Try these challenging Mcqs in ENT(with detailed explanation)
1. A 21-year-old swimmer with an unremarkable medical history comes to the clinic because of pain and itching in his left ear. He also reports some moist discharge from this ear. The symptoms began two days ago and have worsened. He denies any hearing loss, tinnitus, or vertigo. Pain is elicited when the left auricle is pulled superiorly and when the left tragus is pressed inward. The left ear canal is edematous and erythematous, and the considerable yellowish debris present in the canal obstructs visualization of the tympanic membrane.
What is the most appropriate next step in the management of this situation?
A) Irrigate ear canal with hydrogen peroxide
B) Clean ear canal with a cerumen wire loop or cotton swab
C) Apply topical antibiotics to ear canal with dropper
D) Prescribe analgesic medication
E) Refer to otolaryngologist for stent placement
The correct answer is: B
- External otitis arises secondary to skin maceration and failure of the skin-cerumen barrier that provides natural protection against infection. The condition is associated with swimming, excessive cleaning or itching of the ear canal, and usage of objects that occlude the ear canal (e.g., hearing aid, earphones). The organisms most commonly responsible for external otitis are those found in normal skin flora, including P. aeruginosa and S. aureus. Diagnosing external otitis is done clinically, based upon the history and physical examination. Pain caused by tragal pressure or superior movement of the auricle is considered a classic finding of external otitis. Treatment of the condition must always first begin with careful cleaning of the ear canal, as healing is significantly aided by removal of the cerumen, desquamated skin, and purulent debris. Therefore it would be best to clean the ear canal with a cerumen wire loop or cotton swab.
- (Choice A) Irrigation of the ear canal with diluted hydrogen peroxide would also be a good choice, but only if the tympanic membrane is visible and intact.
- (Choice C) Topical antibiotics such as polymyxin or ciprofloxacin are frequently used and have a good effect in patients with external otitis; however, the ear canal should be cleaned first so that the antibiotics will have maximal impact.
- (Choice D) Analgesic medication may be needed to relieve the pain that accompanies external otitis. NSAIDs are usually sufficient, although narcotics may be necessary in some cases. However, this is not the first step taken in managing the situation.
- (Choice E) Referral to an otolaryngologist for stent placement is indicated in those patients who have advanced or severe disease. The stent allows for topical medications to reach deeper into the swollen ear canal.
External otitis is associated with swimming, excessive cleaning or itching of the ear, or usage of occlusive devices. Treatment must first begin with cleaning of the ear canal with a cerumen wire loop or cotton swab. Irrigation with hydrogen peroxide is an acceptable alternative cleaning method if the tympanic membrane is visualized and intact.
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2.An 82-year-old Caucasian female comes to the emergency department for the evaluation of right ear pain and drainage for the past two days. She saw her primary care physician approximately one week ago for decreased hearing from the right ear, and he performed aural irrigation to remove impacted cerumen in her right ear. She has a history of hypertension, diabetes mellitus, and rheumatoid arthritis. She denies any history of smoking or alcohol abuse. Her medications include hydrochlorothiazide, enalapril, glyburide, and low-dose prednisone. On physical examination, her temperature is 37.2C (99F), blood pressure is 146/74 mmHg, heart rate is 100/min, and respiratory rate is 16/min. There is marked tenderness with motion of the right earlobe. Purulent discharge and granulation tissue is noted on the floor of the right external auditory canal at the osseocartilaginous junction. The tympanic membrane appears intact.
(I)Which of the following is the most likely cause of the above findings?
A) Acute otitis media
B) Malignant otitis externa
C) Ramsay Hunt syndrome
D) Acute mastoiditis
The correct answer is: B
- This is a classic presentation of malignant otitis externa (also known as malignant external otitis), which is an invasive infection of the external auditory canal and the bones forming the skull base. The infection usually begins as external otitis and progresses rapidly to involve the adjacent bones at the base of the skull. Patients have marked pain (otalgia) and purulent drainage or discharge from the ear (otorrhea). The finding of granulation tissue at the floor of the bone-cartilage junction in the external auditory canal is pathognomonic of this condition. The tympanic membrane is usually intact.
- Malignant otitis externa is typically seen in elderly patients with diabetes mellitus. Patients with HIV disease and other immunocompromised states are also at a higher risk of having malignant otitis externa. A number of patients with malignant otitis externa usually have an associated history of aural irrigation for the removal of cerumen. Pseudomonas aeruginosa is the usual causative organism in these patients. An untreated infection can progress rapidly to involve the skull base, temporomandibular joint, and cranial nerves, causing osteomyelitis and cranial nerve palsies.
- (Choice A) Acute otitis media is associated with an inflamed, erythematous, bulging and immobile tympanic membrane due to the presence of fluid in the middle ear.
- (Choice C) Ramsay Hunt syndrome (also known as herpes zoster oticus) is an ear manifestation of a reactivated varicella zoster virus. It is characterized by a triad of ear pain, vesicles in the external auditory canal, and ipsilateral facial paralysis.
- (Choice D) Acute mastoiditis is usually seen as a complication of acute otitis media.
Malignant otitis externa is typically seen in elderly, diabetic patients, and is characterized by severe pain and the presence of granulation tissue on the floor of the external auditory canal at the osseocartilaginous junction.
(II)Which of the following is the most appropriate treatment for this patient’s condition?
A) Topical tobramycin
B) Oral amoxicillin
C) Intravenous acyclovir
D) Intravenous ciprofloxacin
E) Acetic acid drops
The correct answer is: D
- Pseudomonas aeruginosa is the usual causative organism in almost all the cases of malignant otitis externa. Anti-pseudomonal antibiotic therapy is therefore the treatment of choice. Fluoroquinolones (ciprofloxacin), anti-pseudomonal penicillins (piperacillin, ticarcillin) with or without aminoglycosides, and third generation cephalosporins (ceftazidime) are all effective in the treatment of malignant external otitis. All patients should be treated with intravenous antibiotics initially, and then switched to oral antibiotics (depending on the clinical response), to complete 6-8 weeks of antibiotic therapy.
- (Choice A) Topical antibiotics have no role in the treatment of malignant external otitis.
- (Choice B) Oral amoxicillin is not effective against Pseudomonas aeruginosa, and should not be used.
- (Choice C) Intravenous acyclovir is used in the management of patients with Ramsay Hunt syndrome.
- (Choice E) Topical acetic acid (and other acidifying agents) is generally used in patients with mild external otitis. It has no role in the treatment of malignant otitis externa.
Systemic anti-pseudomonal antibiotics should be used in the treatment of malignant external otitis.
3.A 54-year-old Caucasian chef presents to clinic complaining about "a new problem with really bad dizziness." She says that when she first sat up in bed this morning, she suddenly felt very unstable and as if her body was spinning in space. She was overcome by nausea but did not vomit, and then the episode passed after approximately one minute. She had similar episode when she was working in the restaurant kitchen. She has not had an episode like this before. She has not been ill recently or in contact with any ill people to her knowledge. Her past medical history is significant for mild chronic obstructive pulmonary disease and ulcerative colitis. Current medications include albuterol, prednisone, mesalamine, and ibuprofen. She has a remote thirty pack-year history of cigarette smoking and drinks alcohol only on social occasions. Her temperature is 36.8C (98F), blood pressure is 124/72 mm Hg (sitting) and 120/68 mm Hg (standing), pulse is 75/min, and respirations are 14/min. Positional nystagmus is noted on physical examination.
Which of the following measures is the most appropriate course of action?
A) Order CT scan of head
B) Order MRI scan of head
C) Perform canalith repositioning procedure
D) Prescribe promethazine
E) Refer for plugging of the posterior canal
The correct answer is: C
- Benign paroxysmal positional vertigo (BPPV) is defined as an abnormal feeling of motion triggered by certain provocative positions. The condition is most often attributed to canalithiasis, or the presence of calcium "rocks" within the posterior semicircular canal. If there is substantial debris in the canal, then linear accelerations (eg, gravity) may cause the endolymph to move inappropriately. This results in the inaccurate sensation of spinning subsequent to movement of the head. Although the condition is often idiopathic, it can also be associated with head trauma or vestibular pathologies. BPPV should first be treated with the canalith repositioning procedure (Epley's maneuvre)(Choice C), which is a series of maneuvers that move particles out of the posterior semicircular canal and into the utricle.
- BPPV is a clinical diagnosis. Further testing is not indicated with typical posterior canal BPPV presentation. Imaging of the head (Choices A and B) is indicated if a mass lesion, hemorrhage, stroke, or Meniere’s disease is thought responsible for the patient’s vertigo.
- Promethazine (Choice D) is a nonselective antihistamine used in the treatment of nausea or vomiting. It may be of help in patients with vertigo but addresses only this particular symptom and not the cause.
- Plugging of the posterior canal (Choice E) is a surgical procedure used in patients with intractable symptoms of BPPV. In most cases, the procedure reduces the functionality of the posterior canal without affecting hearing.
Benign paroxysmal positional vertigo should first be treated with the canalith repositioning procedure, which is a series of maneuvers that moves particles out of the posterior semicircular canal and into the utricle.