MCQs and EMQs for the Diploma in Otolaryngology

Head and Neck Surgery

Irfan Syed, Mahmood Bhutta

• Publisher: CRC Press
• Year: 2021
• ISBN:
  9781785231322
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The Diploma in Otolaryngology - Head & Neck Surgery (DOHNS) is now an intercollegiate examination, and can count towards membership of one of the surgical colleges of Great Britain. The DOHNS has evolved to fit its new role, leaving little up-to-date material available for candidates preparing for the written component. This book by former DOHNS candidates meets that need, focusing on topics that are likely to be examined. Each answer is accompanied by an explanation using current evidence-based research wherever possible. This will be an essential revision text for all DOHNS candidates. 'Applicable to medical students and trainee doctors in general practice as well as ENT and related head and neck disciplines such as neurology and neurosurgery. Each question is followed by the correct answer and clear and concise explanation. Indeed, it is the quality of this additional information that makes this book stand out from its competitors. It provides the student with experience and examination technique in answering these questions, but additionally it is a teaching volume in its own right. It is a credit to its enthusiastic and very competent young teachers in its content, design and clarity, and is another excellent contribution to our thriving specialty.' - from the Foreword by David Howard

Multiple Choice Questions (MCQs)

Otology

1. Pathogens commonly implicated in acute suppurative otitis media include:
   • Streptococcus pyogenes
   • Haemophilus influenzae
   • Respiratory syncytial virus
   • Norwalk virus
   • Moraxella catarrhalis
2. Otosclerosis:
   • Is a bony overgrowth of the stapes crurae
   • Affects men more than women
   • May be caused by the herpes virus
   • May cause taste disturbance
   • May be managed with a hearing aid
3. Retraction pockets of the pars tensa:
   • May be classified by the Sadé grading system
   • May cause a conductive hearing loss
   • Are associated with Ehlers–Danlos syndrome
   • Are associated with osteogenesis imperfecta
   • Are associated with previous insertion of a ventilation tube

1. Answers: TTTFT

Streptococcus pyogenes, Haemophilus influenzae and Moraxella catarrhalis are together cultured from around two- thirds of cases of acute suppurative otitis media. Acute otitis media is preceded by a viral infection in 80–85% of cases, and the most common virus is respiratory syncytial virus. Norwalk viruses cause gastroenteritis.

2. Answers: FFFFT

Otoslerosis is a genetically mediated metabolic bone disease of uncertain aetiology that affects the otic capsule, typically causing fixation of the stapes footplate. It does not affect the stapes crurae. Although some studies have suggested that women are affected more than men, large- scale studies of temporal bones have shown equal prevalence, and the reported sex difference may be a reflection of gender differences in severity of disease or consultation rates. Measles virus has been found in otosclerotic foci, but there is no evidence to suggest that the herpes virus is involved (although it may be implicated in idiopathic facial palsy). Otosclerosis does not cause taste disturbance, but surgery for the disease may disrupt the chorda tympani nerve, resulting in such a symptom. A hearing aid is a conservative approach to management.

3. Answers: TTFFT

Sadé has graded retractions of the pars tensa of the tympanic membrane in four stages (1. mild retraction; 2, on to the incus or stapes; 3, touching the promontory; 4, adhered to the promontory). Retraction pockets can cause a conductive hearing loss either through associated erosion of the ossicles or through a lack of aeration around the ossicles. There is no recognised association with the genetic collagen disorders Ehlers–Danlos syndrome and osteogenesis imperfecta. Retraction may occur at the site of previous ventilation tube placement, and there is also an association with a history of chronic otitis media with effusion.

• 4. Ménière disease:
  • Usually presents in adolescence
  • Is bilateral in two- thirds of cases
  • May be treated by injection of gentamicin into the middle ear
  • Is typically associated with a mid- frequency sensorineural hearing loss
  • Aural fullness is a well- recognised feature
• 5. Recognised complications of acute suppurative otitis media include:
  • Temporal lobe abscess
  • VIIth cranial nerve palsy
  • VIth cranial nerve palsy
  • Bartholin’s abscess
  • Cholesterol cyst/granuloma
• 6. Non- organic hearing loss:
  • May be diagnosed with Stenger test
  • Is sometimes due to inactive chronic suppurative otitis media
  • May present in childhood
  • Is associated with attempts at financial gain
  • Is best managed with a hearing aid

4. Answers: FFTTT

Ménière disease presents with attacks of vertigo that are associated with otological symptoms of tinnitus, hearing loss and aural fullness. It usually presents in the 40–60 years age group, and is bilateral in around 20% of cases. Intratympanic gentamicin treatment can be used to treat unilateral Ménière disease, especially if there is little remaining audiological function. The audiogram typically shows a mid-frequency hearing loss.

5. Answers: TTTFT

Acute suppurative otitis media may cause a temporal lobe abscess by local spread through the tegmen. It may also cause dysfunction of the intra-tympanic section of the facial nerve, especially if it is dehiscent. If infection spreads to the medial part of the temporal bone, it will cause petrous apicitis, which may present as Gradenigo syndrome (pain in the distribution of the ophthalmic branch of the trigeminal nerve and VIth nerve palsy). If infection spreads along the sternomastoid muscle, it may present anterior to this muscle as a Bezold’s abscess (Bartholin’s abscess is an abscess of the vulva). There may be haemorrhage in suppurative otitis media, and the cholesterol from membranes of red blood cells may then form a cystic mass, often erroneously termed a cholesterol granuloma.

6. Answers: TFTTF

Non-organic hearing loss is feigned hearing loss. In adults it is often for financial gain, whereas in children it is often a means of excusing poor school performance. It is by definition not due to any ear disease. Stenger test can be used for diagnosis in non-organic unilateral hearing loss. A pure tone of the same frequency is presented to each ear, but at different levels. In normal individuals such noise is believed to be coming from a single source – the louder one. Individuals who feign hearing loss should have the louder pure tone played to the supposed poorly hearing ear. The individual will then state that they hear nothing, whereas if their hearing loss were real they would actually hear the quieter tone in the good ear. Management does not require a hearing aid, as there is no actual hearing loss.

• 7. Treatment options for benign paroxysmal positional vertigo (BPPV) include:
  • Unterberger testing
  • Betahistine
  • Politzer manoeuvre
  • Epley manoeuvre
  • Endolymphatic sac decompression
• 8. The pinna:
  • Helps to localise sound
  • Is usually absent in Treacher–Collins syndrome
  • Is derived from the first pharyngeal pouch
  • Grows by endochondral ossification
  • Is affected in relapsing polychondritis
• 9. Cholesteatoma:
  • May be congenital
  • Is associated with Niemann–Pick disease
  • Contains cholesterol- rich squamous cells
  • May cause sensorineural hearing loss
  • Can activate osteoclasts

7. Answers: FFFTF

BPPV is a disorder characterised by an abnormal sensation of movement elicited by certain movements. It is thought to be caused by the presence of debris in the semicircular canals, usually the posterior semicircular canal. Medication is rarely effective, and betahistine has no role. Unterberger testing is a method of diagnosis of vestibular disorders, not a treatment. The Epley manoeuvre can reposition debris and abolish symptoms. In resistant cases singular nerve section may be warranted. Endolymphatic sac surgery is used in the treatment of Ménière disease.

8. Answers: TFFFT

The pinna helps to localise sound and is embryologically derived from the six hillocks of Hiss, which are outgrowths from the first and second pharyngeal arches (not the pharyngeal pouch). In first arch malformations such as Treacher–Collins syndrome the pinna may be low- set and small, but it is usually present. It does not ossify, so it does not grow by endochondral ossification. Relapsing polychondritis is a rare condition that mainly affects the pinna, nasal skeleton and laryngo-tracheobronchial tree. The cause of polychondritis is uncertain, but it is probably autoimmune.

9. Answers: TFFTT

Cholesteatoma is a mass of keratinising squamous epithelium in the middle ear cleft. The term is a misnomer, as it does not contain excess cholesterol and is not a neoplasm. In advanced disease it may activate osteoclasts to cause ossicular erosion, often of the scutum or the ossicles. In very advanced disease there can be erosion into the cochlea, causing sensorineural hearing loss. Niemann–Pick disease is a lysosomal storage disease that is unrelated to cholesteatoma.

• 10. Noise- induced hearing loss:
  • Affects the basal turn of the cochlea more than the apical turn
  • May be caused by meningococcal infection
  • Shows genetic variation in susceptibility
  • Is a recognised occupational disease under UK legislation
  • May be a cause of unilateral tinnitus
• 11. Otitis externa:
  • Is a recognised cause of facial palsy
  • May be due to otitis media
  • May lead to malignancy of the squamous epithelium of the external ear
  • May be caused by topical antibiotic drops
  • Swimming is a risk factor
• 12. Vestibular schwannoma (acoustic neuroma):
  • Affects men as often as women
  • May present with sudden hearing loss
  • Magnetic resonance imaging is the best investigation for imaging
  • May be treated with chemoradiotherapy in selected cases
  • Is increased in people with neurofibromatosis type 2

10. Answers: TFTTT

Noise exposure can cause irreversible damage to the outer hair cells of the cochlea, particularly those that respond to noises in the 4–6 kHz frequency range (towards the basal turn of the cochlea). There is genetic variation in susceptibility. Meningococcal infection can also cause hearing loss, but this is a separate pathology to noise- induced damage. Tinnitus is encountered frequently in noise- induced hearing loss, and may be unilateral or bilateral. Legislation to protect UK employees from noise exposure may be found in the Health and Safety at Work Act 1974.

11. Answers: TTTTT

Otitis externa may be due to systemic dermal conditions (such as psoriasis), topical hypersensitivity (including a hypersensitive reaction to antibiotic ear drops), or infection (bacterial, fungal or viral). Infective otitis externa is also known as ‘swimmer’s ear’, and humidity is a risk factor in its development. Otitis externa sometimes occurs secondary to discharge from the middle ear, and it is prudent to visualise the tympanic membrane at some point in all patients with otitis externa. Rarely, and particularly in individuals with diabetes, infection may spread into the temporal bone and cause cranial nerve palsies. Very rarely, chronically inflamed external ear squamous epithelium can undergo malignant change.

12. Answers: TTTFT

Vestibular schwannoma is a benign neoplasm of uncertain aetiology that most often affects the superior vestibular nerve. It has an equal gender incidence, but is much ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword
• Dedication
• Preface
• About the authors
• Multiple Choice Questions (MCQs)
• Extended Matching Questions (EMQs)
• Index