nut chewing
Sharp teeth
Spicy food
 -what are the tx options
conservative
chemoradiotherapy
surgical excision

-list 3 factors (excluding histology) which affect which treatment option is used
staging of disease using TNM classification
patient fitness for surgery
patient consent

Button battery -what is this

button battery

-where is it used in ENT

hearing aid

-list 2 complications occurring if this object was placed in the nose

septal perforation
erosion of nasal mucosa

-list 2 complications occurring if this object was placed in the ear

erosion into bony canal wall
TM perforation

-if an adult pt with learning difficulties presented after swallowing a button battery less than 2 hrs ago
what would be your 1st line Ix
x ray lateral soft tissue neck, chest and abdomen

-what tx is required
removal of FB under GA

-what complication can occur if it is not removed

bowel perforation causing peritonitis

Electronmicrograph of -label diagram

cochlea -which part is affected in Meniere’s disease
-the round window opens into which are
-the oval window opens into which area
-what is the helicotrema
area where scala tympani and scala vestibuli meet

-what is the primary cation in channel ‘A’

Photo: oropharynx with -describe the abnormality and its position
post nasal mass visible pale coloured jelly like mass in oropharynx which appears to be protruding from the nasopharynx
A patient presents with
nasal obstruction and -what is the most likely dx
rhinorrhoea. He has nasal polyposis (antrochoanal polyp)
been treated with an
antihistamine and steroid -list 3 DDx
nasal spray with no nasopharyngeal tumour
effect. On examination adenoidal hypertrophy
you see this appearance meningoencephalocele

-what Ix would you perform

CT scan of the sinuses

-list 2 SE of antihistamines and steroid nasal sprays

drowsiness
epistaxis
Photo of excised larynx -what is the Dx
(laryngectomy specimen) laryngeal ca
(laryngeal Ca)
-what Sx may this present with
hoarse voice
reduced projection of voice/breathy voice
dyspnoea
lump in neck
dysphagia
pain

-what is the classification system used

TNM classification

-what are the tx options

conservative
chemoradiotherapy
surgical excision – laryngectomy

Thyroid disease (list of -what is the Dx

biochemical results with Hashimoto’s
normal values provided –
TSH 6.5, T4 15, thyroid -what Sx may this pt present with
peroxidase antibody may be asymptomatic but has a goitre
>1000)
-what Tx may help in the long term
thyroxine

-what Ix is useful to confirm Dx

anti thyroglobulin antibody
anti thyroid peroxidase antibody

-list 2 indications for surgery

dyspnoea
dysphagia

Hearing aid -is this aid for R or L ear

-Label A,B,C (microphone, switch, receiver)
-what material is it made of
(?acrylic, but silicon is used to obtain the mould)
-what is canal D (?ventilation tube)
-list 2 indications for having canal D
-what are ‘O’, ‘T’ and ‘M’ settings
(off, telephone nad loop, microphone, vent)
-list 2 complications of wearing a hearing aid
wax buildup
OE
cosmesis
ear piece may dislodge into EAC
Draw parts of septum
What is the CC for SNHL Cochlear aplasia e.g mondini 1.5 turn instead of 2.5 turns
in 2 yo Genetic cause for non syndromic HL, connexin 26, gap junction beta 2 gen (GJB2)
Infections: OM, meningitis, rubella, CMV
EVA (enlarged ventricular aqueduct syndrome) –enlarged endolymphatic duct
Syndromic: Downs syndrome, CHARGE, Waardenburg,