ENT – OSCE Compiled [3rd to 7th Batch]

2 stations each about 8 ~10 minutes long

BLUE = Distinguishing word | Green = Physical Exam | Yellow = Key Points Pink = Not defined yet

7th Batch ENT OSCE: ..................................................................................................................................... 3

Female Group 1A - F1: ............................................................................................................................... 3
Female Group 2B - F1: ............................................................................................................................... 3
Female Group 3B - F1: ............................................................................................................................... 3
Male Group 1A - M1: ................................................................................................................................... 4
Male Group 2A - M1: ................................................................................................................................... 5
Male Group 3A - M1: ................................................................................................................................... 5
History & Physical Taking ............................................................................................................................... 6
Ear:.............................................................................................................................................................. 7
[VIP] Hearing Loss | (X Repeated) .......................................................................................................... 7
General Approach ................................................................................................................................ 7
Osteosclerosis ................................................................................................................................... 11
Sensorineural Hearing loss ................................................................................................................ 15
Tinnitus | (X Repeated) .......................................................................................................................... 17
TM Perforation ....................................................................................................................................... 19
Nose: ......................................................................................................................................................... 20
Epistaxis ................................................................................................................................................ 20
Neck | Nose & Throat (Nasopharynx) | (X Repeated) ............................................................................... 21
[VIP] Neck Mass .................................................................................................................................... 21
Nasopharyngeal Carcinoma with OM & Effusion ............................................................................... 21
Thyroglossal duct cyst (TDC) [Midline Neck Mass] ........................................................................... 24
Malignant lymph node [Lateral Neck Mass] ....................................................................................... 25
Parotid Mass ...................................................................................................................................... 26
Facial nerve Palsy ................................................................................................................................. 27
Infection Cases | (X Repeated) ................................................................................................................. 30
Peritonsillar Abscess .......................................................................................................................... 30
Croup ................................................................................................................................................. 32
Adenoid hypertrophy causing recurrent otitis media .......................................................................... 34
Otitis Media + Nasopharyngeal mass ................................................................................................ 35
Recurrent otitis media ........................................................................................................................ 36
Sore Throat ........................................................................................................................................ 36
Acute Sinusitis ................................................................................................................................... 37
Tonsillitis ............................................................................................................................................ 37
Other Cases .............................................................................................................................................. 38
Orbital cellulitis caused by Ethmoid sinusitis ..................................................................................... 38

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 Epistaxis & Nasal septum deviation ................................................................................................... 38
Tonsillectomy ..................................................................................................................................... 38
Cranial Nerves Examination .............................................................................................................. 38
Unknown (TO CHECK what our seniors meant...) ............................................................................. 39
Appendix ....................................................................................................................................................... 40
Topic | (X Repeated) ................................................................................................................................. 40
Others: .......................................................................................................................................................... 40

Our Seniors tried to answer the questions as much as they can.

Please go over it for your OSCE and make changes/updates as you guys see fit.

A few points to keep in mind about this questions for you guys:
• There is a SP in the room that you take history from:
o She says no to all the questions that you ask her.(Do not get thrown off by her saying no !!!)
o The point of taking history in this station is just to asses that you asked all the important question
regardless of the answer.
• After you take the history the examiner will start asking you questions about:
o Risk factors
o Index of suspicion (DDx & Dx)
(Both these statements pretty much have the same answers so don't get thrown of by it)
• Those station assess your approach to hearing loss. (There is no diagnosis to be achieved in most cases)

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 7th Batch ENT OSCE:
Female Group 1A - F1:
Station 1:
Recurrent Otitis media caused by adenoids
Question where: 1) Hx 2) Phx 3) Investigation 4) Management

Station 2:
Bilateral neck mass caused by nasopharyngeal carcinoma
Question where: 1) Hx 2) Phx 3) Investigation 4) Management

Female Group 2B - F1:

Station 1:
We didn’t perform the physical exam (Just mentioned it and explain the possible findings)
Croup (sub-glottitis):
A 2 years old child, present with 2-3 hrs with noisy breathing
Take Hx from the mother
Radiology of croup: Steeple sign
Endoscopy of the larynx showing: A narrowed subglottis & normal epiglottis
Differentiate between Croup vs. Epiglottis
Management of Croup
Etiology of Croup & Epiglottis

Station 2:
Otosclerosis SNHL
A female with Sudden Right hearing loss and worsen with pregnancy
Examination of the ear
Interpretation of audiogram (otosclerorsis)
Main concern about the patient: pregnancy
Differential diagnosis of conductive hearing loss
Tympanogram: asking about type B, seen in otitis media with effusion

Female Group 3B - F1:

Neck exam with differentials of anterior and lateral neck masses
Same as group 1 & 2

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Male Group 1A - M1:
Station 1:
Otitis media:
-Sheet given to read: history of upper respiratory tract infection 4 weeks ago, patient presents with typical
otitis media symptoms (otalgia, etc)
-Nurse acts as mother of child
1. Take history (same as concepts; ask about risk factors such as breastfeeding, going to daycare, use of
pacifiers and congenital anomalies such as cleft palate, treacher collins, etc)
2. Assessment (same as concepts; inspection of ear, pneumatic otoscopy, audiometry, tympanometry)
When we mentioned these they brought out 3 pictures.

Otitis Media with effusion

1. View from otoscope, asked to describe; loss of transparency of tympanic membrane, effusion behind
tympanic membrane, bulging, etc.
2. Tympanogram:
-Type B tympanogram
-what does this mean? -- most likely middle ear effusion
3. Audiogram:
Bone conduction- air conduction gap seen in right ear
What does this mean? -- co conductive hearing loss
Management: "different" part. The boy has only has the OM for 4 weeks, which is classified as subacute
OM, but he considered it chronic because of the way the patient presented. ( See table comparing
presentation of chronic and acute OM). Management: management of chronic OM from lecture ( no
antibiotics, consider myringotomy tube if effusion is present, follow up in 3 months)
-Patient returned with effusion again, myringotomy tube fell out as well -- consider adenoidectomy

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Station 2:
Idiopathic Facial nerve palsy:
-Exact same as concepts; history, assessement, management
-"New" question: what are the risk factors for Bells palsy:
Please consider the fact that "Bells palsy" means idiopathic; infections, trauma, acoustic neuroma are all
wrong
1. Pregnancy
2. Diabetes
3. Viral prodrome
4. Being Unvaccinated - not completely sure, I said it in the station w Dr Nabeel 3zzli and said yeah actually
there's studies that show a link and stuff 😂. Above 3 are risk factors are enough.

Male Group 2A - M1:

Station 1:
40 something Y/O presented with a 4 days history of Dysphagia.
Questions:
History
Assessment
Causes
CNS involved
Comment on examination
What investigations
DDx

He wanted us to include foreign body "even though he was in his 40s and the history was for 4 days and he
presented to the clinic"

Station 2:
2nd station was a case of Lymphoma.

Baby with tonsillitis

Questions:
Take history and physical.
Ask for FNA and you did tonsillectomy and still there
What would you do?
CT and MRI, he showed it to us. (Lymph node enlargement in Right (a cystic rim like lesion)

What is next?
You do another biopsy "excisional biopsy"
and it showed lymphoma
How would you treat?
Refer the patient to oncologist "this was the answer that he was looking for"
Male Group 3A - M1:
Exactly same as concepts:
Station 1: (Case Tonsillitis with Lymphoma (a lymph node enlargement in Right neck))
Station 2: (Case of Otosclerosis in pregnancy same as concepts exactly)

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 History & Physical Taking
Ear:.............................................................................................................................................................. 7
[VIP] Hearing Loss | (X Repeated) .......................................................................................................... 7
General Approach ................................................................................................................................ 7
Osteosclerosis ................................................................................................................................... 11
Sensorineural Hearing loss ................................................................................................................ 15
Tinnitus | (X Repeated) .......................................................................................................................... 17
TM Perforation ....................................................................................................................................... 19
Nose: ......................................................................................................................................................... 20
Epistaxis ................................................................................................................................................ 20
Neck | Nose & Throat (Nasopharynx) | (X Repeated) ............................................................................... 21
[VIP] Neck Mass .................................................................................................................................... 21
Nasopharyngeal Carcinoma with OM & Effusion ............................................................................... 21
Thyroglossal duct cyst (TDC) [Midline Neck Mass] ........................................................................... 24
Malignant lymph node [Lateral Neck Mass] ....................................................................................... 25
Parotid Mass ...................................................................................................................................... 26
Facial nerve Palsy ................................................................................................................................. 27
Infection Cases | (X Repeated) ................................................................................................................. 30
Peritonsillar Abscess .......................................................................................................................... 30
Croup ................................................................................................................................................. 32
Adenoid hypertrophy causing recurrent otitis media .......................................................................... 34
Otitis Media + Nasopharyngeal mass ................................................................................................ 35
Recurrent otitis media ........................................................................................................................ 36
Sore Throat ........................................................................................................................................ 36
Acute Sinusitis ................................................................................................................................... 37
Tonsillitis ............................................................................................................................................ 37
Other Cases .............................................................................................................................................. 38
Orbital cellulitis caused by Ethmoid sinusitis ..................................................................................... 38
Epistaxis & Nasal septum deviation ................................................................................................... 38
Tonsillectomy ..................................................................................................................................... 38
Cranial Nerves Examination .............................................................................................................. 38
Unknown (TO CHECK what our seniors meant...) ............................................................................. 39

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 Ear:
[VIP] Hearing Loss | (X Repeated)
General Approach
1) (1X) Case 2: Hearing Loss Scenario 3:
a) Take History of hearing loss for one day
• History
1. When | How
2. Any:
a. Trauma | Pain |
b. Tinnitus | balance issue | Nausea & Vomiting |
c. Fever | Night sweats | Weightless
d. Recent URTI
e. Drugs used recently?
3. What about other ear?
b) Tests?
1. Rinne test then Weber test
2. Otoscopy
3. Tympanogram
4. Refer to audiologist
5. MRI head
c) Doctor ask what if on Rinne test the hearing was better on the not affect ear?
• Sensorineural Hearing Loss (SNHL)
d) What do you suspect the diagnosis?
• Sudden Sensorineural hearing loss
e) What are the causes
1. Idiopathic
2. Viral infections
3. Ischemia
4. Brain stroke
f) How to manage
1. STEROIDS
2. PPI
3. Manage symptoms
4. Follow up & Retest

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2) (2X) Case 3: Hearing Loss Scenario 2: A mother bring in her 2 y/o son. She is worried that her son only
babbles and hasn't started speaking yet.
a) Take Full History (Risk factors, Index of Suspicion)
• SOCRATES:
1. Does your child respond to you when you speak to him?
2. Did you notice any discharge from the ear?
3. Did he have any previous infections to the ear?
4. Any history of trauma?
5. Any facial abnormalities?
6. Any vision problems?
7. Did you notice any other developmental delay in comparison to his siblings?
• Past Medical/Surgical
1. Was your child ever diagnosed with meningitis?
2. Has he been diagnoses with any syndromes?
3. Past surgeries in the head and neck area?
• Neonatal History:
• A] Pre-Neonatal History
1. Length of pregnancy (prematurity)
2. Complications during pregnancy (TORCHE)
3. Smoking/Drinking/Drug use during pregnancy (Ototoxic drugs)
• D] Peri-Neonatal
1. Birth trauma
2. Complications
• E] Post-Neonatal
1. What was his weight at birth
2. APGAR Score
3. Skin color (Jaundice, Cyanosis)
4. NICU Admission
• Developmental History:
1. Just mention that you would ask about it
• Vaccination:
1. Is he UpToDate/ Ask for vaccination card
• Family History:
1. History of hearing loss in the family
• Social Allergies:
1. Smoking exposure,
2. Does he/she have any Allergies, pets
3. Travel
b) What alerts you in the history? (Just mention all the risk factors basically already asked in history)
1. TORCHE infection
2. NICU admission
3. Low birth weight/prematurity
4. Trauma/otitis media
5. Meningitis
6. etc…

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 c) Give 4 investigations:
1. Physical exam (Rinne and Webber)
2. Auditory brain stem response
3. Otoacoustic emissions
4. CT
d) Give differentials for Congenital Conductive hearing loss:
1. Absence or malformation of outer ear, ear canal, or middle ear
2. Otosclerosis
e) Give differentials for Congenital Sensorineural hearing loss:
1. Syndromic/non-syndromic causes
2. Acoustic neuroma
f) Give differentials for Acquired Conductive hearing loss:
1. Otitis media
2. Cholesteatoma
3. Impacted wax
4. Foreign body
g) Give differentials for Acquired Sensorineural hearing loss:
1. Ototoxicity
2. Noise induced
3. Meniere’s disease
4. Sudden SNHL
h) How would you manage this patient?
• Diagnose and manage the cause of hearing loss (may need to use steroids, Hyperbaric oxygen,
antibiotics, surgery)
• Consult the patient about hearing aid and options
• Refer to a speech pathologist
• When school time comes instruct the school about child condition and how to help( sit in-front
of the class, sit on the right or left side of the class depending on which ear is better)
• Social and society support

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3) (1X) Case 3: Pt w/ conductive hearing loss because of a trauma.
a) Examine the patient:
•
b) Perform special hearing tests like:
• Tuning forks
• Otoscopy
• Tympanometry & Audiogram (Say that you will refer to audiologist)
c) Audiogram shows:
• Conductive hearing loss
d) Tympanometry shows:
• Type B
• Stiff tympanic membrane.
e) What are the possible underlying causes for conductive hearing loss?
• Mention 4
f) Most important causes of Conductive hearing loss:
• Facial nerve damage
• Cerumen impactum
• Foreign body.

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Osteosclerosis
4) (4X) Case 1: Hearing loss Scenario 1 (Osteosclerosis): A 24 or 34 y/o female presented with a 3 or 4 months
history of hearing loss. She stated that it started around the time she was pregnant with her last baby. The
patient also reported that both her sister and mother had a similar condition
a) Perform a full examination of the ear (mostly done orally)
• See OSCE File: http://oscestop.com/Ear_exam.pdf
• Remember!!! (first do Rinne’s and then Weber’s test)
• To Start:
1. Wash + Introduce + Permission + Explain:
2. Inspection & Palpation for any abnormalities of the (But Ask about Pain first !!):
a. Post-auricular area (with mastoid process)
b. Pinna
c. External auditory meatus
d. Preauricular region
3. Tympanic otoscope for:
a. External auditory canal (Again Ask about pain first)
b. Comment on it:
i. Hair in outer third
ii. Cerumen
iii. Skin
iv. Rash
v. Any Discharges,
vi. Bleeding
vii. Stenosis
viii. Tumors
ix. Osteoma
4. Visualize the tympanic membrane and comment on it:
a. Color
b. Position (normal/retracted/bulging)
c. Mobility of TM
d. Integrity (perforation or not)
e. Tube
f. Sclerosis
g. Lateral process of the malleus
h. Retraction pocket
i. Air-fluid level
j. Blood
k. Cholesteatoma)
5. Examination of the facial nerve and for nystagmus
6. Open field hearing assessment:
a. Rinnie’s test and Weber’s test with a 512 Hz or above forks.
b. See This Video (Very Usefull): https://www.youtube.com/watch?v=FgF91K7dU8Y
b) What is the frequency of the fork used in Rinnie’s and Weber’s test?
a. 512 Hz (They showed us forks kit of different frequencies and told us to choose)

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 c) We were asked how to hold the otoscope in the right way and choose the appropriate tip size for the
patient:
• Make sure you know how to hold it properly and choose the right tip for adults age group)
• ---
1. Wash, Introduce, Permission, Explain
2. Inspection of and the preauricular region, external auditory meatus, , the post-
auricular (with mastoid process) for any abnormalities.
3. Ask about pain and palpate preauricular region, helix, tragus, postauricular region
(mastoid), and lymphnodes (all the chains)
4. Tympanic otoscope for the external auditory canal (Ask about pain first) and
comment on it (hair in outer third, cerumen, skin, rash, discharges, bleeding,
stenosis, tumors, osteoma)
5. Visualize the tympanic membrane and comment on it (color, position
(normal/retracted/bulging), mobility of TM, integrity (perforation), tube, sclerosis,
lateral process of the malleus, retraction pocket, air-fluid level, blood, cholesteatoma)
6. Examination of the facial nerve and for nystagmus
7. Hearing assessment – first Rinne’s and then Weber’s test, mention you use 512Hz
tuning fork
d) What are the investigations that you would do for this patient?
• Tympanometry
• Audiometry
Then an Audiometry was shown and asked

e) What do the symbols mean?

• X = Left Ear O = Right Ear (Both for  Air conduction | Not Masked)
• ] or > = Left [ or < = Right (Both for  Bone conduction | Masked vs. Not masked)
f) What type of hearing loss is this?
• Comment on:
1. Degree
2. Type
3. Frequency if applicable
• In our case it was Mild Conductive hearing loss in the right ear (Carhart’s notch @ 2 KHz)
g) What is happening at 2000Hz

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 • Carhart’s notch @ 2K Hz pointing towards  Otosclerosis
Then A tympanometry was shown, and then asked:

h) Which one of the following graphs is consistent with Otitis media with effusion?
1. Graph B
i) Which one of the following graphs is consistent with the likely diagnosis (Otosclerosis)?
1. Type As
j) What is your diagnosis?
• Otosclerosis (Type of a conductive hearing loss)
k) What is your differential diagnosis? (DDx of Conductive hearing loss)
• Otitis media +/- effusions (MC)
• Middle ear fluid
• Otitis externa
• Perforated tympanic membrane
• Impacted cerumen
• Foreign body
• Otosclerosis
• Ossicular chain discontinuity/fixation
• Tympanosclerosis
• Cholesteatoma
• Trauma
• Easy to remember from outside to inside:
1. Trauma
2. Impacted cerumen
3. Foreign body
4. Otitis externa
5. Cholesteatoma
6. Perforated tympanic membrane
7. Tympanosclerosis
8. Otitis media +/- effusion
9. Otosclerosis
10. Ossicular chain discontinuity/fixation
• There was a contradiction in which one is the most common cause
l) How do you manage the patient?

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 • Trial of hearing aids for 6 months
• Discuss future hearing loss with associated with pregnancy
• Medical such as:
1. Bisphosphonates (may prevent further SNHL by inhibiting bone resorption)[Category C in
Pregnancy]
2. Sodium fluoride (should be avoided in pregnancy / renal disease)
3. But since she is pregnant you hove to balance the risk of those medication …
• Surgery: Stapedectomy
• Contraindication:
1. Poor Eustachian tube function and/or TM Perforation
2. Active Infection

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Sensorineural Hearing loss
5) (3X) Case 4: Case of a Diagnosis of Idiopathic SNHL of sudden onset: WHO Classification of Sensoneural
hearing loss: 3, 3, & 30 rule: Sensorineural hearing loss developing over 3 days involving 3 contiguous
pure tone frequencies exceeding 30 Db
a) Etiologies / DDx?
1. Idiopathic
2. Autoimmune:
a. Primary (inner ear)
b. Secondary (any systemic disease – Wegener’s Sarcoidosis etc)
i. (Usually bilateral)
3. Viral
4. Vascular
5. Labyrinth disease
6. Syphilis, meningitis
7. 10% of acoustic neuromas present this way
8. Trauma: temporal bone fractures
9. Ototoxicity (aminoglycosides, cisplatin)
10. Initial stage of Meniere’s disease (cuz cant be diagnosed from 1 episode)
11. Neurogenic: GBS, MS
12. Ramsay Hunt (HZO) – poor prognosis even after giving steroids
b) Investigations
1. ESR, ANA & Rheumatoid Factor & other… markers: To rule out autoimmune causes
2. MRI: To rule out soft tissue tumors
3. CT: To Rule out Vascular causes if there is presence of any neurologic deficits
c) Management (This is an ER (Emergency) !!!):
1. For N&V + Vertigo: Antiemetics
2. Patient presented within 2wks: Oral steroids (more efficit) or intratympanic injection. For
2wks and taper
3. No role of antivirals & hyperbaric O2 controversial.
4. Bring them back in a few days. Also to check prognosis.
5. F/U in a month, if no improvement hearing aid (CROS helps the patient to find a suitable
hearing aid – receiver in the healthy ear and processor in the affected ear). Patient
should be educated beforehand of this handicap.
6. Also educate about headphone use, listening to loud noise and avoidance of sports that
involve head trauma.
7. ---
8. Symptomatic txt: Antiemetic (if nauseated due to vertigo)
9. If patient presented within 2 weeks give oral steroids, high dose (60mg prednisone) or if
oral steroids are CI intratympanic injection for 2 weeks and taper. (Contraindications of
steroid: in immunocompromised px like DM, pregnancy, peptic ulcer disease or any GI
bleed). Oral prednisone is more efficient than the injection.
10. No role of antivirals and there’s an optional role of hyperbaric Oxygen (due to vascular
etiology) – Dr. Nabil doesn’t recommend it.
11. HBO2 is controversial
12. Prognosis: 65-70% has spontaneous recovery

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 13. 1/3rd no recovery, 1/3 full recovery, 1/3rd partial recovery
14. Prognosis depends on degree of hearing loss (mild HL is good, down sloping is bad), if
there’s quick recovery in the first few days (good prognosis) and if contralateral ear has
SNHL too (bad prognosis).
15. Bring them back in a few days. Also to check prognosis.
16. F/U in a month, if no improvement hearing aid (CROS helps the patient to find a
suitable hearing aid – receiver in the healthy ear and processor in the affected ear).
Patient should be educated beforehand of this handicap.
17. Also educate about headphone use, listening to loud noise and avoidance of sports that
involve head trauma.
d) Prognosis
• 1/3rd no recovery, 1/3 full recovery, 1/3rd partial recovery
• Prognosis depends on degree of hearing loss (mild HL is good, down sloping is bad), if there’s
quick recovery in the first few days (good prognosis) and if contralateral ear has SNHL too (bad
prognosis).
e) Complications?
• Unilateral hearing loss:
1. Inability to locate sounds (especially from the affected ear)
2. inability to discriminate speech in background noise

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Tinnitus | (X Repeated)
1) (2X) Case 1: Tinnitus Scenario: A 27 y/o female presented with noise in her ear 24 hours ago.
a) Q1: Take History
1. Sudden onset, roaring noise, only in her right ear.
2. Continuous sound due to which she can’t sleep.
3. Happened for the first time.
4. 3-4 wks ago had URTI and didn’t take ABx.
5. Tinnitus, +ve vertigo, no discharge, ear fullness is present, doesn’t know if she has hearing
loss but she might.
6. No changes in voice, no nasal symptoms, no headache, no rash in the ear, no swellings in
the H&N region.
7. Loud noise exposure? No.
8. She doesn’t recall any FB or insects going inside her ear.
9. Neurological sx: no facial weakness or any other weakness in the body
10. PMHx: 3 weeks ago she had URTI, no past history of hearing loss, no Hx of trauma, no
past surgical Hx.
11. Ear surgeries? No
12. Med: Only birth control pills, no ototoxic agents
13. Family Hx: no family history of hearing loss, her niece and nephew have had few cases of
ear infections. Also MS in him and his family.
14. Social Hx: No smoking, no recent air travel, occasional ear phone use
b) Q2 Physical Examination
• Examine facial nerve
• Look for nystagmus
• Examine nasopharynx (to look for NPC but it presents with CHL)
• Ear Exam:
1. Examine normal ear first. For the affected ear, using an otoscope, look for:
a. No impacted ear wax
b. Granulation tissue
c. Inflammation
d. Exostoses (bony tumors)
e. FB (usually in children), Tumors
f. Tympanic membrane integrity:
i. Color
ii. Position- retracted or bulging
iii. Perforation
iv. Mobility
(using a pneumatic otoscope)
2. Hearing Assessment:
a. Tuning fork 512 Hz
b. Rhine: Positive bilaterally (AC > BC): This means either normal or SNHL
c. Weber: Lateralized in left ear; this means right ear has conductive hearing
loss/other seniors answer was SNHL (TO CHECK)

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 c) Read the Audiogram report

• Audiogram left ear is normal. Right ear has down-sloping with mild – severe hearing loss (See
image
d) Tympanometry: Was normal Curve A (A – Normal)

• Notes - Hearing loss on audiogram:

1. Mild – 40 dB
2. Moderate 40-70 dB
3. Severe >70 dB
4. Moderate-severe: high frequency > low
• On Examiantion don’t forget to mention that you will do:
1. CNs + CN 7
2. Full ENT exam
3. Examine for nystagmus: Was Normal in our case

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TM Perforation
1) (TO CHECK 1X) Case 1: TM perforation (evaluated by Dr.Nabil): Read the case (paper) showing picture of
perforated eardrum and case of 6 y/o boy complaining of ear problem, usually after swimming,
“somewhat confusing, but it is basically Topic of Central Perforation” describe to the mother about:
a) Findings
•
b) Causes
•
c) Investigation (he will show you audiogram showing conductive hearing loss)
•
d) Counselling
•
e) Management
•

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 Nose:
Epistaxis
1) (1X) Case 1: An Old lady came to ER with nose bleeding (epistaxis)
a) Take History?
• Don't forget to ask about blood thinner meds !!!!
b) What is the management
• Start with ABC then the epistaxis management
• Very important:
1. If all the managements fails we will do  Embolization & Ligation
(You should know all the arteries names!)
• You should give Abx with posterior packing
c) Why give Abx with posterior packing?
• To prevent sepsis that can be caused by staphylococcus aureus
d) What are the complications of posterior packing
• Alar Necrosis
• Trauma/Injury
• Sepsis
• Septal perforation (more for Anterior Packing)

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 Neck | Nose & Throat (Nasopharynx) | (X Repeated)
[VIP] Neck Mass
Nasopharyngeal Carcinoma with OM & Effusion
1) (4X) Case 1: Neck Mass Scenario 1 (Nasopharyngeal Carcinoma): A 27 y/o man presented to the clinic with
a history of bilateral neck mass for 4 or 6 months. (picture of a black man with large bilateral neck mass
was shown)
a) Take full history from the patient (just verbally telling the examiner what you would like to ask)
• 1.SOCRATES: Site (bilateral?), Onset, character (painless), triggers (Infection, trauma),
progression, compressive symptoms (breathing, swallowing) etc.
• 2.Associated Symptoms:
• •Ear symptoms: Discharge, Pain & hearing loss
• • Nose symptoms: Bleeding, Discharge, Breathing obstruction, Anosmia (postive history of
epistasis, and nasal blockage), headache, Epistaxis
• • Mouth Symptoms: Non-healing oral ulcers
• • Throat: URTI infection (for EBV), hoarseness, dysphonia, dysphagia
• • Thyroid symptoms
• • Constitutional symptoms: Fever, Weight loss, Appetite changes, n/v (positive for unintentional
weight loss)
• 3.Past medical: DM, HTN, Exposure to radiation (frequent imaging, dental X-ray)
• 4. Past Surgical;
• 5.Family history: Cancers
• 6.Social: Special diet (nitrosamine diet – salted fish), Smoking & drinking, occupation, exposure
to animals (cat scratch)
• 7.Travel history (TB)
• ---
• SOCRATES: Site (bilateral?), Onset, progression ..etc,
• Associated: pain, fever, trauma, infection, compression symptoms (swallowing, breathing)..
• Previous URTI infection (for EBV)
• Ear symptoms (discharges, pain, hearing loss)
• Nose symptoms (bleeding, discharges, breathing obstruction, headache, anosmia)
• Patient had Recurrent otitis media
• Constitutional symptoms (fever, wight loss, appetite changes)
• Past medical, surgical, family history.
• Social: Special diet (nitrosamine diet), Smoking & drinking. Exposure to animals (cat scratch)
• Travel history (TB)
b) List the risk factors
• 1.EBV infection
• 2.Radiation
• 3.Smoking
• 4.Alcohol
• 5.Nitrosamine diet - Salted fish
• 6.Occupation/environmental exposure (e.g. nickel)
• 7.Genetics – Eastern Asian, Southern Chinese
c) Q3 Examination of neck
• 1.Ensure the patient is stable; airway not compromised.

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 • 2.Examine the neck
• 3.Comment on the mass (tenderness, size, shape, consistency, tenderness, fluctuation, Mobility
etc…)
• Full ENT Examination
• 4.Otoscope for any ear abnormalities (to examine for the presence of any primary tumor)
• 5.Nasopharyngoscopy & laryngoscope (to examine for the presence of any primary tumor)
d) Q4 Picture of the right nasopharynx was shown, what is this:
• There is a mass protruding from the right nasopharyngeal wall near the right Eustachian tube

a) Q5 Differential for neck mass: (some weren’t asked this qn, some answered based on the
nasopharyngeal mass some on neck mass so not sure)
• Lymphadenopathy, Thyroid/Parathyroid tumor Q5 Differential for Nasopharyngeal mass:
Carcinoma, Polyp, Lymphoma
• Neck mass:
1. Lymphadenopathy
2. Thyroid/Parotid tumor
3. ..etc
• Nasopharyngeal mass:
1. Carcinoma
2. Polyp
3. Lymphoma
b) Q6 Further investigations?
• Lab: EBV DNA
• Imagine: CXR, CT or MRI for staging the cancer
• Biopsy:

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 1. The nasal mass for definitive diagnosis
2. US guided FNA for the neck masses
c) What is the management of nasopharyngeal carcinoma?
• Radiotherapy +/- chemotherapy based on staging
• Surgery with radiotherapy: Salvage of remnants of the cancer in the LN or poor prognostic
indicators
• Fluorouracil: first 2 years every 3m, 3rd-5th year every 4-6m, then yearly
• (Note: Surgery is instituted in the setting where the patient is treated with radiotherapy and has
remnants of the cancer in the LN  Neck dissection)
2) (1X) Case 2: Nasopharyngeal carcinoma (NPC) –with a case of Otitis media with effusion
a) Take history
•
b) Asked us to read conductive hearing loss Audiogram and tympanogram
•
c) Showed a picture of NPC in nose
•
d) Asked differentials for mass in nose
•
e) Asked about causes for recurrent OM
•
f) Gave a tuning fork and asked us to show him how we use it
•
3) (1X) Case 3: Lateral & Midline masses: The Doctor showed us pictures of both lateral & midline masses and
asked us to:
a) Differentials (get the list from Dr.Nabils lecture)
•
b) He asked us how we’d manage it (Approach it)?
• Hx
• Phx
• Investigation:
1. CT
2. Biopsy (CT guided for example)
c) (TO CHECK) Asked about the management of thyroglossal duct cyst?
• Sistrunk (Sistrunk procedure) for thyroglossal cyst removal
d) Asked what would your differential be if he’s 40+?
• Neoplasm

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 Thyroglossal duct cyst (TDC) [Midline Neck Mass]
4) (3X) Case 2: Neck Mass Scenario 2: A 4 y/o boy brought to the clinic with a midline neck mass.

a) Give a differential diagnosis (give as many as you can of midline masses DDx in children)
• 01] Thyroglossal duct cyst
• 02] Epidermoid cyst
• 03] Dermoid
• 04] Laryngocele
• 05] lymphadenopathy
• 06] Thyroid/Parathyroid tumor
• 07] Ectopic thyroid
• 08] Ranula
• 09] Teratoma
• 10] Lipoma
• 11] Vascular Anomoly
• etc…
b) What could it be if it was a lymph node:
• Reactive hyperplasia or malignant
c) What is the most likely diagnosis:
• Thyroglossal duct cyst (TDC)
d) Where could a Thyroglossal duct cyst be located:
• Anywhere along the course of its embryological development from the foremen cecum till the
thyroid gland
e) How would differentiate between TDC & other midline masses:
• TDC moves with protrusion of the tongue

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Malignant lymph node [Lateral Neck Mass]
5) (4X) Case 3: Neck Mass Scenario 3: A 47 y/o man came in to the clinic with a lateral neck mass.

(This was the exact picture)

a) Give a differential diagnosis (as many as you can)
• 01] Branchial cleft cyst
• 02] Tumor/Lymphoma
• 03] Dermoid
• 04] Lymphadenopathy
• 05] Carotid aneurysm
• 06] Carotid body tumors
• 07] Neurogenic Tumors
• 08] Neuroma
• 09] Lipoma
• 10] Sialadenitis
• 11] Salivary gland tumour
• 12] Vascular anomaly
• 13] Sarcoma
b) What is the most likely diagnosis:
• Malignant lymph node
c) Explain what you would do for a neck exam.
• 1.Mention that you would like to evaluate the cranial nerves especially the facial since a lateral
neck mass could be a parotid tumour
• 2.Mention also that you would like to examine the ear, nose & throat of the patient
• 3.In inspection of the neck don’t forget to mention: scars, skin changes, if there is a mass
describe it: is it diffuse or nodule? Size, location, movement with swallowing & tongue
protrusion
• 4.Ask the patient if she is in any pain before palpation
• 5.The nurse who was the SP had a diffuse goiter
d) What is an adequate exposure for neck examination:

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 • Above the clavicles
e) Why would you precious the sternum in neck examination:
• Check for a retrosternal thyroid
f) Bruit over the thyroid is most likely due to:
• Graves’s disease
g) Bruit over the lateral neck is most likely due to:
• Carotid body tumour
Parotid Mass
6) (TO CHECK 1X) Case 4: Neck Mass Scenario 4 (Parotid Mass): Pleomorphic adenoma
a) History
•
b) Risk factors
•
c) Investigations (labs, ultrasound, FNA) & CT findings,
•
d) I remember they asked about which section you want to order for the CT
•
e) And they showed a CT and asked what do you see
•
f) Management:
• Radiotherapy & Surgery
g) And other differentials for the mass
•

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 Facial nerve Palsy
1) (3X) Case 1: Facial Nerve Palsy Scenario 1: A 27 y/o female with face drooling, can’t smile, cannot close her
eye and had a recent upper respiratory infection

a) Take Full History (what would you ask in the history)?

• (SOCRATES, pain, fever, ear or parotid surgery, FM, DM, HTN);
• Important points
1. Side, complete or spares the forehead
2. Sensitivity to sounds, altered taste, closing the eye
3. Ear symptoms: discharge, pain & rash
4. Stroke symptoms: weakness, slurred speech
5. CPA angle symptoms: other cranial nerves
6. Parotid symptoms: swelling, pain & drooling
7. History of URTI, DM & HTN
8. Radio/chemotherapy
9. Surgeries & trauma
10. Travel & tick bites
• Pregnancy
b) Physical examination: (examine the ear, face and other cranial nerves)
• Facial nerve:
1. Raise your eyebrows
2. Close your eyes
3. Puff your checks
4. Purse your lips
5. Smile & Show your teeth
6. Taste testing
7. Schirmer test & acoustic reflex.
• Ear, Nose, Throat & Neck examination
• Other Cranial Nerve Examination & Neurological examination…
c) Describe the picture:
• Complete Left sided facial paralysis
d) Differential Diagnosis:
• Idiopathic (Bell’s)
• Neurologic (Guillain-Barré syndrome or MS or strokes)
• Infectious (HSV, VZV, Lyme)
• Middle ear pathologies
• Neoplastic (CPA angle & parotid tumours)

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 • Traumatic & iatrogenic
• Inflammatory (sarcoidosis)
• Toxic (Botulism)
• Pregnancy
• Migraine headache
e) Working diagnosis:
• Bell’s palsy
f) Possible Causes?
• Bell’s palsy is Idiopathic
• Possible Etiology include: Lyme disease, HSV, VZV, DM, sarcoid, pregnancy, migraine headache
g) Signs suggestive of bell’s palsy:
• Sudden episode with complete facial muscles involvement. No other neurological deficit.
h) Criteria for Bell’s palsy:
• Paralysis of all muscle groups on one side of the face
• Sudden onset
• Absence of signs of central nervous system disease or neurological deficits
• Absence of signs of ear or CPA disease.
i) How to diagnose Bell’s palsy:
• Diagnosis of exclusion
j) Differentiate upper (Cerebrovascular) from lower motor lesion: (How would differentiate Bell’s palsy
from a cerebrovascular accident?)
• Upper motor lesion: spares the upper third of the face
• Lower motor lesion: affects the whole face
• (In Bell’s complete paralysis of that side where the cerebrovascular accident spares forehead)
k) Why does it spare the forehead:
• Due to the bilateral innervation from the cortex
l) What are the good prognostic factors for Bell’s palsy:
• Young age
• Incomplete paralysis
• Early recovery
• Absences of hyperacusis or taste loss
• Lack of post auricular pain
• No associated comorbidity.
m) Any need for investigations:
• No need for any investigations at this point
• Investigation are indicated only if:
1. Other etiologies are suspected, or
2. If no recovery ensues
• Imaging is only indicated if:
1. MS or stroke is suspected
2. Incomplete paralysis
3. No recovery within 3 months.
n) Again Imaging modality if indicated?: (CT, MRI)
• Imaging is only indicated if MS or stroke is suspected, incomplete paralysis, no recovery within 3
months.

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 o) If the patient showed no recovery what investigations you would order:
• EMG
• Nerve Conduction studies
• MRI
p) Management
• Steroid for one week and taper it off for another week,
• Acyclovir
• Eye care:
1. Lubrication
2. Eye shields at night
3. Refer to ophthalmology
• Follow up within 1 week then in 3 months
q) What are the other options if patient showed no recovery:
• Surgical decompression, or
• Fascial reanimation, and
• Refer to ophthalmologist
r) What is synkinesis
• Involuntary movements with voluntary movements due to aberrant regeneration
• For example: voluntary smiling will induce an involuntary twitching of the eyelid
s) What is the House Brackmann scale:

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 Infection Cases | (X Repeated)
Peritonsillar Abscess
1) (3X) Case 1: Infection Scenarios 1 (Peritonsillar Abscess): A 30 or 27 y/o female patient with dysphagia,
odynophagia, difficulty breathing and sore throat.

a) History:
• (SOCRATES, pain, fever ask about OM and other sites of infection)
• Take Just a brief histroy focusing on centor criteria
b) Physical Examination:
• Examine the oral cavity and comment on the findings
c) Describe the picture:
• Uvula deviation
• Bulging red mass on the right side
d) Clinical Signs of Peritonsillar abscess:
• Trismus
• Swelling with erythema
• Uvula deviation
e) Imaging modality:
• CT
f) Investigations:
• Blood culture
• Culture and sensitivity
• Pus culture
• ESR
• CRP
g) Cause of the abscess:
• Polymicrobial
h) Differential diagnosis:
• 1.Retropharyngeal abscess
• 2.Submandibular abscess,
• 3.Parapharyngeal abscess,
• 4.Infectious mononucleosis,
• dental infection

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 • pharyngitis
i) Management:
• Airway
• Antibiotics (Amoxicillin)
• Incision & drainage.
j) Complications:
• Carotid rupture
• Jugular venous thrombosis
• Abscess rupture leading to aspiration pneumonia
• Sepsis
• Necrotizing fasciitis
• Necrotizing mediastinitis
2) (TO CHECK 1X) Case 2: 1: A female presented with symptoms of peritonsillar abscess.
a) Take complete history (ask about each symptoms)
•
b) What investigations would you do?
•
c) A picture of the abscess will be shown then asked to Describe it?
•
d) A CT scan will be shown then asked to describe it?
•
e) What is your management?
•

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Croup
3) (6X) Case 2: Infections Scenario 2 (Croup): A 2 y/o boy presented to you with noisy breathing (croup)
a) Take history from the patient's father?
• Do History as you normally do it… and see the next question
• (Make sure u differentiate between croup and epiglottis in your history as well as foreign body
by asking things such as onset, constitutional symptoms (high fever more likely epiglottitis, if
there is any witness, if there is a history of URTI: the kid had symptoms of URTI for the past 48
hours and the answers of the simulated mother were with croup too.
• 1-Hx: onset, sudden, progressive, ask about fever, cough( barking), N/V, foreign body, drooling,
neck extension, past medical/surgical, day care, other people around him that are sick, vaccine
b) What are important things to rule out in history
• A. Foreign body aspiration:
1. When was the patient last seen well?
2. Was he playing with toys then he development the symptoms?
• B. Epiglottitis:
1. Drooling, Hyper-extended neck, Tripod positioning, High Grade fever, Toxic looking,
barking cough, No Hx of family members being ill ??
c) What do you think this is?
• Croup
d) What is the most likely diagnosis: From HX?
• its Croup
e) What are the Differences between (Croup and Epiglottitis)
• Croup: BARKING cough more common, Inspiratory Stridor, Hoarseness, cricoid cartilage
narrowing Steeple's sign (AP view X-ray), fever (Viral)
• Epiglottitis: Drooling, Hyperextended neck, Tripod positioning, Barking cough rare, Inspiratory
Stridor, epiglottis inflammation (cherry red) Thumb sign (Lateral View x-ray), High Grade fever
(Bacterial)
• Croup: humidity, inhaled epinephrine and steroids
• Epiglottitis: more toxic presentation, don't touch till you’re prepared for tracheostomy, then try
to secure airway and intubate. Epiglottitis is bacterial so add Abx to management
• Stridor: epiglottis inflammation (cherry red) Thumb sign (Lateral View x-ray), High Grade fever
(Bacterial)
f) (TO CHECK) What do you see on X- ray?
• Steeple sign
g) What is the management of Croup?
• 5- Management: airway, steroids, epinephrine
• (make sure you maintain the airway (the child was breathing so not severe) then take him to x
ray: they will show u steeple sign)
• For Treatment (don't forget epinephrine and glucocorticoids)
• Investigations:
1. Is a Clinical diagnosis
• Calm the patient (crying) avoid provocative procedures like IV lines and phlebotomy, even
examination and X-ray (Role is to exclude more life threatening conditions like epiglottitis).
• Check Vitals.
• If stable then X-ray

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 • Management:
1. ABC: Assess the need for intubation (low threshold for intubation)
2. If stable and Vitals are normal:
a. X-ray AP and Lateral View  To exclude Epiglottitis and retropharyngeal abscess
and for steeple’s sign.
b. Racemic Epinephrine Nebulizers ( Repeated every 2 hours)
c. Steroid Nebulizers Dexamethasone lowest dose possible or budesonide.
d. Cool tent mist is a NO NO:
i. Can be used based on expert opinion
ii. May cause Hypothermia, Bronchoconstriction, and obscures regular
observation of patient.
e. Watch for complications and monitor improvement.
h) Q5 what are the indications to hospitalizes the patient
• Progressive or severe persistent Stridor
• Altered mental status
• Respiratory distress
1. Cyanosis
2. Hypoxia / Vitals
• Need for continuous observation
• Resolves within 2-3 days if persists for more than 2 weeks it’s not croup!
i) Q7 Etiologies for Epiglottitis:
• H. Influenza type b
• Strep. Pneumonia and pyogenes
• Staph Aureus.
j) Q8 Etiology of Croup:
• Parainfluenza (type 1,2,3)
• Influenza
• Adenovirus
• Mycoplasma pneumonia (rare)

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Adenoid hypertrophy causing recurrent otitis media
4) (TO CHECK 1X) Case 3: Infections Scenario 3 (Adenoid hypertrophy causing recurrent otitis media): A child
with recurrent infections
a) Take history
•
b) What are your investigations?
•
c) X-ray of head:
• You should know the changes in patient with adenoid hypertrophy
d) What is your management
• Nasal steroids
• Abx
• Surgery
e) What are the tests you should do for otitis media
•
f) Wave in tympanogram in this case: it is otitis media with effusion so (B wave), he asked how it looks
like
•
g) What is the treatment for otitis media (name the antibiotics)

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Otitis Media + Nasopharyngeal mass
5) (1X) Case 4: Infections Scenario 3 (Otitis Media + Nasopharyngeal mass): One station was a patient with
otitis media with effusion causing conductive hearing loss. The otitis media was due to Eustachian tube
obstruction by nasopharyngeal carcinoma.
a) Take History of hearing loss
• It has been there for more than 4 months in a 55 old lady
• No tinnitus, balance problem, vomiting, nausea… etc
• Taken antibiotics multiple courses.. no improvement
• Because of that… ask about nasal symptoms
• Discharge. Blockage… bleeding… loss of smell
b) What is a very important test you want to do
• Rihnoscopy to rule out nasopharyngeal carcinoma
• Otoscopy, tympanogram
c) Otoscopy shows a picture ( what do you see)
• Otitis media with effusion
d) Rhinoscopy shows a picture (what do you see)
• A mass in the nasopharynx
e) What to do next
• Biopsy
f) How to treat
• Radiotherapy is first and most important
• Surgery

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Recurrent otitis media
2) (1X) Case 3: A young child presents to you with recurrent otitis media. I think it was the ninth time in one
year and he is having no complications. The nurse shows you a picture and you describe a bulging TM with
no cone of light and now it seems he is having a new infection.
a) What do you want to do now?
• Recommend a myringotomy with typanostomy tube insertion
• Tell her it will fall in 9-12 months.
b) She will ask about the anesthesia and any further Treatment?
• I said because he is a child we will do it under general as he will not be cooperative.
• Tell her to better avoid swimming.
• We might give ear drops for the infection.
Sore Throat
6) (1X) Case 5: A child presents with a sore throat
a) Take a history and physical
• *just say what you want to do, ask*
b) They'll show you a picture of the mouth and you have to describe what you see.
•
c) DDx?
• Tonsillitis
• Diphtheria
• mono... Etc
d) Management of it
•
7) (TO CHECK 1X) Case 6: Station 2: Pt w/sore throat, malaise, fever for 3 days.
a) History
•
b) Assessment
•
c) Investigations
•
d) Management
• Paradise criteria for tonsillectomy
• Centor criteria for management of strep throat.
• (She had recurrent tonsillitis and it was complicated and indicated for tonsillectomy but you
have to mention what management you'll do before tonsillectomy…)

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Acute Sinusitis
9) (1X) Case 6: Infections Scenario 5 (Acute Sinusitis)
a) Take history and do physical
•
b) DDx?
•
c) Investigations?
•
d) Management?
• including stabilizing the patient
• making sure the airways are secured (ABCDs)
• treatment ( first lines, second lines)
• follow up and referral.
e) You will be asked to mention the complications of untreated sinusitis along with above mentioned.
•
Tonsillitis
10) (1X) Case 7: Infections Scenario 6 (Tonsillitis)
a) Physical is very important in this station and the complication of adenotonsillitis such as quenzy
(paratonsillar abscess-->obstruct the airway) + you also have to mention the systemic
Complications such as Rheumatic heart disease, etc. Toronto notes are a very good source.

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 Other Cases
Orbital cellulitis caused by Ethmoid sinusitis
3) (1X) Case 2: Sinusitis (evaluated by Dr.Menielle Thomas): Read the case (paper) showing picture of orbital
cellulitis caused by ethmoid sinusitis and case of 4 y/o boy complaining of eye problem “basically Topic of
Sinusitis”
a) Take brief history
•
b) What you will do in physical examination
•
c) Investigation
•
d) She will then show you CT showing ethmoid sinusitis with orbital cellulitis and ask you to describe it
•
e) Management
•
Epistaxis & Nasal septum deviation
4) (1X) Case 4: A man is involved in a fight and shows a picture:
a) Ask you to describe.
• It shows epistaxis with nasal septum deviation.
b) How you will manage?
• Basically, they want to hear the stepwise approach and do not forget to mention about
rhinoplasty for the septum deviation.
Tonsillectomy
5) (1X) Case 5: Mother asking about tonsillectomy (know the normal number of pharyngitis recurrence per
year, and try to recognize viral vs bacterial and know treatments of each) in our station it was not
recommended to do tonsillectomy
Cranial Nerves Examination
1) (2X) Case 1: Cranial Nerve Examination: Go through examination of all cranial nerves (Orally) Was done
according to Dr.Nabil’s instructions in review session
a) Perform Full Cranial Nerve examination:
• 1 – Olfactory: Use non-noxious stimulus such as coffee bean one nostril at a time
• 2 – Optic: Light reflex, and check visual acuity by asking them to count how many fingers you are
holding up, if can’t do that move your hand and see if they can notice the movement, if still
nothing then shine light and ask them if they see the light
• 3, 4, 6 – H movement
• 5 – Trigeminal: Test sensation on all 3 divisions on both side of face, ask them to open jaw and
move it sideways (Muscles of mastication), Differentiate ophthalmic, maxillary & mandibular
division areas supplied.
• 7 – Facial nerve: Ask them to raise eyebrows, close eyes, puff cheeks and show their teeth
• 8 – Vestibulocochlear: Whisper 1-2 words into each ear (free field hearing test)
• 9 – Glossopharyngeal: Gag reflex by putting tongue depressor at back of throat
• 10 – Vagus: Gag reflex and voice by asking them to say a few words
• 11 – Spinal Accessory: Ask them to raise their shoulders and turn their neck to both sides
• 12 – Hypoglossal: Stick tongue out. Asked about lesion if tongue is deviated, lesion is on
ipsilateral side

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 Then Picture of drooping eye lid, and asked:
b) What is the sign called?
• Ptosis
c) What is the nerve that supplies the muscle?
• Oculomotor
d) What are possible etiologies?
• Myasthenia Gravis, Horner syndrome
e) What is Horner syndrome caused by?
• Damage to sympathetic trunk
f) What are the 3 signs of Horner syndrome?
• Ptosis, Miosis and anhidrosis
Unknown (TO CHECK what our seniors meant...)
1) (TO CHECK 1X) Case 6: Thumb sign (3 steps of management), nasal septal deviation (septoplasty), orbital
cellulitis is from ethmoid sinus.
2) A 24 y/o female complains of right ear tinnitus of 24hr duration.
a) Take complete history
•
b) Investigations
•
c) An audiogram and tympanogram will be shown
•
d) Differential diagnosis
•
e) What’s the diagnosis-> it was sudden sensorineural hearing loss
•
f) What is the Management/Treatment?
•
g) Prognosis?
•
h) Handicap of this condition and how will you rehabilitate them.
•
3) A 28 y/o lady presented with hearing loss that started in her pregnancy and that is present in two of her
family members.
a) Perform complete ear exam:
• You will be instructed to say it orally only
• Don't forget to mention examining:
1. Pre/post auricular lymph nodes
2. Occipital as well as anterior and posterior cervical chains.
3. Don't forget facial nerve exam and ask her to:
a. Raise eyebrow
b. Blow up cheeks
c. Close eyelids and try to open against resistance
d. Smile with showing teeth
4. Don't forget to test for nystagmus too
5. Then perform rinne and weber test
b) After that they show audiogram that shows

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 • Conductive hearing loss in 1 year (you have to interpret that)
c) Most likely diagnosis is?
• Otosclerosis, give other differentials too
d) Management:
• Hearing aids or surgery such as stapedectomy
4) Station 1: Patient has bilateral neck mass (nasopharyngeal carcinoma)
a) Take history:
• Ask about onset
• Sudden/gradual
• Progressive
• Recent URTI
• He has epistaxis and nasal blockage
• Ask about ear, past medical + surgical
• He is a smoker and he drinks.
b) For physical:
• Just say you want to examine the mass
• ENT
• Scope
c) He'll show you a pic?
• Say it's nasopharyngeal carcinoma
d) Labs:
• EBV DNA
e) Risk factors
•
f) Management
• Radio therapy + chemo
• +\- examine the lymph nodes

Appendix
Topic | (X Repeated)
1) Test
2) Test

Others:
1) Test
2) Test

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