Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

Otorhinolaryngology (ENT) Clerkship

Paper- A Part I

A 67-year-old farmer presents to his local health center with a complaint of throat pain and hoarseness for 3 months.
He recalls that the throat pain started a few weeks before his voice became hoarse. 2 weeks-ago he started to note
progressive dysphagia, odynophagia, recurrent bouts of coughing, unintentional weight loss and right sided otalgia.
He admits to drinking alcohol and smoking a pack of cigarettes almost every day for the past 40 years. On physical
examination, no obvious lesions are seen in his oral cavity. Inspection of his nose and ears is unremarkable but on
neck palpation, a 1.5cm lesion is noted at the thyroid cartilage along with a 2cm x2 cm right-sided level III lymph
node. He is subsequently referred to the ENT clinic for further assessment and definitive management.

1. Which of the following investigations would be the LEAST helpful in the workup and evaluation of the
patient above?
a. Direct suspension micro-laryngoscopy
b. Flexible Fiber-optic laryngoscopy
c. Plain chest radiograph
d. Computed tomography of the Neck & Chest
e. Soft tissue lateral Neck X-ray
f. Fine needle aspiration cytology
g. Laryngo-tracheo-bronchoscopy
h. Barium swallow
i. Rigid Oesophagoscopy

2. Given the clinical information provided above which of the following is MOST likely diagnosis?

a. Metastatic Papillary thyroid carcinoma

b. Carcinoma of the left Palatine tonsil
c. Adenoid cystic carcinoma of a minor salivary gland in the larynx
d. Apical Bronchogenic carcinoma
e. Laryngeal carcinoma confined to the Right Glottis
f. Anaplastic carcinoma of the thyroid
g. Oesophageal carcinoma
h. Advanced Supraglottic Carcinoma
i. Nasopharyngeal carcinoma
j. Subglottic carcinoma

3. The patient is offered surgical intervention but declines and fails to follow-up at the ENT clinic. He
eventually re-presents 4 weeks later to the Accident and Emergency department with stridor. He is
moderately cachectic. What is the next most appropriate management option?

a. Orotracheal Intubation in A&E

b. Total thyroidectomy & neck dissection
c. Oesophageal stenting & radiotherapy
d. Total laryngectomy & Neck dissection
e. Emergency high tracheostomy in OT
f. Emergency low tracheostomy
g. Immunotherapy
h. Chemo-radiotherapy
i. Radiotherapy
j. Apical Lung resection

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

A 45-year-old lawyer visits his private ENT specialist with a complaint of left sided facial weakness that he noticed
on waking up this morning. His wife is concerned that he could have a mild stroke. He is a known diabetic (type
II) on metformin. He enjoys swimming and playing soccer in his spare time. He recently recovered from an upper
respiratory tract infection while on vacation in the Bahamas. During the interview, he explains that "everything
sounds louder than usual" but has no ear pain. He denies any vertigo, ear discharge or hearing loss. On external ear
examination both auricles, appear normal. There are no vesicles or granulation tissue in either of the external
auditory canals. Otoscopy shows both tympanic membranes have a normal light reflection. On Facial inspection;
there is incomplete eye closure and drooping of the mouth on the left side. He is also unable to furrow his brow on
the left side. His upper and lower limb motor examination shows strength to be 5/5 throughout. His hbA1C a week
ago was 5.5%.

4. What is the next most appropriate step in the management of this patient?
a. treat with Vitamin B12, sliding scale insulin and adjust the dose of his metformin
b. order a CT scan or MRI of the Brain & temporal Bones to rule out a Stroke or Brain tumour
c. recommend oral anti-retroviral therapy, eye protection, physiotherapy and prednisone for 6 weeks
d. Encourage him to discontinue swimming & treat with oral Levofloxacin, aural toileting &
ciprofloxacin ear drops
e. Request Magnetic Resonance Angiography to rule out an aneurysm
f. Request titers for Lyme disease given his recent travel history
g. Prescribe empirical antiretroviral therapy and offer to treat his wife for herpes
h. Order a chest X-ray to rule out Sarcoidosis as a cause of his facial paralysis

5. The patient above likely suffers from an inability to dampen loud noises because of temporary denervation
to;
a. Tensor tympani
b. Levator Veli Palatini
c. Tensor veli palatini
d. Posterior belly of the digastric
e. Anterior belly of the digastric
f. Stapedius
g. Stylohyoid muscle
h. Corda tympani

6. A 35-year-old, pharmacist presents to the ENT clinic with a history of intermittent hearing loss in the right
ear. This is often accompanied by tinnitus. She also admits to having three episodes of vertigo lasting at
least 20 minutes along with nausea and vomiting. There are times when she feels fullness in the right ear
but there has never been any ear discharge or ear pain. She denies any trauma or instrumentation to the ear.
Last month the vertigo was so severe that she lost her balance and fell to the ground. At present her ENT
examination in unremarkable.

Which of the following diagnoses best fits this clinical picture?

a. Vestibular Schwannoma
b. Benign Paroxysmal Positional Vertigo
c. Otosclerosis
d. Presbycusis (age-related hearing loss)
e. Noise-related hearing loss
f. Idiopathic endolymphatic hydrops (Menieres disease)
g. Labyrinthitis
h. Ototoxic medications
i. Syphilis
j. TORCH infection

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

7. A Pure tone audiometry in the above patient is likely to show:

a. A normal Audiogram
b. An increase in the bone conduction threshold with a peak at 2 kHz
c. Low frequency hearing loss
d. High frequency hearing loss
e. Low to mid frequency conductive hearing loss
f. Mixed hearing loss

8. Which of the following interventions is most likely to benefit this patient?

a. Modified Epley Maneuver

b. Intravenous Penicillin
c. Stapedotomy
d. Salt restriction, benzodiazepines & diuretics
e. Trans-labyrinthine surgical excision of a tumor at the cerebellopontine angle
f. Stereotactic Radiotherapy

9. A 40-year-old male is brought to the emergency department after he awoke and noticed that he couldnt
hear anything in his left ear. Prior to going to bed last night, he was "hearing just fine". He denies otalgia,
otorrhea or vertigo. His examination is unremarkable. The following are possible causes of sudden
sensorineural hearing loss EXCEPT:

a. Meniere's disease
b. Multiple sclerosis
c. Varicella zoster virus
d. Embolic Microvascular occlusion of the labyrinthine artery
e. Acoustic Neuroma
f. Sickle Cell disease
g. Ossicular chain disruption
h. Aminoglycosides
i. Vasculitis

10. Which of the following treatment options is considered first-line therapy in the management of Sudden
Sensorineural hearing loss (SSNHL)?

a. Intra- tympanic gentamicin injection

b. Intra-tympanic glucocorticoid Injection
c. Anti-retroviral therapy
d. Thrombolytics
e. Vasodilators
f. Hyperbaric oxygen therapy
g. 100% oxygen

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

11. A 29-year-old woman presents to your private practice with a complaint of nasal congestion, sneezing, and
runny nose. She reports that these symptoms started as a teenager and are worse during the earlier months
of the year. The patient has a known history of asthma and is maintained on Seretide. She is also currently
receiving treatment for eczema. Anterior rhinoscopy reveals that she has boggy bluish turbinates bilaterally.
Blood investigations reveal an Elevated Serum IgE. Nasal sputum cytology shows increased eosinophils.

Which of the following is the next most appropriate step in the management of this patient?

a. Request urgent computed tomography scan of the paranasal sinuses

b. Prescribe intranasal vasoconstrictors long term
c. Prescribe Oral antibiotics
d. Trial of Intranasal corticosteroids & antihistamines along with avoidance of allergens
e. Send Swab of the nasal cavity for culture & sensitivity
f. Septoplasty
g. Caldwel-luc-procedure

12. A 45-year old woman with recurrent left middle ear infection (otitis media) complained of partial dryness
of her mouth to her ENT surgeon. Taste sensation and hearing were normal. After a thorough clinical
examination at the hospital, the doctor concluded that the infection must have spread to a component of the
glossopharyngeal nerve (CN IX) that supplies the parotid gland. On which of the following walls of the
middle ear is this nerve component located?

a. Medial wall
b. Anterior Wall
c. Lateral wall
d. Posterior wall
e. Roof
f. floor

A 34-year-old woman G2 P2 complains of recent hearing loss in the right ear. She says her hearing is improved with
background noise. Otoscopic examination shows an area of redness behind tympanic membrane due increased
vascularity of the cochlear promontory. BC > AC on Rinne tuning fork testing. Weber lateralizes to the right ear.
She has a positive family history of hearing loss. You suspect ankylosis of the stapes footplate to the surrounding
bone.

13. What is the most likely diagnosis?

a. Tympanosclerosis
b. Glomus Jugulare
c. Sensorineural deafness
d. Glomus tympanicum
e. Otospongiosis
f. Acute suppurative otitis media
g. Ossicular chain disruption
h. Cholesteatoma

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

14. Which part of the boney labyrinth is most likely involved?

a. Cochlear (round) window

b. Cochlear duct
c. Internal acoustic meatus
d. External acoustic meatus
e. Vestibular (oval window)

15. What type of graph will her impedance tympanometry show?

a. Type As
b. Type Ad
c. Type B
d. Type C
e. Type D

16. A 36-year-old woman with a history of poor dental hygiene presents with facial pain, fever, nasal
congestion and purulent nasal discharge. Inspection of her oral cavity reveals an infected upper 2 nd
premolar. An acute bacterial infection of the adjacent paranasal sinus is suspected. Emperic antibiotic
therapy is started. Irrigation of this particular sinus through its opening is a supportive measure to
accelerate the resolution of the sinus infection. Which of the following nasal spaces is the most likely
approach to the opening of the infected paranasal sinus?

a. Inferior meatus
b. Nasolacrimal duct
c. Superior meatus
d. Middle meatus
e. Spheno-ethmoidal recess
f. The choana

17. What is the most commonly isolated bacterial pathogen implicated in this particular sinus infection?

a. Pseudomonas Aeruginosa
b. Streptococcus Pneumoniae
c. Streptoccocus Pyogenes
d. Moraxella catarrhalis
e. Staphylococcus aureus
f. Anerobes

18. A 23-year-old man comes to you complaining that he can't stop crying, i.e. tears regularly run down the
right side of his face. You suspect that one of the lacrimal ducts on the right side of the face is blocked.
You look into an endoscope to see if the nasolacrimal duct is blocked. Into which part of the nasal cavity
would you look to see the opening of the duct?
a. Inferior meatus
b. Ostiomeatal complex
c. Superior meatus
d. Hiatus semilunaris
e. Middle meatus
f. Spheno-ethmoidal recess
g. The choana

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

19. A 32-year-old man is found to have an anterior neck mass that moves on swallowing during routine
physical examination. He recalls being told by his mother that he received radiotherapy as a child many
years ago. Fine needle aspiration cytology of the nodule shows features in keeping with thyroid cancer and
the patient is scheduled for a total thyroidectomy. During surgery, your consultant asks you to identify one
of the nerves that innervates the muscle responsible for abducting the vocal cords.

Which of the following vascular structures is MOST closely related to this nerve & what is the name of the
muscle that the nerve eventually innervates?

a. Superior thyroid artery & cricothyroid muscle

b. Middle thyroid vein & Lateral cricoarytenoid muscle
c. Inferior thyroid artery & Posterior cricoarytenoid muscle
d. Inferior thyroid vein & Thyroarytenoid
e. Superior thyroid vein &arytenoid

20. Review of the final pathology report confirms thyroid malignancy. You suggest to your consultant that
post- operative radiotherapy may benefit this patient as this malignancy is known to be the most
radiosensitive. Which of the following cytological or histological features of this particular type of thyroid
cancer is most likely to be seen on microscopy;

a. Eosinophilic and congophilic acellular material

b. Amyloid stroma that stains positively for congo-red
c. Cohesive clumps of Anaplastic cells
d. Vascular and lymphatic invasion
e. Nuclear grooving, psammoma bodies & Orphan annie nuclei
f. Nodular hyperplasia
g. Hurthle cells

21. Following thyroidectomy, it was noted that the patient frequently aspirated fluid into his lungs. On
examination, it was determined that the area of the piriform recess above the vocal fold of the larynx was
numb. What nerve may have been injured?

a. External branch of the superior laryngeal nerve

b. Hypoglossal nerve
c. Internal branch of the superior laryngeal nerve
d. Lingual nerve
e. Recurrent laryngeal nerve

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

22. A 28-year-old woman is referred to the otolaryngology clinic by her General practitioner because of a 2cm
x2cm solitary thyroid nodule. She is otherwise asymptomatic but has a history of laparoscopic surgical
resection of an adrenal tumor five years ago. Her father and aunt died of an unknown condition. On
examination, the patient has a marfanoid habitus, oral mucosal neuromas, thick lips and eyelids. There is no
cervical lymphadenopathy. The mass appears to be situated in the isthmus of the thyroid. Her BP is 120/70,
Pulse 90, RR 16.

What is the next most appropriate step in the management of this patient?

a. Core needle biopsy

b. Ultrasound of the thyroid and TSH measurement
c. Computed tomography of the neck & Chest
d. Fine needle aspiration cytology
e. Radioisotope scan
f. 24hr urinary metanephrines
g. Calcitonin levels
h. Thyroglobulin levels
i. PET scan

23. Microscopic analysis shows amyloid stroma that stains positively with Congo red, and genetic testing
shows her to have a defect in the RET-Proto-oncogene. Which of the following treatment options is the
most appropriate for this patient?

a. Chemo-radiotherapy
b. Thyroid isthmusectomy
c. Left hemithyroidectomy
d. Right hemithyroidectomy
e. Near total thyroidectomy
f. Subtotal thyroidectomy
g. Total thyroidectomy
h. Iodine 131 ablation

24. 6 hours post operatively you are called to review the above patient because she is now having difficulty
breathing. On examination, her neck appears tense and swollen and the neck drain placed at the end of the
operation appears to have dropped out. What is the next best step in the management of this patient?

a. Intubate the patient

b. Emergency tracheostomy on the ward
c. Emergency cricothyroidotomy
d. Indirect laryngoscopy
e. Fine needle Aspiration the hematoma with a large bore needle
f. Re-insert the neck drain and set up suction
g. Remove neck sutures on the ward
h. Neck exploration in operating theatre

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

25. 14-year-old patient presents to the Emergency Department (ED) with an intractable nosebleed. Pinching of
the nose has failed to stop the bleed. In the ED a topical vasoconstrictor is tried but also fails to stop the
bleeding. Universal precautions are taken & An IV access is sited. Blood is taken for CBC, group &
crossmatch and coagulation studies. His vital signs are stable and he is awake and conversant. Anterior
rhinoscopy reveals a discrete area of bleeding from the mucosa of the anterior inferior part of the right
nasal septum. His admission Haemoglobin is 11.2g/dL, plts 250 x109, WBC 11 x 109, Clotting studies:
pending

Which of the following is the next most appropriate step in the management of this patient?

a. Observation
b. Anterior nasal packing
c. Posterior nasal packing
d. 75 % Silver nitrate to both sides of the nasal septum
e. Chemical or Electrocautery of Kiesselbachs plexus
f. Electrocautery of woodruffs plexus
g. Tranexamic acid
h. 2 sprays of adrenaline solution
i. Merocel tampon

26. Unfortunately, the appropriate treatment option listed above failed to control the bleeding. His hemoglobin
level drops to 10.5g/dL but his vital signs remain stable. Which of the following management options
would be most appropriate at this time?

a. Intubate the patient to secure his airway

b. Anterior nasal packs
c. Posterior nasal packs only
d. Anterior & Posterior nasal packs
e. Whole Blood transfusion
f. Fresh Frozen plasma
g. Platelet transfusion

27. Bleeding continues despite choosing the appropriate intervention above and the decision is made to carry
the patient to the operating theatre for examination under anesthesia. Which of the following would be the
most appropriate initial surgical intervention?

a. Internal carotid artery ligation

b. Septoplasty
c. Internal Maxillary artery ligation
d. Anterior ethmoidal artery ligation
e. Sphenopalatine artery ligation
f. External carotid artery ligation
g. Common carotid artery ligation
h. Arterial embolization

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

28. Which of the following arteries is LEAST likely to be contributing to this patient's epistaxis if the bleeding
is thought to be originating from the nasal septum?

a. Anterior ethmoidal artery

b. Greater palatine artery
c. Sphenopalatine artery
d. Lateral nasal artery
e. Superior labial branch of the facial artery

29. A 33-year-old woman presents to the outpatient department complaining of the sensation of the room
spinning whenever she moves sideways on the bed while lying supine or whenever she bends down to pick
up something from the refrigerator. She has no other symptoms. Inspection of her ears, nose and throat is
otherwise unremarkable and she has no signs of cerebellar dysfunction. What would be the most
appropriate next step?

a. Dix-hall-Pike test
b. Reassurance
c. Advice on posture
d. MRI of the brain
e. Carotid Doppler
f. Computed tomography

30. A 30-year-old woman presents to the Accident & emergency department with epistaxis for the last 20 30
minutes. Her vital signs are within normal limits. Examination with a nasal speculum fails to identify the
exact location of bleeding. She is advised to start external nasal compression which appears to slow the
bleeding. Laboratory investigations reveals a hemoglobin level of 13 g/dL, platelet count is 30 x 10 9 .
Prothrombin time of 14/13.2 and activated partial prothrombin (aPPT) of 30/29.2 and a normal bleeding
time. Blood film shows no schistiocytes. Which of the following is the most likely cause of her epistaxis?

a. Hemophilia A
b. Hemophilia B
c. Disseminated intravascular coagulation
d. Thrombotic thrombocytopenic purpura
e. Immune thrombocytopenic purpura
f. Evans syndrome
g. Von Willibrands disease
h. Vitamin K deficiency

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

31. A 12-month-old female with no significant past medical history is brought to your office by her mother for
fever of 2 days. The mother states the patient had a runny nose and cough prior and has noticed the patient
pulling on her right ear over the past 2 days. The mother also reports a temperature of 102 F at home for the
past two days, which has somewhat responded to acetaminophen. The patient has no known drug allergies
and does not currently take any medications. Vital signs today are T 39C, HR 110, BP 100/60, RR 20,
SpO2 100%. Physical exam is notable for an abnormal erythematous and bulging right tympanic membrane
that is only minimally mobile on pneumatic otoscopy.

Which of the following is the most appropriate treatment for the patient?

a. Tympanocentesis
b. Oral Amoxcillin
c. Intravenous antibiotics
d. No treatment necessary
e. Myringotomy and grommet insertion

32. Regarding the anatomy of the facial nerve which of the following statements is correct?

a. It enters the temporal bone through the external acoustic meatus

b. It exits the temporal bone through the mastoid canaliculus
c. It supplies taste sensation to the posterior 1/3 of the tongue
d. The lesser petrosal nerve is one of its branches at its 2nd genu
e. It gives off the chorda tympani just before it exits the stylomastoid foramen

33. A 63-year-old male presents to the ENT clinic with a painless right sided neck mass. He admits to daily
alcohol use & smoking 2 packs of cigarettes almost every day for the last 30 years but has been otherwise
well. He reports mild odynophagia but no shortness of breath, hemoptysis or hoarseness. On palpation of
the neck, the mass is 2.5 cm, firm and fixed to underlying structures. ENT examination in the clinic didnt
reveal any other positive findings. You ascertain that this mass is likely a metastatic lymph node.

Lymph node metastasis is most likely originating from which primary site?

a. Adenocarcinoma of a minor salivary gland

b. Squamous cell carcinoma of the Maxillary sinus
c. Nasopharyngeal carcinoma
d. Squamous cell carcinoma of the oropharynx
e. Lymphoma
f. Squamous cell carcinoma of the oesophagus
g. Laryngeal carcinoma

34. What is the next step in the management of this patient?

a. Computed tomography +/- PET scanning

b. Magnetic resonance imaging
c. Triple endoscopy + /-Biopsy
d. Fine needle aspiration of the neck mass
e. HPV testing
f. Excisional Biopsy of the neck node
g. Radiotherapy

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

35. A 42-year-old construction worker presents to a private otorhinolaryngologist, with a 3-month history of
unilateral nasal obstruction, clear nasal discharge, epiphoria and nasal pain. He denies a history of smoking
or alcoholism. On clinical examination, a reddish gray polypoidal mass with a friable appearance is noted.
Which of the diagnosis best fits this clinical picture?

a. Esthesioneuroblastoma
b. Allergic rhinitis
c. Nasal polyps
d. Juvenile angiofibromatosis
e. Nasopharyngeal carcinoma
f. Inverted papilloma
g. Septal deviation
h. Rhabdomyosarcoma
i. Allergic fungal rhinosinusitis

36. A 16-year-old boy presents with acute pain in the right ear and little bleeding from the same ear. He had
been in a boxing match and had sustained a blow to the ear. There is little amount of blood in the auditory
canal and a small perforation of the eardrum. What is the most appropriate management?

a. Admission for parental antibiotics

b. Nasal decongestant
c. Oral amoxicillin
d. No intervention necessary, review as an outpatient
e. Packing of ear
f. Surgical intervention
g. Syringing

37. A 25-year old university student was recently diagnosed with papillary carcinoma of his right thyroid lobe.
On clinical examination, he is also found to have multiple ipsilateral 3cm level III-V, cervical lymph nodes.
Surgeons discuss with him the possibility of performing a total thyroidectomy along with a radical neck
dissection.

Which of the following structures is preserved in a radical neck dissection?

a. Lymph nodes Levels I-V

b. Sternocleidomastoid
c. Spinal accessory nerve
d. Internal jugular vein
e. Phrenic Nerve

38. A 35-year-old male complains of a 6-month history of hearing loss, and persistent foul-smelling ear
discharge. He denies tinnitus, otalgia or vertigo. Otosocopic examination shows a small tympanic
membrane perforation in the pars flaccida and a white, flaky collection of dead skin cells protruding
posteriorly and superiorly.

What is the treatment of choice in the management of this patient

a. modified radical mastoidectomy

b. Underlay myringoplasty
c. Insertion of a ventilation tube
d. Antibiotic Ear drops
e. Meatoplasty
f. Stapedotomy

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

39. Weber testing of the patient above with the tuning fork placed on the forehead, will most likely show:

a. Air conduction greater than bone conduction

b. Bone conduction greater than air conduction
c. Sound heard equally in both ears
d. Lateralization to the right ear
e. Lateralization to the left air

40. The following are typical features of Gradenigos syndrome except:

a. Retro-orbital pain
b. Otorrhea
c. Abducens nerve palsy
d. Occulomotor nerve paralysis
e. Trigeminal nerve involvement
f. Petrous apecitis

41. A 5-year-old girl is brought to the accident and emergency unit by her mother who says that the child spat
up a table spoon of blood this morning. The child had been running a fever and was being treated at home
with DPH and Panadol. Mother reports that her daughter had adenoidectomy and tonsillectomy 5 days ago
but she was told that the procedure was uneventful and the child was discharged the following day. Review
of the surgical notes showed that no bleeding was seen on oral inspection in the recovery room or 24 hours
after the procedure. This patient is most likely having

a. A primary bleed from the tonsillar bed

b. A reactionary bleed due to slippage of a ligature
c. Early hemorrhaging due to dislodgement of a clot
d. Secondary hemorrhaging due to an URTI
e. Tertiary hemorrhaging
f. Epistaxis

42. You are asked by your senior resident to assist in performing a tracheostomy for a patient in the intensive
care unit. Which of the patients listed below would LEAST likely benefit from a tracheostomy?

a. 28 -year-old male with severely comminuted & bleeding midface fractures due to a MVA
b. 67-year-old male with decreased vital capacity diagnosed with Guillain-Barr syndrome
c. 16-year-old girl with HBSS admitted to ICU intubated for 15 days
d. 42-year-old woman with Myasthenia gravis and decreased respiratory effort
e. 37-year-old woman with intrathoracic tracheal stenosis
f. 22-year-old patient with 40% burns to the torso, neck and face and laryngeal edema
g. 35-year-old Male admitted with respiratory failure due to chronic bronchiectasis that requires
suctioning every 30 minutes.

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

43. Which of the following statements is CORRECT with regards to the proper tracheostomy technique?

a. The patient is made to lie supine with the neck hyper-flexed

b. A vertical skin incision gives a better cosmetic outcome when compared to a horizontal
c. the external jugular veins are routinely ligated to reduce bleeding
d. Strap muscles are retracted medially to visualize the tracheal rings
e. The thyroid isthmus is divided or retracted if necessary
f. An incision is usually made through the cricoid cartilage to gain access to the anterior trachea
g. Monopolar diathermy is suitable for excision of cartilage between tracheal rings 2-4
h. A yankauers suction tip is best used for clearing bloody secretions from the tracheal lumen
i. The common carotid vessels should be ligated and retracted to prevent bleeding

44. A 47-year-old store owner presents to the Emergency department after waking up in the early hours of the
morning with a swollen and slightly painful tongue. He was fine until last night when he drank peanut
punch and went to bed. He has no known drug or food allergies. While giving the history his voice is
muffled. He is a known hypertensive maintained on enalapril and nifedipine. He also takes NSAIDs for
joint pains. He denies sore throat, fever or skin rash. His last vital signs are T 99.4, P 80, BP 150/90, SPo2
94% on R/A. On physical exam, his tongue is markedly enlarged. His floor of mouth, uvula and soft palate
all appear edematous. Visualization of his oropharynx is not possible. His skin shows no signs of urticaria,
wheals or hives.

The most likely diagnosis is:

a. Dental abscess
b. Vincents angina
c. Ludwigs angina
d. Peritonsillar abscess
e. Parapharyngeal abscess
f. Hereditary Angioedema
g. Retropharyngeal abscess
h. Supraglottitis
i. Insect bite
j. Anaphylactic shock

45. In severe epistaxis, the pterygopalatine fossa may be entered surgically to ligate the:

a. Posterior ethmoidal artery

b. External maxillary artery
c. Internal maxillary artery
d. External carotid artery
e. Anterior ethmoidal artery
f. Internal carotid artery

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

46. A 68-year-old woman presents to your office with stabbing facial pain for 6 months which comes in
paroxysms. Each episode last only for a few minutes. She describes the pain as a severe attack with dull
aching persisting between these attacks. Touching the face or cold water applied to the face aggravates the
pain. What is the next best step in the management of this patient's condition?

a. Carbamazepine
b. Aspirin
c. Sumatriptan
d. Ibuprofen
e. Botox injections
f. Electroneuronography
g. EEG
h. CT scan of the Brain

47. A 15-year-old male is referred to the ENT clinic with a left sided neck lump, hearing loss, intermittent
epistaxis and nasal congestion. He is otherwise doing well. Clinical examination reveals a conductive
hearing loss with fluid behind the tympanic membrane. Which of the following statements is MOST
accurate regarding the likely diagnosis;

a. Epstein Barr Virus plays no role in the pathogenesis of this disease

b. Smoking is the strongest risk factor for this disease
c. A post nasal space X-ray is likely to be helpful
d. The eustachian tube opening should be biopsied
e. Surgery is the primary mode of treatment
f. Cytomegalovirus infection is commonly associated with this condition
g. Endemic to Southern China and north Africa
h. An incisional biopsy of the neck node is recommended

48. An elderly man with a history of cardiac disease presents to the clinic with wax impaction. He is sent to
have his ear canal syringed but during the procedure he has a syncopal episode.

Which of the following nerves is most likely to have been affected?

a. Nervus intermedius
b. Great auricular nerve
c. Auricular branch of the Vagus nerve
d. Tympanic branch of the Glossopharyngeal nerve
e. Auriculotemporal branch of the trigeminal
f. Vestibulocochlear nerve
g. Posterior occipital nerve

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49. A young man returns to the outpatient department after having nasal polypectomy for the second time.
Postoperatively he complains of blood stained watery fluid dripping from his right nostril on bending for 2
days. The nasal discharge forms a halo on the patients shirt. What is the most accurate investigation to
confirm the most likely diagnosis?

a. Beta 2 transferrin
b. Beta 2 micro-globulin
c. GMR
d. Culture and sensitivity
e. Positive Halos sign
f. Lumbar puncture

50. A 13-year-old boy is brought to A&E by the school nurse because his nose started to bleed profusely in
class. He tells you that he has had intermittent epistaxis several times before but never this severe. 3 weeks
ago, he started having unilateral nasal congestion and cheek swelling. On Inspection of his oral cavity there
is anterior displacement of his soft palate and a mass in his right nostril.

The most likely diagnosis is:

a. Nasopharyngeal carcinoma
b. Inverted papilloma
c. Hereditary Haemorrhagic Telangiectasia
d. Juvenile angiofibromatosis
e. Nasal polyps
f. Maxillary carcinoma
g. Rhabdomyosarcoma
h. Esthesioneuroblastoma
i. Encephalocele

51. The most appropriate investigation to order is

a. Intra-nasal incisional Biopsy

b. Plain radiograph of the post nasal space
c. Contrast enhanced CT scan of the nose and paranasal sinuses
d. Neck Angiogram
e. PET scan
f. Ultrasound
g. Sestamibi scan

52. A 60 woman complains of severe ear ache and ear discharge for the last 3 weeks. On examination, she has
a granulation polyp along the floor of the right ear canal. Her RBG is 17mmol/L. An ear swab is likely to
isolate;
a. Streptococcus Viridans
b. Group A strep
c. Escherichia. coli
d. Staphylococcus aureus
e. Pseudomonas Aeruginosa
f. Klebsiella Pneumoniae
g. Staph epidermidis

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

53. A 25-year-old male diagnosed with tubotympanic chronic suppurative otitis media presents to the clinic for
review. The affected ear is dry. What is the best treatment option?

a. Cortical mastoidectomy
b. Combined approach mastoidectomy
c. Tympanoplasty
d. Ossiculopasty
e. Syringing
f. A cochlear implant

54. The contents of the tympanic cavity include:

a. Cochlea
b. Utricle
c. Facial nerve
d. Greater petrosal nerve
e. Eustachian tube
f. Tensor tympani
g. Endolymph
h. Perilymph

55. A 58-year-old male with history of T3N2bM0 tongue base squamous cell carcinoma is treated with primary
chemoradiation. A one-year post-treatment PET/CT reveals no evidence of oropharyngeal carcinoma but a
2 cm FDG avid right thyroid nodule is discovered incidentally. What is the next best step in the
management of this patient?

a. Close observation with ultrasound assessment in 6 months

b. Close observation with repeat PET/CT in 6 months
c. Fine-needle aspiration biopsy
d. Thyroid lobectomy
e. Total thyroidectomy

A 50-year-old, nurse presents to the outpatient department with a 5cm diameter firm mass just inferior to the
left angle of the mandible. The lesion has been present for the past 4 months and has been increasing in size.
There is no colicky postprandial pain associated with swelling. Many years ago, she received low dose
radiotherapy for a benign skin condition. Over the past 48 hours she has developed lower lip weakness .

56. Which of the following options is the least probable diagnosis?

a. Adenoid cystic carcinoma of the submandibular gland

b. Mucoepidermoid carcinoma of the parotid gland tail
c. Submandibular duct sialolithiasis
d. Metastatic squamous cell carcinoma of the lateral tongue
e. Metastatic Adenocarcinoma of the minor salivary glands

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57. The surgeon decides to do an excisional biopsy of the mass. The following intra-operative complications
could be expected, EXCEPT;

a. Marginal mandibular nerve injury

b. Glossopharyngeal nerve palsy
c. Hypoglossal nerve palsy
d. Hemorrhage from the facial artery
e. Hemorrhage from the facial vein
f. Lingual nerve injury

58. During the patient consultation, she requests more in-depth information regarding her diagnosis. Which of
the following statements would be the most accurate regarding salivary gland neoplasms:

a. Chemo-radiotherapy is the primary mode of treatment for most salivary gland tumours
b. Malignant neoplasms are more likely to occur in the parotid gland than the minor salivary glands
c. The incidence of malignancy increases as the size of the salivary gland decreases
d. Pleomorphic adenomas occur more commonly the minor salivary glands than major salivary
glands
e. A painful swelling in the region of the submandibular triangle is a likely sign of a salivary gland
malignancy

A 42-year old woman presents to your office with moderate right sided hearing loss that she noticed several months
ago. She also complains of a noise in her right ear that is very disturbing. Physical examination shows right sided
hearing loss, an asymmetric smile, and decreased corneal reflex in her right eye. There is hypoesthesia of the
posterior superior aspect of the external auditory canal. Otoscopy shows no abnormalities. Air conduction is greater
than bone conduction in both ears but when the tuning fork is placed on the forehead she hears the vibration better in
the left ear than on the right.

59. This patients condition suggests a lesion in which of the following locations?

a. Facial canal
b. Meckels cave
c. Middle ear
d. Inferior colliculus
e. external auditory canal
f. cochlea
g. cerebellopontine angle
h. medial geniculate body

60. Which type of hearing loss is this patient expected to have?

a. Central hearing loss

b. Conductive hearing loss
c. Mixed hearing loss
d. Sensory type-hearing loss
e. Neural type hearing loss
f. Psychogenic hearing loss

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 Cornwall Regional Hospital- ENT, Head & Neck Surgery Department

61. The investigation of first choice is;

a. Computed tomography of the temporal bone

b. Gadolinium enhanced MRI of the brain and skull base
c. Facial nerve electroneuronography
d. MRI without gadolinium of the cerebellopontine angle
e. X-ray of the base of skull
f. Temporal lobe brain Biopsy
g. Brainstem evoked response
h. Technetium 99
i. Pure tone audiometry

62. A 30-year-old male presents with a right-sided frontal headache and right-sided periorbital oedema,
erythema and sensory loss. Examination reveals a furuncle over his right cheek, a dilated right pupil that
reacts sluggishly to light, and lateral gaze palsy of the right eye. What is the most likely diagnosis?

a. Cavernous sinus thrombosis

b. Brain abscess
c. Orbital rim fracture
d. Migraine headache
e. Lateral sigmoid sinus thrombosis
f. Posterior cerebral artery aneurysm
g. Orbital sepsis
h. Periorbital sepsis
i. Frontal sinusitis

63. A patient presents with left-sided facial weakness, loss of sensation to the anterior two-thirds of the tongue,
and hyperacusis. Tear production is normal in both eyes and there is no vestibular dysfunction. At which of
the following regions would a lesion to the facial nerve result in the symptoms described?

a. Left stylomastoid foramen

b. Left parotid gland
c. Left facial canal
d. Left geniculate ganglion
e. Left cerebellopontine angle

64. An adolescent boy is seen in the Emergency Department after experiencing a sharp pain in his throat after
eating bony fish. The ENT surgical registrar on call manages to retrieve the fish bone non-surgically but is
unsure if there may have been damage to the mucosa of the piriform fossa. Which nerve constitutes the
afferent (sensory) supply to the piriform fossa?

a. External laryngeal nerve

b. Glossopharyngeal nerve
c. Hypoglossal nerve
d. Internal laryngeal nerve
e. Recurrent laryngeal nerve

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65. A 30-year-old woman presents with a 6-week history of weight loss and anxiety. She takes no regular
medication and has smoked 10 cigarettes daily for 6 years. Examination reveals a resting heart rate of
108/min, a fi ne resting tremor of the hands, lid lag, and periorbital oedema. A diffusely enlarged goitre is
noted, with a non-tender 2 cm nodule on the right thyroid lobe. No obvious lymphadenopathy is noted but a
thyroid bruit is found on auscultation. Initial blood tests reveal a free T4 level of 31.5 pmol/L (1022), TSH
level of 0.10 mU/L (0.45), and the presence of thyroid peroxidase antibodies. Radioisotope scanning of
the thyroid reveals a diffuse uptake with no uptake in right nodule. What is the most likely diagnosis in this
patient?

a. De Quervains thyroiditis
b. follicular carcinoma of the thyroid
c. Graves disease
d. Papillary carcinoma of the thyroid
e. Toxic multinodular goiter

66. A 30-year-old male undergoes a right superficial parotidectomy. Eight months later he presents to the
outpatient department complaining of flushing and sweating of the right side of his face on eating. He is
diagnosed as having Freys syndrome and is listed for botulinum toxin injections. Misdirected re-
innervation of which nerve is responsible for this syndrome?

a. Greater auricular nerve

b. Facial nerve
c. Trigeminal nerve
d. Auriculotemporal nerve
e. Greater petrosal nerve

67. Which of the following is not a complication of longstanding adenoidal hypertrophy?

a. Failure to thrive
b. Serous Otitis media
c. Cor Pulmonale
d. Nasopharyngeal obstruction
e. Chronic sinusitis
f. Dysphagia
g. Cyanosis
h. Obstructive sleep apnea

68. A 24-year-old man has a 2cm lump in the middle of his neck that moves upwards on swallowing and on
protrusion of the tongue. Which is the next best step in management of this patient?

a. Ultrasound, CT or radioisotope scan

b. Sistrunk operation
c. Thyroidectomy
d. Lumpectomy
e. Fine needle aspiration
f. Core needle biopsy
g. Open biopsy

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69. A 44-year-old woman with type 1 diabetes has an intermittent swelling beneath the right lower jaw on
eating. On physical examination, she appears to be in pain and her right lower jaw appears swollen and
erythematous. A hard mass is palpable in the floor of her mouth. She first noticed her symptoms 1 year ago.
She has a history of renal impairment and an allergic reaction to contrast. Which of the following
statements is CORRECT regarding this patients likely diagnosis and management?

a. She likely has a stone or calculus in Stensons duct

b. There is only a 20% chance that a radio-opaque substance will be seen on an intra-oral X-ray
c. She likely has inflammation of her parotid gland
d. fine needle aspiration cytology is indicated as she most likely has a malignancy of the
submandibular gland
e. Sialography is indicated in this patient as it is the gold standard investigation to detect stones in
the submandibular duct
f. She may benefit from a course of antibiotics, anti-inflammatory agents, sialogogues and glandular
massage

70. A 40-year-old woman has undergone a total thyroidectomy for a multinodular goitre. She is a member of
her local choir and has noticed that she is no longer able to reach high notes as she used to prior to her
surgery and that her voice fatigues. Which is the single most likely nerve that has been injured at surgery?

a. External laryngeal nerve

b. Glossopharyngeal nerve
c. Internal laryngeal nerve
d. Recurrent laryngeal nerve
e. Ansa cervicalis

71. An 87-year-old man is brought to the ENT clinic by his daughter who complains that her father has been
having difficulty hearing for many years. She explains that she and other family members have to call him
several times before he responds. Otologic inspection is unremarkable. An audiogram shows high
frequency hearing loss in both ears. You diagnose him as having presbycusis. His hearing loss may be
attributed to all the following EXCEPT;

a. Degeneration of sensory hair cells

b. Degeneration of auditory neurons
c. Degeneration of stria vascularis
d. Degeneration of the ossicular joint
e. Structural changes in the basilar membrane

72. Which of the following statements is false regarding the palatine tonsils

a. The main blood supply is the Tonsillar br. Of the facial artery
b. It is embryologically derived from the 2nd branchial pouch
c. Radiation of pain to the ear in tonsillitis is transmitted along the Vagus nerve
d. Lymphatic drainage is to the jugulodigastruc nodes
e. They may become enlarged and inflamed secondary viruses such as EBV, HIV, adenovirus or
herpes zoster

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73. A 22-year-old man presents for elective surgical excision of a painless neck mass. He says the mass
fluctuates in size and came up after a respiratory tract infection. On examination, he has a fluctuant painless
4 cm x 5 cm neck mass. The most frequent site of this mass is at;

a. Upper third of antero-medial border of the sternocleidomastoid muscle

b. Lower third of the antero-medial border of the sternocleidomastoid muscle
c. Upper third of the posteromedial border of the sternocleidomastoid muscle
d. Supraclavicular fossa
e. Submandibular triangle
f. Submental triangle
g. Occipital triangle

74. Causes of conductive hearing loss includes all the following except;

a. Osteogenesis imperfecta
b. Tympanic membrane retraction
c. Viral Labyrinthitis
d. Tympanosclerosis
e. Nasopharyngeal carcinoma
f. Otosclerosis
g. Wax impaction
h. Ossicular chain disruption

75. Which of the following is CORRECT regarding malignant otitis externa?

a. Occurs more commonly in patients with diabetes insipidus

b. Contains high mitotic figures
c. Is treated with radiotherapy
d. Has malignant potential
e. Often causes hypoglossal nerve palsy
f. Patients with the disease are usually young
g. Commonly treated with IV antibiotics against pseudomonas

76. Which of the following statements is most accurate regarding the anatomy of the eustachian tube?

a. It length is about 5-7 cm

b. Opens into the medial wall of the nasopharynx
c. Is boney along its medial 2/3rds
d. It has a smaller angle to the horizontal plane in adults than in children
e. Tube is lined with respiratory ciliated mucosa

77. During a surgical procedure a nerve that travels in-between the internal carotid artery and internal jugular
vein & deep to the posterior belly of the digastic muscle is injured. All the intrinsic and extrinsic muscles of
the tongue are supplied by this nerve EXCEPT;

a. Genioglossus
b. Palatoglossus
c. Styloglossus
d. Superior longitudinal
e. Inferior longitudinal
f. Hyoglossus

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78. A 26-year-old male is admitted to the intensive care unit for ventilatory support after sustaining multiple
injuries during a motorbike accident along the north-south highway. After several weeks his condition
improves but he becomes hypoxic whenever orotracheal extubation is attempted by the anaesthetist.

The most likely cause of his respiratory distress is

a. Sepsis
b. Bleeding from the oral cavity
c. Fracture of the cricoid cartilage
d. Granuloma on the vocal cords
e. Ventilator-associated Pneumothorax
f. tracheomalacia
g. Subglottic tracheal stenosis
h. Trachea-oesophageal fistula
i. Laryngeal web
j. Traction injury to the recurrent laryngeal nerve
k. Bronchial intubation

79. What is the next best step in the management of the patient above?

a. Intravenous antibiotics
b. Tracheostomy
c. MRI of the neck
d. Computed tomography of the neck
e. Pulmonary function test
f. Tracheal dilatation
g. Tracheal resection of the stenotic segment
h. Direct laryngoscopy +/- bronchoscopy
i. Chest x-ray
j. Thoracostomy tube placement

80. A 62-year-old man comes to see complaining of frequent bouts of dizziness and fainting when looking up
and over his shoulder. He occasionally experiences diplopia and headaches. There is no hearing loss and no
nystagmus illicited by the Dix-Hall-Pike manoeuvre. When you ask him to look up he drops to the floor
unconscious. Which of the following conditions does this patient suffer from?

a. Menieres disease
b. Labyrinthitis
c. Benign paroxysmal positional vertigo
d. Perilymph fistula
e. Vertibrobasilar insufficiency

81.

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