Meniere’s disease :

• Dizziness, tinnitus, deafness, increased feeling of pressure in the ear.

* Vertigo is usually the prominent symptom.

• Episodes last minutes to hours

• MRI is normal

• Usually a female >> male ; 20-60 years old

• Typically symptoms are unilateral but bilateral symptoms may develop after a number of years.

Treatment:

• Acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required. Note that vertigo and nausea can be alleviated by prochlorperazine, cinnarizine, cyclizine, or promethazine.

This question examines your knowledge of the indications of antibiotic use in tonsillitis and also the indications of tonsillectomy. Antipyretic analgesics such as paracetamol and ibuprofen are of proven benefit and recommended for relief of fever, headache and throat pain in patients with sore throat.

This child neither falls in the category for use of antibiotics or for a tonsillectomy.

In this case, the causative organism is likely viral. Tonsillectomy is not a treatment for the acute condition but aimed at reducing the incidence of recurrent infections.

No further intervention is needed as the tympanic membrane is normal. This is a transient inflammation of the pinna from an injury during a hit in a rugby match. It is self limiting and of no worry.

It is important to note that even if a newborn passes this test, they could still develop hearing loss later on in their development.

There is also the possibility that hearing loss could be ‘missed’ during assessment due to the subjective nature of the test. Since this baby’s motor and verbal milestones are normal, the next best step would be to refer this child for a hearing assessment.

Whenever you see an intellectually disabled child with a foreign object in the ear, the answer would be removal under general anaesthesia. Consider them to be uncooperative. The pea is not a magnetic material and hence it cannot be removed by a magnet. It will swell up if syringing is attempted.

Irrigation with water is contra-indicated for soft objects, organic matter or seeds which may swell and increase the level of pain and difficulty to remove if exposed to water.

Removal by hook is not suitable if the child is uncooperative.

Olive oil only works for ear wax or used to float an insect out by pouring olive oil into the ear.

General anaesthesia to remove the foreign object is usually needed in this sort of scenario. This is to avoid injury.

Hearing loss, feeling of pressure in the ear with tinnitus, vertigo and involvement of cranial nerve e.g. right abducens nerve are suggestive of acoustic neuroma.

MRI of the cerebellopontine angle is the investigation of choice.

The term temporomandibular disorders (TMDs) refers to a group of disorders affecting the temporomandibular joint (TMJ), masticatory muscles and the associated structures.

One of the contributing factors is muscle overactivity which include bruxism (grinding of teeth) which is seen in this stem.

Symptoms of temporomandibular disorders include facial pain, restricted jaw function and joint noise.

The pain is around the temporomandibular joint but is often referred to ENT.

Adhesives may be removed manually within 1-2 days once desquamation has occurred. Referral to an ear, nose and throat specialist is required if an adhesive is in contact with the tympanic membrane. Foreign objects in the ear is a very commonly asked question.

You need to know the management of these specific scenarios which include super glue in ear, seed in ear, insect in ear, wax buildup, and a foreign body in ear with an uncooperative child. Another foreign body which needs an urgent ENT referral is batteries that are stuck in the auditory canal. These need to be taken out within 24 hours.

A furuncle also known as boils is an infected hair follicle. It may be seen as a complication of otitis externa. It is seen as an abscess of skin overlying the ear canal cartilage.

Staphylococcus aureus is the most common cause. Furuncles are typically seen as a hard, tender, red nodule surrounding a hair follicle that enlarges over a few days. Diabetics or patients who are on immunosuppressive drugs are more predisposed to furuncles.

Most furuncles in the ear canal resolve spontaneously with some requiring flucloxicillin. Only very few of the furuncles grow larger require incision and drainage.

Functional dysphonia refers to a voice disturbance that occurs in the absence of any structural abnormality of the larynx or any cord paralysis. It is a diagnosis of exclusion.

Angioedema in severe cases can cause hoarseness but it also presents with difficulty in breathing which is not the case here.

Laryngeal obstruction like angioedema would have difficulty in breathing.

The diagnosis here is otitis media with effusion. The hearing tests would typically show a mild conductive hearing loss.

Otitis media with effusion : Also known as glue ear is common with the majority of children having at least one episode during childhood. An important risk factor for otitis media with effusion is parental smoking.

This is extremely important to note as questions sometimes ask which would be the best management and then provide an option of “tell parents to stop smoking”.

Presentation:

• Hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss in childhood).

May present as :

o Listening to the TV at excessively high volumes or needing things to be repeated.

o Lack of concentration, withdrawal especially in school

• Secondary problems such as speech and language delay, behavioural or balance problems may also be seen

• Rarely complains of ear pain

• May have prior history of infections (especially upper respiratory tract) or oversized adenoids.

Signs:

• Variable, eg retracted or bulging drum. It can look dull, grey, or yellow.

* There may be bubbles or a fluid level

Diagnosis:

• Audiograms: conductive defects.

• Impedance audiometry

Treatment:

• Observation

• Surgery: If persistent bilateral OME over 3 months - insert grommets

• Hearing aids: Reserve for persistent bilateral OME and hearing loss if surgery is not accepted.

Tonsillitis is usually caused by a viral infection or, less commonly, a bacterial infection. The given case is a bacterial tonsillitis (probably caused a streptococcal infection).

Note that the pain for tonsillitis may be referred to the ears. If the sore throat is due to a viral infection the symptoms are usually milder and often related to the common cold. In streptococcal infection the tonsils often swell and become coated and the throat is sore. The patient has a temperature, foul-smelling breath and may feel quite ill.

The differences are variable and it is impossible to tell on inspection if the infection is viral or bacterial in real life. However in your exam, look for these main four signs that point towards tonsillitis being caused by a bacterial infection rather than a viral infection.

4 signs:

• a high temperature

• white pus-filled spots on the tonsils

• no cough

• swollen and tender lymph nodes  

In this question it is unlikely to be Infectious mononucleosis (glandular fever) as it affects teenagers most often. They may be quite unwell with very large and purulent tonsils and a long-lasting lethargy. An enlarged spleen is classically described.

Ear wax softening drops are the first thing to try for a buildup of earwax. Prescribe ear drops for 3–5 days initially, to soften wax and aid removal.

Sodium bicarbonate 5%, sodium chloride 0.9%, olive oil, or almond oil drops can be used.

If symptoms persist, consider ear irrigation If irrigation is unsuccessful, there are three options:

• Advise the person to use ear drops for a further 3–5 days and then return for further irrigation.

• Instill water into the ear. After 15 minutes irrigate the ear again.

• Refer to an Ear Nose and Throat specialist for removal of wax. 

Advise people against inserting anything in the ear. Cotton buds, matchsticks, and hair pins can cause the wax to become impacted by pushing it further into the canal.

The key word here is “a headache that worsens on bending his head forward”. There are two types of headaches which can worsen on bending. Sinus headaches and migraines.

Sinusitis, however, usually is not associated with nausea or vomiting.

Migraines, depending on severity, are often accompanied by nausea, vomiting and sensitivity to light.

Sinus headaches are an uncommon type of headache caused by inflamed sinuses. It happens when there is a build-up of pressure inside the sinuses and the small opening from the sinuses to the nose becomes blocked.

The pressure builds up and causes pain behind the face and head. They are felt as a dull, throbbing pain in the upper face especially in the area of the cheeks (maxillary sinus), bridge of the nose (ethmoid sinus), or above the eyes (frontal sinus).

It is usually on one side and tends to be worse first thing in the morning. The pain may get worse when you move your head, strain or bend forward. It is usually accompanied by a stuffy nose.

Examination of the facial area may reveal local tenderness, redness, swelling, and the presence of clear or discolored nasal discharge.

Remember: Both sinus headaches and migraine headache pain often gets worse when you bend forward. However migraines are more severe than sinus headaches and symptoms may include nausea and vomiting.

In ENT the topics to focus on would be acute otitis media, otitis media with effusion and cholesteatoma.

The case scenarios where mothers notice their children “turning up the TV volume” or “doing badly in school”, before thinking of behavioral / developmental problems, go with physical problems (i.e. hearing). This is usually the presentation of otitis media with effusion.

A tympanogram would show a hearing loss. If this was his first visit, reassurance and review in 3 months would be the most appropriate.

But as this problem has been persisting for more than 12 months, a referral for a grommet insertion would be the more appropriate choice.

From the history and the mechanism of injury, one can conclude that this patient has a perforated eardrum. Perforation of the eardrum can lead to a temporary conductive hearing loss, tinnitus, earache and discharge of blood or mucus or both from the ear.

Nausea and vomiting may also occur. Regardless of the fact that this patient is bleeding from the ear, the best investigation to do is still an otoscopy.

Most small perforations heal on their own however, larger perforations may need a referral to an ENT specialist.

One would not jump right away to a CT as an initial investigation for blood in the external auditory canal. If you see blood, look for the source of the blood.

Treatment of epistaxis :

If haemodynamically compromised -

• arrange immediate transfer to A and E.

Use first aid measures to control bleeding e.g. Lean forward, open mouth. Pinch cartilaginous (soft) part of nose firmly and hold for 10 to 15 minutes without releasing the pressure, whilst breathing through their mouth.

If haemodynamically stable -

• just use first aid measures to control bleeding

• If bleeding does not stop after 10 - 15 minutes of nasal pressure, (and still haemodynamically stable), then do NASAL CAUTERY (using silver nitrate). If cautery is ineffective or bleeding point cannot be seen, then NASAL PACKING.

The likely diagnosis here is an acute sinusitis which is an inflammation of the membranous lining of one or more of the sinuses.

Upper respiratory tract infections are one of the predisposing factors to sinusitis which explains the history in the stem of the cold 3 days ago.

Tenderness at the anterior wall below the inferior orbital margin can be found in maxillary sinusitis.

The maxillary sinus is innervated by the infraorbital nerve and anterior, middle and posterior superior alveolar nerves. Hence, pathology here may be felt as referred pain and described as upper jaw pain, toothache or pain directly at the skin of the cheek.

Insects should be killed prior to removal, using 2% lidocaine. Olive oil can also be used to float the insect out by pouring olive oil into the ear.

This may sound like benign paroxysmal positional vertigo but because of the history of a runny nose, cough and fever, it is more likely to be vestibular neuritis.

Vestibular neuritis follows a viral infection and can cause vertigo, nausea and vomiting on the movement of the head. Develops over hours and resolves in days. Usually followed by a viral infection.

If haemodynamically compromised -

• arrange immediate transfer to A and E.

Use first aid measures to control bleeding e.g. Lean forward, open mouth.

Pinch cartilaginous (soft) part of nose firmly and hold for 10 to 15 minutes without releasing the pressure, whilst breathing through their mouth.

If haemodynamically stable -

• just use first aid measures to control bleeding

• If bleeding does not stop after 10 - 15 minutes of nasal pressure, (and still haemodynamically stable), then do NASAL CAUTERY (using silver nitrate). If cautery is ineffective or bleeding point cannot be seen, then NASAL PACKING.

This is a classic case of Meniere’s disease.

All four clues are present: dizziness, tinnitus, deafness, and increased feeling of pressure in the ear.

Treatment is prochlorperazine.

Weber’s test lateralized to the right and bone conduction is better than air conductionon the right. This clearly shows a conductive deafness on the right. There are no features of encephalopathy.

Tympanosclerosis has characteristic chalky white patches seen on inspection of the eardrum. Since the eardrum here was viewed as normal, it is unlikely to be tympanosclerosis.

The only answer left would be otosclerosis. Bone and air conduction must be tested and in otosclerosis it typically reveals a purely conductive, predominantly low-tone loss.

Other hints in this stem are:

• Female gender – otosclerosis usually occurs in females (2:1 female:male ratio)

• Pregnancy accelerates the progression of osteosclerosis. Performing both Rinne's and Weber's test allows differentiation of conductive and sensorineural deafness.

Noise-induced hearing loss is hearing impairment from exposure to loud sound. In this case since the hearing loss is resulting from noise that occurs at his workplace, the shipyard, it is referred to as occupational hearing loss.

When there is excessive loud noise, the force leads to cellular metabolic overload, and damage to hair cells in the inner ear which can caue high-frequency sensorineural hearing loss. This is most often bilateral.

This patient should be referred to an audiologist who would be able to confirm a sensorineural hearing loss and provide hearing aids.

The diagnosis can be seen with the examination of the ear.

A red tympanic membrane that is bulging is classical for otitis media. We know that the membrane is bulging because there is a loss of light reflex. 

The absence of the light reflex occurs when there is a distortion of the shape of the tympanic membrane such as a bulging membrane due to an increase of inner ear pressure seen in otitis media.

Acute otitis media is acute inflammation of the middle ear and may be caused by bacteria or viruses.

Treatment : Amoxicillin.

A cholesteatoma represents a destructive expanding growth consisting of keratinising squamous epithelium in the middle ear and/or mastoid process much like an abnormal collection of skin cells inside your ear that left untreated can continue to grow and damage the bones of the middle ear. Physical findings often show a canal filled with mucus, pus and granulation tissue.

A white mass behind the tympanic membrane is one of the other features in 90% of cases of acquired cholesteatoma, the tympanic membrane is perforated.

Congenital cholesteatoma is incorrect. 

Submandibular neoplasms often appear with diffuse enlargement of the gland. Any masses of this sort need to be investigated. In fact, any salivary gland swelling that is present for more than 1 month needs to be investigated or removed.

Ultrasound-guided fine needle aspiration (FNA) cytology is used to obtain cytological confirmation.

The history of cannabis here is of no value. It has no relation to laryngeal cancer or any of the above cancers.

Given the history of smoking, hoarseness of voice, dysphagia, and haemoptysis, the likely diagnosis is laryngeal cancer.

Laryngeal Cancer :

• Smoking is the main avoidable risk factor for laryngeal cancer 

• Chronic hoarseness is the most common early symptom.

• Other symptoms of laryngeal cancer include pain, dysphagia, a lump in the neck, sore throat, earache or a persistent cough.

• Patients may also describe breathlessness, aspiration, haemoptysis, fatigue and weakness, or weight loss.

This is the picture of Acute Otitis Media which has led to tympanic membrane perforation. Sometimes a child may report that the pain suddenly settles. This is followed by discharge.

The reason that the pain suddenly settles is that the tympanic membrane has perforated, releasing the pressure immediately. Otitis media can be bacterial or viral but most are self limiting and do not require antibiotics.

If an antibiotic is required, prescribe a five-day course of amoxicillin.

For children who are allergic to penicillin, prescribe a five-day course of erythromycin or clarithromycin.

The most common bacterial pathogens are Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis and Streptococcus pyogenes of which amoxicillin would be suitable. The most common viral pathogens are respiratory syncytial virus (RSV) and rhinovirus.

Given the options, Candida albicans would be the only culprit that would cause odynophagia.

Oesophageal candidiasis :

• Dysphagia

• Odynophagia (pain on swallowing) food or fluids

High yield topics to focus on would be acute otitis media, otitis media with effusion and cholesteatoma.

A classical scenario of benign paroxysmal positional vertigo.

A Dix-Hallpike test would help provide the diagnosis > The Dix-Hallpike manoeuvre would be positive if the patient reports of vertigo and nystagmus. Whilst standing and lying blood pressure is also important in clinical practice to perform to exclude orthostatic hypotension, the description of symptoms here describe benign paroxysmal positional vertigo clearly and not orthostatic hypotension.

This may sound like benign paroxysmal positional vertigo but because of the history of runny nose, cough and fever, it is more likely to be vestibular neuritis.

Vestibular neuritis follows a viral infection and can cause vertigo, nausea and vomiting on movement of the head. Vestibular neuritis develops over hours and resolves in days. Usually followed by a viral infection.

Strictly speaking the term means inflammation of the vestibular nerve but the aetiology is thought to be a vestibular neuropathy.

Presentation :

• Onset is usually very abrupt

• Recurrent vertigo attacks lasting hours or days

• Unsteadiness, nausea and vomiting (feel as if the room is rotating)

• Moving the head aggravates symptoms

Note: Labyrinthitis is a similar syndrome to vestibular neuritis, but with the addition of hearing symptoms (sensory type hearing loss or tinnitus). There is no hearing loss with vestibular neuritis.

All her blood work is normal. This is likely a anatomical defect. Trauma to the nose is the most common cause. Nose picking, insertion of foreign bodies and excessive nose blowing may also be seen as trauma.

The diagnosis here is otitis externa.

Symptoms of otitis externa include minimal discharge, itch, pain and tragal tenderness due to an acute inflammation of the skin of the meatus This is a frequent question and the treatment options include: Topical gentamicin or Topical gentamicin with hydrocortisone.

Both are correct.

The diagnosis here is otitis media with effusion. The hearing tests would typically show a mild conductive hearing loss.

The term she uses “the room spinning around her” is a classic description of vertigo. The fact that she notices this when changing posture tells us that it is likely due to a change of head position which is classic for benign paroxysmal positional vertigo.

Acute otitis media may occur after a viral upper respiratory tract infection which in this case is the tonsillitis.

Cervical lymphadenopathy which is seen in this stem is seen commonly with tonsillitis and it is one of the signs that point you towards a bacterial aetiology.

Malignant otitis externa is an aggressive infection rather than a malignancy, or cancer. It is rare. In some cases, the infection can spread to the outer ear and surrounding tissue, including the bones of the jaw and face.

Despite the term “malignant” being used, it is NOT cancerous. Conductive hearing loss and foul-smelling purulent otorrhoea is also one of the features in malignant otitis external.

 Risk factors for malignant otitis externa include diabetes and a weakened immune system.

Without treatment, malignant otitis externa can be fatal with a 50% mortality rate. Presentations like this need an urgent referral to ENT.

Nasal polyps :

• Lesions arising from the nasal mucosa, occurring at any site in the nasal cavity or paranasal sinuses.

Note that nasal polyps tend to be bilateral.

Associations :

• Asthma

• Aspirin sensitivity It is particularly important to remember the association with asthma.

Note: The association of asthma, aspirin sensitivity and nasal polyps is known ans Samter’s triad.

Presentation :

• Nasal obstruction

• Rhinorrhoea

• Anosmia (loss of smell)

Irrigation with water is contra-indicated for soft objects, organic matter or seeds which may swell and increase the level of pain and difficulty to remove if exposed to water. Suction with a small catheter held in contact with the object may be effective.

The child’s hearing loss and increasing the TV volume suggests that she has otitis media with effusion. This is supported by the otoscopy findings.

This is usually the presentation of otitis media with effusion. As this is his first visit, reassurance and review in 3 months would be the most appropriate.

Steroids predispose to fungal infection and can cause laryngeal candidiasis which results in hoarseness.

Otitis externa is difficult to examine because of tenderness. Typically there is pain when moving the tragus.

Serous discharge is more typical for an external ear infection rather than middle ear infection. In middle ear infections, the discharge is usually thick. Itching is also a common symptom with otitis externa which usually occurs before the pain begins.

Occasionally, hearing loss and fever may be seen in the stem.

Leukoplakia :

• Seen as white thickening of the oral mucosa

• The key word that question writers would have to give is that “the white patch that adheres to oral mucosa cannot be removed by rubbing”

• These should be biopsied as it is premalignant.

This patient has conductive hearing loss. With that information, we are able to rule out a few options here.

Acoustic neuroma, and presbycusis present with sensorineural hearing loss, so we can cross those out right away.

Meniere’s disease classically has four clues which are present in the stem: dizziness, tinnitus, deafness, and increased feeling of pressure in the ear (Note: Vertigo being the prominent symptom).

Glue ear (Otitis media with effusion) is more common in children.

WIth the given family history, otosclerosis fits the best.

In older children and adults, AOM usually presents with earache. If the child was younger, he may pull or rub his ear, or may have nonspecific symptoms such as fever, irritability, crying, poor feeding, restlessness at night, cough, or rhinorrhoea.

This patient is uncooperative and needs an ENT referral. General anaesthesia to remove the foreign object is usually needed in this sort of scenario.

The diagnosis can be seen with the examination of the ear. A red tympanic membrane that is bulging is classical for otitis media. We know that the membrane is bulging because there is a loss of light reflex.

The absence of the light reflex occurs when there is a distortion of the shape of the tympanic membrane such as a bulging membrane due to an increase of inner ear pressure seen in otitis media.

The diagnosis here is otitis media with effusion. The hearing tests would typically show a mild conductive hearing loss.

“Bone conduction is better than air conduction in the left ear” tells us that patient has conductive deafness. “

The sound was localised towards the left side on Weber’s test” - as sound is localised to the affected side, then this is unilateral conductive deafness.

Thyroglossal cysts represent the most common congenital anomaly of the neck and account for 2-4% of all neck masses.

They form along the embryological tract of the thyroid. They usually present as fluctuant swellings in the midline of the neck along the line of thyroid descent.

These cyst tend to move upwards on tongue protrusion because they are attached to the thyroglossal tract which attaches to the larynx by the peritracheal fascia. They are painless and mobile but can become painful if infected.

The description of a mobile mass fits a benign parotid tumour such as pleomorphic adenoma. A mandibular tumour or tonsillar carcinoma would not be described as mobile. Parotitis is unlikely as parotitis is described as a painful and tender mass at the angle of the jaw.

Sjögren's syndrome does involve parotid gland enlargement and occasional tenderness but no other features of Sjögren's syndrome were given in this stem such as dryness in the eyes or mouth.

Therefore benign parotid tumour is still more likely than Sjögren's syndrome.

PLEOMORPHIC ADENOMA :

• Also called benign mixed tumour

• It is the most common tumour of the parotid gland and causes over a third of submandibular tumours

• The most common salivary gland tumour

Features :

• Presents around middle age

• Slow-growing and asymptomatic

• Solitary

• Painless

• Usually mobile

• Firm single nodular mass

Although pleomorphic adenomas are classified as a benign tumors, they have the capacity to undergo malignant transformation.

Treatment involves removing by superficial parotidectomy or enucleation.

Hearing loss, tinnitus, vertigo points towards an affected vestibulocochlear nerve.

An acoustic neuroma would be up on the list of differentials. An MRI of the internal auditory meatus will show a benign tumour in the cerebellopontine angle. Sometimes, in the stem, they would include facial palsy as a feature.

MRI scan can be used to identify gross structural causes of hearing loss. They are useful in cases where a tumour is suspected or to determine the degree of damage in a hearing loss caused by bacterial infection or auto-immune disease.

“Air conduction (AC) is better than bone conduction in both ears” – tells us that this is a normal finding.

“The sound was localised towards the left side on Weber’s test” – tells us that there is unilateral sensorineural deafness on the opposite side of where the sound localises to which is right sensorineural deafness.

Hearing screening is offered to all babies within 4 to 5 weeks of birth. Babies who were born in the hospital are normally given a newborn hearing test before they are discharged otherwise it would be done in the first few weeks of life.

The hearing screening programme offers 2 types of test:

• Automated otoacoustic emission (AOAE)

• Automated auditory brainstem response Automated otoacoustic emission (AOAE) test takes a few minutes. A soft-tipped earpiece is placed in the newborn’s ear and clicking sounds are played. Vibration of the hair cells in response to noise generates acoustic energy which is detected by a microphone in the external meatus.

If AOAE test is performed and there is no clear response in one or both eares, then the automated auditory brainstem response (AABR) test is performed. The AABR test involves placing 3 electrodes on the infant’s forehead and neck

. Clicking sounds are then played. The electrodes would measure brain wave activity in response to the clicks.

Given that AOAE test is not even an option in this question, the next most appropriate answer would be the AABR test.

AABR also has the benefit of detecting auditory neuropathy in children who are deaf but have normal otoacoustic emissions (i.e. in those who have a normal cochlea).

The first symptom of nasopharyngeal carcinoma is often a painless swelling or lump in the upper neck. This is often due to a swollen lymph node.

Other symptoms include nasal obstruction, epistaxis and otitis media from eustachian tube obstruction. Hearing loss (conductive deafness) in one ear and tinnitus are also symptoms seen in nasopharyngeal carcinoma.

Smoking and alcohol can increase the risk of nasopharyngeal carcinoma but then again, they increase risk in many other types of cancers. One specific risk factor for nasopharyngeal carcinoma is an infection with the Epstein-Barr virus.

Hearing loss, tinnitus, vertigo points towards an affected vestibulocochlear nerve. Absent corneal reflex and reduced facial sensation are due to the trigeminal nerve being affected.

Acoustic neuroma could account for these set of symptoms in which case MRI of the internal auditory meatus would reveal a benign tumour at the cerebellopontine angles causing their effects by exerting pressure on the surrounding structures.

MRI of the internal auditory meatus is a dedicated scan to look at the cerebellopontine angles. If required, an MRI of the brain could be requested later for further evaluation of the mass.

Peritonsillar abscess (Quinsy) :

• A complication of acute tonsillitis

• Pus is trapped between the tonsillar capsule and the lateral pharyngeal wall

• Typically preceded by a sore throat for several days

Presentation :

• Sore throat

• Dysphagia

• Pain localized to one side of the throat

• Peritonsillar bulge

• Uvular deviation - Bulging tonsil pushes the uvula away from the affected side

• Fever

• Trismus (difficulty opening the mouth)

• Altered voice quality ('hot potato voice') due to pharyngeal oedema and trismus

Management :

• Antibiotics (usually IV benzylpenicillin) and aspiration or formal drainage

Nasal septal abscess is the likely diagnosis here given the temperature and general malaise. Nasal septal abscess is where there is a collection of pus between the mucoperichondrium and septal cartilage. It results from a bacterial infection of a nasal septal haematoma.

This is why it is particularly important to incise and drain a septal haematoma as to prevent an abscess from forming.

Paranasal sinus tumours (maxillary, ethmoid, frontal, sphenoid) are commonly well differentiated squamous cell carcinoma. They present with signs and symptoms similar to this stem which include with local swelling, pain, and ocular symptoms if the orbit is involved.

Pain particularly in the upper cheek, nasal obstruction, blood in nasal discharge point towards a likely diagnosis of paranasal sinus carcinoma.

Although he has not complained of any weight loss, this patient has many signs and symptoms of tonsil carcinoma. Carcinoma of the tonsil is a type of squamous cell carcinoma.

Risk factors include smoking, regular alcohol intake and HPV infection.

Tonsillitis is incorrect. Although this patient complains of a sore throat, he has no pain, no acute onset of symptoms, no fever and no swollen regional lymph nodes.

Peritonsillar abscess is incorrect

Sialadenitis refers to inflammation of a salivary gland and may be acute or chronic, infective or autoimmune.

The patients suffering from sialadenitis generally experience redness, swelling and pain in the affected side of the mouth.

This occurs due to the enlargement of gland as a result of inflammation caused by bacteria or virus infection.

The swelling may become enormously enlarged, sometimes even reaching the size of an orange, with overlying inflamed reddened skin and edema.

Mild pain and swelling are usually common before and during meals.

Fluctuation test may be positive in the swelling if it is filled with fluid.

Other symptoms of sialadenitis include a foul taste in the mouth, decreased mobility in the jaw, dry mouth, skin changes, weight loss, shortness of breath, keratitis, dental pain, skin discharge and lymphadenopathy.

The patient may run fever with rigors and chills along with malaise and generalized weakness as a result of septicemia. In severe cases, pus can often be secreted from the duct by compressing the affected gland.

The duct orifice is reddened with reduced flow. There may or may not be a visible or palpable stone.

Hearing tests in the children:

• 2-4 years: Conditioned response audiometry: The child is trained to put pegs into holes or give toys to a parent on a particular auditory cue. 

Live insects cause great distress. Drown the insect in olive oil and if necessary then syringe it out.

BENIGN PAROXYSMAL POSITIONAL VERTIGO

• One of the most common causes of vertigo encountered.

• Characterised by the sudden onset of dizziness and vertigo triggered by changes in head position.

Presentation:

• Vertigo usually occurs on turning over in bed or lying down (basically any movement of the head)

• Each episode typically lasts 10-20 seconds but can last a few minutes

• Nausea during episodes

Diagnosis :

• Hallpike's Manoeuvre positive

Treatment:

• Mostly spontaneous resolution with exacerbations

• Epley’s manoeuvre : A repositioning technique used to reposition otoliths back into the utricles from the posterior semicircular canals.

Acute sialadenitis is an acute inflammation of a salivary gland. Patients typically present acutely in A and E with erythema over the area, pain, tenderness upon palpation, and swelling.

The infection is often the result of dehydration with overgrowth of the oral flora.

A common scenario would be postoperative dehydration. Purulent material may be observed.

Chronic sialadenitis, in contrast, is typically less painful and is associated with recurrent enlargement of the gland (often following meals) typically without erythema.

The chronic form of the disease is associated with conditions linked to decreased salivary flow, rather than dehydration. These conditions include calculi (sialolithiasis)

Chronic hoarseness is the most common early symptom of laryngeal cancer. The typical patient would be an elderly male patient who smokes and presents with progressive hoarseness, then stridor, difficulty or pain on swallowing.

Later with haemoptysis and ear pain if the pharynx is involved. While it is true that alcohol is a risk factor for laryngeal cancer, smoking is the main avoidable risk factor and is known to be the number one cause of laryngeal cancers.

This man is suffering from presbyacusis. Patients with presbyacusis often lose the ability to hear high-frequency sounds.

Speech has two components: vowels which are low-frequencies and consonants which are high-frequencies. When the high-frequency sounds are lost, consonants are lost, which results in difficulty in understanding speech.

“Don’t shout, I’m not deaf!’ is a common phrase used by elderly patients suffering from presbyacusis.

Otosclerosis is a distractor. It usually occurs at an earlier age.

Acquired cholesteatomas develop as a result of chronic middle ear infection and are usually associated with perforation of the tympanic membrane at the attic.

Clinical presentation usually consists of conductive hearing loss, often with purulent discharge from the ear.

In congenital:

• mass medial to the tympanic membrane

• normal tympanic membrane

• no previous history of ear discharge, perforation, or ear surgery.

Branchial cyst :

i) Branchial cyst is an anterior triangular lump. 

ii) The pharyngeal pouch is a posterior triangular lump.

iii) Thyroglossal is a midline lump 

iv) thyroid swelling moves with swallowing.

Unilateral recurrent laryngeal nerve injury

External laryngeal nerve functions to tense the vocal cords by activating the cricothyroid muscle, increasing pitch.

Press soft parts of the nose

Gentamycin topical. Diagnosis is otitis externa.

Infection is a common cause of secondary haemorrhage. Patients should be admitted to observe the course of bleeding and treatment is given with IV antibiotics.

Pea is not a magnetic material and hence it cannot be removed by a magnet, it will swell up if syringing is attempted, as hook placement is likely with risk of pushing the pea deeper it is not also suitable in a mentally retarded child, and olive oil is not of help in case of pea. So to avoid injury it is better to remove under GA.

MRI. Features are suggestive of acoustic neuroma, so MRI is the preferred option.

Nasal infection. Infection is one of the most important causes of secondary hemorrhage.

Tonsillitis is usually caused by a viral infection or, less commonly, a bacterial infection. The given case is bacterial tonsillitis (probably caused by group A streptococcus).

There are four main signs that tonsillitis is caused by a bacterial infection rather than a viral infection.

They are:

• a high temperature

• white pus-filled spots on the tonsils

• no cough

• swollen and tender lymph nodes (glands).

Head roll test. This is a case of “benign paroxysmal positional vertigo” for which the diagnosis is made by head roll test.

Otosclerosis. There are no features of encephalopathy. As the Weber test is lateralized it is unlikely to be functional hearing loss. In tympanosclerosis ear drum becomes chalky white. So as the eardrum is normal it is not tympanosclerosis.

Weber test is lateralized to the right and deafness is also on the right. So it is not sensorineural deafness but conductive deafness which makes otosclerosis the most likely diagnosis.

Anatomical. Bleeding time, coagulation profile, Hb%, cell count, and parameters are normal. So the likely cause of bleeding here is anatomical defect.

Unilateral recurrent laryngeal nerve

Chronic secretory OM with effusion

Otitis externa.

Otitis media with effusion does not present with earache and fever. The patient has otitis media with effusion from before but currently, he has developed earache and fever and this is due to otitis externa. Please note diagnosis is made for recent complaints though other diseases may co-exist!

Otitis media with effusion

Functional dysphonia is poor voice quality without any obvious anatomical, neurological, or other organic difficulties affecting the larynx or voice box. It is often secondary to viral infection.

Benign paroxysmal positional vertigo (BPPV).

Dizziness, nausea, vomiting, and nystagmus which keep coming from time to time are common features of BPPV.

Buccal prochlorperazine. Probable case of Menieres disease. Treated with prochlorperazine.

Otoscopy

Bluish grey tympanic membrane with air-fluid levels.

In glue air there occur conductive deafness so the child watches TV with high volume and does not respond to others for this deafness.

Otitis media.

Buccal prochlorperazine.

Both prochlorperazine and cyclizine can be used in Meniere’s disease.

Stop smoking.

Admit and IV antibiotics. Secondary hemorrhage can occur from sloughing of tissue from surgical wound following infection.

Alcohol drops. It is a living object. So it should be killed first and so alcohol drop is the correct option.

MRI of the internal auditory meatus. The likely cause is acoustic neuroma for which appropriate investigation is MRI internal acoustic meatus.

Here no sensory neural hearing loss.

SNHL present in acoustic neuroma, Meniere’s disease, and labyrinthitis.

Runny nose, cold, cough and fever are recognized triggers of vestibular neuronitis but not BPPV.

Breathlessness and stridor in a child playing with a toy is most likely due to aspiration of foreign body (toy or part of toy) for which laryngoscopy should be done.

No further intervention is needed. As the tympanic membrane is normal this transient inflammation of the pinna from injury during a rugby match is likely self-limiting which needs no further intervention.

AC>BC indicates Rinne positive; i.e. The deafness is not conductive. Again hearing loss is on the right side.

Weber lateralized to the left. We know Weber lateralized to the same side of conductive deafness and to the opposite if there is sensory neural deafness.

So it is now obvious that the deafness of the right ear is sensory neural deafness for which MRI brain is the next best investigation.

Audiometry. Conditioned response audiometry 2-4 years, pure tone audiogram for greater than 5 years, less than 6 months otoacoustic emission or brainstem evoked response, distraction test for 6-18 months.

None required. Diagnosis is laryngitis.

Maxillary sinus.

Nasal polyp

Antibiotic drop with steroid.

Discharge from ear and tragal tenderness are features of otitis externa. The key treatment is aural toileting. Drop advised is Sofradex (Framycetin + dexamethasone).

Buccal prochlorperazine.

Dilatation of the endolymphatic spaces of the membranous labyrinth causes sudden attacks of vertigo lasting ~2–4h (nystagmus is always present); or there may be increasing fullness in the ears ± tinnitus followed by vertigo.

Symptoms often become bilateral.

Fluctuating SNHL is common (may become permanent).

Oral penicillin V.

One of the indications of antibiotics is the presence of three or more center criteria and as the patient fulfilled three central criteria he should be given antibiotics.

The patient has the following three center criteria:

1. history of fever

2. lymphadenopathy and

3. absence of cough.

Acute OM.

High fever, severe earache, vomiting, bulging tympanic membrane and H/O associated URTI is highly suggestive of acute OM.

Secretory OM

Most secondary hemorrhage occurs due to infection which erodes a vessel. So the patient should be admitted for IV antibiotics.

Chronic sinusitis

Incision and drainage with antibiotics.

The diagnosis is peritonsillar abscess and treatment is I&D with antibiotics.

Otitis externa.

Extreme tenderness to examine indicates otitis externa.

Traumatic perforation of the tympanic membrane (TM) can cause pain, bleeding, hearing loss, tinnitus, and vertigo.

Diagnosis is based on otoscopy.

Treatment often is unnecessary.

Antibiotics may be needed for infection. Surgery may be needed for perforations persisting more than 2 months, disruption of the ossicular chain, or injuries affecting the inner ear. 

External laryngeal nerve (smaller, external branch of the superior laryngeal nerve) lesion causes mono-toned voice (loss of ability to produce pitched sound) that is dysphonia.

Temporomandibular joint pain may cause pain in ear and teeth and grinding is a recognized cause of this symptom.

Admit and IV antibiotics.

Secondary hemorrhage can occur due to infection causing sloughing out of part of the arterial wall due to infection. It is managed by IV antibiotics following admitting the patient to hospital.

In congenital cholesteatoma there is usually no perforation. In acquired cholesteatoma perforation is in pars flaccida.

Malignant OE.

In some cases, otitis externa can spread to the outer ear and surrounding tissue, including the bones of the jaw and face. This infection is known as malignant otitis externa. Although the term malignant is used it is not a cancer.

Bilateral OM with effusion

For acute suppurative otitis media 1st line antibiotic is Amoxycillin..

Remove with a hook.

Place a hook behind the object and pull it out.

Small perforations are usually healed by themselves within 6-8 weeks and doctors often prescribe antibiotics to prevent infections during this healing period.

This patient has conductive hearing loss. So it is not acoustic neuroma.

Meniere’s disease has symptoms like vertigo, tinnitus, fullness, along with hearing loss. There is no history of noise pollution, not presbycausis as his age is 45.

So his deafness fits more with otosclerosis.

These are by exclusion. Points in favour of otosclerosis:

i) Conductive hearing loss.

ii) Age of 45 yrs

iii) Moderate hearing loss in both ears across all frequencies.

There is supraorbital pain in frontal sinusitis and tenderness over the maxilla in maxillary sinusitis. Also, mild fever may present in acute sinusitis.

Hallpikes maneuver.

Vertigo which comes on with sharp movement of the head and neck points towards the diagnosis of benign positional vertigo which can be demonstrated by the Hallpike maneuver.

Under general anesthesia

Fever, earache and dull tympanic membrane following URTI are pointing to the diagnosis of acute otitis media.

Tonsillar carcinoma

Meniere’s disease.

SNHL vertigo and tinnitus lasting 30 minutes are consistent with Meniers disease. Here attacks are episodic symptoms resolve but hearing loss is progressive. In acoustic neuroma, hearing loss is not episodic.

Otosclerosis is also not episodic and conductive type. Benign positional vertigo, no hearing loss, and vertigo with sharp posture change. Unilateral loss of vestibular function and hearing associated with nausea and vomiting which is preceded by viral infection.

If horseness is of >3 weeks in man >50 yrs and smoker and heavy drinker to rule out cancer do CXR and laryngoscopy- NICE guideline.

Acoustic neuroma.

SNHL, tinnitus, and papilledema (raised intracranial pressure) are suggestive of acoustic neuroma.

MRI acoustic canal.

Diagnosis is right sided acoustic neuroma.

Anatomical defect

Hallpike maneuver is the preferred method to detect benign positional vertigo.

In hypoglossal nerve palsy the tongue will be curved toward the damaged side, combined with the presence of fasciculations or atrophy of the tongue on the same side.

Pressure over the soft tissues

The swimming history, irritation in both ears, and ear being hot, red, swollen, and painful indicates inflammation of the external acoustic meatus called Otitis Externa.

This is the picture of Acute Otitis Media which has led to tympanic membrane perforation.

PO Amoxicillin for 7 days is the antibiotic of choice.

Presentation may prompt one to think otitis media, but in swimming there is only exposure of the external ear to the water and no other risk factor for otitis media!! So it is not otitis media but otitis externa.

Bleeding from post operative site may occur from infection which causes necrosis and sloughing out of dead tissue. So such bleeding is treated by antibiotics to control risk of further bleeding.

The case described is Menier’s disease and to reduce the frequency of vertigo episodes (Prophylaxis) betahistine is given.

Birth to 6 months, Brainstem evoked response.