Theme:Diagnosis of epistaxis

AAnticoagulant overdose
BCarcinoma maxillary antrum
CCoagulopathy
DHypertension
ENasal polyposis
FNasopharyngeal angiofibroma
GOrf
HSarcoidosis
ISeptal perforation
JTrauma
Select the most appropriate cause for
epistaxis in these patients:

A 80-year-old male presents with a

history of epistaxis of 2 hours duration.
He states that he feels light headed on
occasions and is aware of tiredness. He
has otherwise been quite well.

Incorrect - The correct answer is

Hypertension

A 36-year-old male presents with

bleeding from his right nostril. He has
previously been well and is employed as
a sheep farmer. On anterior rhinoscopy
he is found to have a polyp on anterior
part of nasal septum.

Incorrect - The correct answer is Orf

A 42-year-old man presents with

episodic epistaxis. He gives a history of
excessive crusting, occasional epistaxis
and has also noticed a whistling sound
on talking and deep inspiration. He is

employed in a chrome plating factory.

On examination, he has gross septal
deviation to the left and crusting over his
septum.

Correct

A 65-year-old gentleman with prosthetic

heart valve presents with epistaxis. He
takes anticoagulation medications but
doesnt remember if he has taken his
tablets correctly. He has not seen his
general practitioner or the
anticoagulation nurse for the last 3
months.

Correct

A 55-year-old presents with recurrent

epistaxis. He says that he has been
suffering from a cold and sinusitis that
has persisted for the last 6 weeks. He is
employed as a carpenter. No cause for
bleeding is apparent on examination.
However, anaesthesia of right cheek is
noted.

Correct

Explanation: Epistaxis or nasal bleed is a

very common condition. Causes for
epistaxis, like most conditions, could be
classified into: Traumatic fractures of
the nasal bones, maxilla, and floor of the
cranial cavity or soft tissue injury around
the nasal cavity. Nose picking is the
commonest cause of epistaxis in

children. Neoplastic include both

benign (angiofibroma of nasal cavity)
and malignant (maxillary or other Para
nasal sinus carcinoma, Kaposi sarcoma).
Nasal polyps are a common cause of
epistaxis but these are generally
produced by mucosal hypertrophy rather
than true hyperplasia and so are not
strictly Neoplastic. Infective are rare
causes of epistaxis. However severely
congested conchae could bleed with very
trivial trauma or conditions like Orf.
Systemic illnesses a variety of systemic
illnesses could give rise to nasal bleed.
The common ones for a spontaneous
epistaxis are hypertension, bleeding
diathesis including haematological
malignancies. Miscellaneous these
include medications including
anticoagulants.
Chromium is an irritant and may cause
destructive nasal septum lesions with
chronic exposure. This would explain the
crusting and deviation. Nasal orf
acquired from sheep through direct
contact may also produce epistaxiz.
Similarly a chronic sinusitis/cold may
through repeated nose blowing cause
nose bleeds. However, it would not
account for the facial anaesthesia which
points to a destructive lesion in the right
maxilla and involvement of the V nerve
and hence a nasopharyngeal Carcinoma.
Risk factors include wood dust, nickel
exposure, smoking, and EBV exposure.
In the absence of any other signs or
features in the 80-year-old man who
presents with headaches and tiredness,
the most likely cause for these symptoms
and epistaxis would be hypertensionparticularly common in the elderly and
usually isolated systolic hypertension
systolic above 140, diastolic below 90.
Head and neck swellings 2
ABranchial cyst
BCarotid body tumour
CCystic hygroma

DLymphadenopathy
EParotid adenolymphoma
FParotid pleomorphic adenoma
GSubmandibular tumour
HSubmandibular duct calculus
IThoracic outlet syndrome
JThyroglossal cyst
Which of the head and neck lesions
above best matches with the case
scenarios below?
A 60-year-old woman is seen in clinic
with a mass underneath her mandible. It
has increased significantly in size over
the past 2 months and is non-tender.

Correct
Submandibular gland tumours are more
frequently malignant than those of the
parotid (50% vs. 20%) although not as
common as the minor glands where 80%
of tumours are cancer. Adenoid cystic
tumours, the commonest variety are
aggressive compressing and invading
along nerves (lingual, hypoglossal &
mandibular branch of the facial). Patients
should have an FNA and a CT scan
followed by surgery with node dissection
if operable of radiotherapy.

A 58 year Tibetan man is seen in the

clinic with a painless mass on the left
side of his neck lying just anterior to the
sternocleidomastoid. He is asymptomatic
and no other masses are palpable.

Incorrect - The correct answer is

Carotid body tumour
Carotid body tumours usually present as
painless masses but occasionally may

compress the vagus or hypoglossal

nerves causing dysphagia, hoarseness,
stridor, or weakness of the tongue. They
are more common in people living at
high altitude. The majority (90%) are
spontaneous of which 5% bilateral but in
familial cases (10%), 30% are bilateral.
Treatment is surgical excision.

A 43-year-old woman is seen in A&E

with a 4 x 3 cm painful swelling beneath
her left mandible. It has been rapidly
increasing in size over the previous week
and the pain has increased as the lesion
has enlarged.

Correct
The submandibular gland is the
commonest site for calculi (85%), this
being due to the higher calcium content
in its saliva compared to the other
glands. Calculi are seen equally in men
and women and can be seen at any age.
Some stones can be removed by opening
Warthins duct and milking the stone
along but many require excision of the
gland.

A 70-year-old male smoker is seen in the

clinic with a 3 x 3 cm soft mass on his
right cheek anterior to his earlobe. It has
been present for 5 years and is
asymptomatic, the patient being referred
by the GP for a confirmatory diagnosis.

Correct
Adenolympha or Warthins tumour is the
second commonest parotid tumour (15%)
and a strong association with smoking. It

is softer, slower growing and is

commoner beyond middle age in men
with a 5:1 male:female ratio. Up to 10%
are bilateral. They are easier to excise,
do not seed in the wound, and there is no
malignant potential.

A 53-year-old woman is seen in the

clinic reporting pain in her left hand on
exertion such as when she brushes her
hair. At rest her pulses are palpable but
they disappear after repeatedly elevating
her arm. An X-ray is performed that
confirms the diagnosis.

Correct
Thoracic outlet syndrome includes
compression or thrombosis of the
subclavian artery and vein and
compression of the brachial plexus as
they pass over the first rib. Cervical ribs,
abnormalities arising from the 7th
cervical vertebra, are amongst the
commonest causes. Patients complain of
upper limb claudication when asked to
perform repeated movements such as in
brushing the hair. Some complain of
pain, numbness and tingling (C8 & T1)
and autonomic features such as pale,
cold hands may be present. Adsons test
is the definitive test. Cervical ribs may
be identified on chest X-rays or thoracic
inlet views but fibrous ribs will not show.
A Doppler scan will accurately define
vascular compression and MRI will
demonstrate nerve injury. Treatment is
by means of excising the cervical rib or
releasing scalene muscles if these are
compressing.

Epistaxis

AAnterior nasal packing

BFFP
CIce pack on the bridge of nose and
pinching of the nose
DNeomycin cream
ECautery
FPost nasal packing
GReassurance
HVitamin K
For each patient below, choose from the
list above the most suitable treatment
option

The mother of a six-year-old boy

telephones her local Accidents and
emergency department for advice on
what to do with her perfectly healthy son
who returned from playing with friends
with a very slight nose bleed. He is
otherwise well

Correct

An 8-year-old boy presents with slight

bleeding from his nose 2 days ago. On
examination, the nose showed mild
redness only

Correct

A 65-year-old retired accountant presents

to Casualty after returning from an
overseas holiday with a blood pressure of
230/110 mmHg. He complains of nose
bleeds of 2 hours duration and dull
headaches. His antihypertensives are
reinitiated, but anterior nasal packing is
unsuccessful

Correct

A 10-year-old girl presents with slight

bleeding from the anterior part of her
nose. In the Accident & Emergency a
small bleeding point is visualised.

Incorrect - The correct answer is

Cautery

A 75-year-old man with atrial fibrillation

presents with epistaxis. He takes
warfarin regularly, but has not bothered
to see his general practitioner or the
anticoagulation nurse for the last 3
months. He has maintained a regular
dose of 5 mg daily. His INR is 8

Incorrect - The correct answer is

FFP
Epistaxis is a common and often uncomplicated problem that can occasionally
become difficult to control. Epistaxis occurs in two different sites: anterior and
posterior. Anterior nosebleeds often result from mucosal trauma or irritation. Anterior
nosebleeds are by far the most common among otherwise healthy patients. A large
proportion are self-limited and can be managed definitively in the primary care
setting. Proper tamponade involving grasping the alae distally so all mucosal surfaces
are opposed and application of a cold compress applied to the bridge of the nose are
manoeuvres that can control simple bleeds in the home setting but should also be
taught to high-risk patients for use at home Cautery, either chemically or electrically
is the first-line management of a small visualized bleeding vessel of an anterior
source. The next step in management of suspected anterior bleeding if cautery and
local injection are unsuccessful is nasal packing to tamponade local bleeding. If
anterior packing is unsuccessful then posterior packing with a Foley 14G catheter
usually combined with anterior packing is used. Anticoagulated patients are at high
risk of epistaxis. Anticoagulant reversal is sometimes required

Rhinorrhoea
AAcute sinusitis
BAllergic rhinitis
CChoanal atresia
DCSF rhinorrhoea
EDrugs
FEnvironmental irritant
GForeign body
HNasal polyps
ITumour
For each scenario choose the most likely
diagnois:

A 7-year-old girl presents following a

fall from a horse and brief
unconsciousness. She has bilateral
orbital bruising and a clear discharge
from her nose.

Correct
In the 7-year-old girl, bilateral orbital
bruising following major trauma
suggests a basal skull fracture. The
discharge is likely to be CSF, and this
can be confirmed by glucose stick.

Following an apparently normal

pregnancy and delivery, a term 3.4kg
male infant presents with central
cyanosis, which improves with crying.

Correct
Cyanosis in the newborn usually worsens
with crying, as intrathoracic pressure
raises right atrial pressure causing
shunting at atrial level. Since newborns
are obligate nasal breathers, cyanosis

improving with crying therefore suggests

nasal obstruction, such as .

A 3-year-old boy presents with persistent

nasal discharge, present for the last 6
months. He is on the 3rd centile for
height, below the 3rd centile for weight,
and has had recurrent chest infections.

Correct
In a child with failure to thrive and
recurrent chestiness it is essential to
exclude cystic fibrosis. In this condition
are more common.
Diagnosis of hearing loss.
AAcute otitis media
BAcoustic neuroma
CBarotrauma
DBenign positional vertigo
EMastoiditis
FOtosclerosis
GOtotoxitiy
HPetrous bone fracture
IRamsay-hunt syndrome
JWax obstruction
For each patient below choose from the
list above the single most likely
diagnosis:
A 50-year-old man of poor hygiene,
complains of deafness after every
shower.

Correct
Wax obstruction. This is a common
cause of transient conductive deafness.
Wax can be seen on examinatiion of ears
and ear drums are not visible.

A 20-year-old man presents with a head

injury, some bruising on the side of his
head and hearing loss.

Correct
The auditory canal lies within the petrous
part of the temporal bone hence the
presentation with hearing loss.

A 70-year-old man treated with

gentamycin comes 10 days later with
hearing loss.

Correct
Aminoglycosides are a common cause of
ototoxicity and presents as sensorineural
deafness.

A 40-year-old lady, presents with

sensorineural deafness and corneal
anaesthesia. On examination, a CT brain
scan showed a lesion in the cerebellopontine angle.

Correct
Acoustic neuroma is a neurofibroma of
usually the vestibular division of VIII
cranial nerve. Ipsilateral sensorineural
deafness, cerebellar signs, facial and
corneal anaesthesia are well recognised
modes of presentation.

A 5-year-old boy presents with fever and

is refusing to allow examination of his
right ear.

Correct
Acute otitis media is particularly
prevalent in children.

A 70-year-old lady presents with rash

around the left ear and severe pain within
that ear.

Correct
Ramsay hunt syndrome due to herpes
zoster affecting the distribution of the
facial nerve. Pain is referred back to ear.
Problems of the nasal mucous
membranes
AAcute ethmoiditis
BAcute frontal sinusitis
CAcute maxillary sinusitis
DAllergic rhinitis
EVasomtor rhinitis
FCatarrh
GChronic sinusitis
HJuvenile angiofibroma
IMaxillary adenocarcinoma
JNasal polyps
Select the most likely diagnosis in the
following cases:

An 8-year old boy presents to his GP

with a two-month history of nasal
blockage and a recent torrential nosebleed.

Correct
This boy has a juvenile angiofibroma. It
can extend widely into the nose and
maxilla. If possible it should be excised;
of not radiotherapy is effective but
increases the risk of late malignant
change.

A 70-year old retired carpenter presents

to his GP with a four-month history of
right-sided nasal blockage. Recently he
had a blood stained nasal discharge. He
also complains of epiphora and that his
dentures are now ill-fitting.

Correct
This man has a maxillary
adenocarcinoma caused by longstanding
exposure to wood dusts. Spread into the
palate has caused a lump with ill-fitting
dentures and blockage of the lacrimal
duct has caused epiphora.

A 25-year old lady presents to her GP

with a two-day history of bilateral
forehead pain. She recently had an upper
respiratory tract infection. On
examination the forehead is tender to
touch.

Correct
This lady has acute frontal sinusitis
secondary to an upper respiratory tract
infection. This is a worrying condition
because infection can easily spread

through the posterior wall into the

anterior cranial fossa.

Differential diagnosis of hearing

loss.
AAcoustic neuroma
BAcute otitis media
CBarotrauma
DOtotoxicity
EPetrous temporal bone fracture
FWax impaction
Select the most appropriate
diagnosis for the following
patients who present with hearing
loss:

A 45-year-old man who is treated

with gentamicin for abdominal
infection presents with deafness.
He has had peak and trough
Gentamicin concentrations
measured and have been within the
recommended therapeutic range.
On examination, tuning fork tests
and audiometry suggests a global
decrease in hearing acuity.

Correct

A 55 year man with poor physical

hygiene presents with sudden onset
severe left earache and deafness
after taking a shower. He says he
tried to clean his ears but it only
worsened the pain. It is very

difficult to get views of his

eardrums.

Correct

Deafness could result when there is

impediment to conduction of sound
waves from exterior to the brain or
conductive lesions could be in
the auditory canal, middle ear or
sensory neural lesions of inner
ear (cochlear) and acoustic nerve.
Clinical examination includes
tuning fork tests which assess air
conduction (AC) and bone
conduction (BC) in the individual
compared to that of the examiner
(presuming his hearing is normal).
The common tests used are
Rhinnes test and Webbers test.
Rhinnes test has two components
first where the AC of the
Examiner and the patient are
compared. The second part helps
differentiate conductive deafness
and sensory neural deafness. In
normal individuals, the AC > BC.
But, in conductive deafness, BC >
AC. If a person is found to be deaf
by Rhinnes 1 and has a normal AC
BC relation, he has sensory neural
deafness. Webbers test compares
BC on both sides and lateralizes to
the normal side.
Gentamicin is well recognized to
be Ototoxic and is particularly
toxic to the Cochlear. Although,
ensuring adequate therapeutic

concentrations may minimize this

side effect, ototoxicity may still
occur even with concentrations
maintained in the therapeutic
range. Hearing reduction after a
shower is not uncommon with
water in the auditory canal and
may exacerbate hearing decline
associated with wax. However,
discomfort and hearing loss may
be compounded by trying to
displace the water through stuffing
objects into the auditory canal.
Differential diagnosis of epistaxis
AAcute pharyngitis
BAllergic sinusitis
CDrug induced
DEthmoid bone fracture
EFrontal sinusitis
FIdiopathic Thrombocytopenic Purpura
(ITP)
GMaxillary adenocarcinoma
HSepsis
From the above list, choose the most
appropriate diagnosis for the following
presentations:

A 72-year-old lady is being treated for

Myocardial Infarction in the Coronary
care unit. She has been thrombolysed 72
hours ago and is being anticoagulated for
a refractory atrial fibrillation. She has
developed epistaxis. Her observations
are all normal but the nurse has noticed
the she bruises very easily.

Correct

An 8 year boy presents with epistaxis.

He has multiple bruises which according
to the parents result from seemingly
trivial injuries. He has a cousin with a
similar problem who is receiving steroids
for it. On examination, he is also found
to have splenomegaly.

Correct
Epistaxis or nasal bleed is a very common condition. Causes for epistaxis, like most
conditions, could be classified into: Traumatic fractures of the nasal bones, maxilla,
and floor of the cranial cavity or soft tissue injury around the nasal cavity. Nose
picking is the commonest cause of epistaxis in children. Neoplastic include both
benign (angiofibroma of nasal cavity) and malignant (maxillary or other Para nasal
sinus carcinoma, Kaposi sarcoma). Nasal polyps are a common cause of epistaxis but
these are generally produced by mucosal hypertrophy rather than true hyperplasia and
so are not strictly Neoplastic. Infective are rare causes of epistaxis. However
severely congested conchae could bleed with very trivial trauma. Orf is one infective
cause of infective epistaxis. Ulcers due to sexually transmitted disease are also
described. Systemic illnesses a variety of systemic illnesses could give rise to nasal
bleed. The common ones for a spontaneous epistaxis are hypertension, bleeding
diathesis including haematological malignancies. Miscellaneous these include
medications including anticoagulants. In the patient with Myocardial Infarction,
epistaxis is probably due to Thrombolysis and/or anticoagulation. Splenomegaly in
the boy gives the clue to the suggested diagnosis of ITP.
Differential diagnosis of epistaxis
AAcute pharyngitis
BAllergic sinusitis
CDrug induced
DEthmoid bone fracture
EFrontal sinusitis
FIdiopathic Thrombocytopenic Purpura
(ITP)
GMaxillary adenocarcinoma
HSepsis
From the above list, choose the most
appropriate diagnosis for the following
presentations:

A 55-year-old carpenter presented to his

GP with recurrent episodes of spotty
bleeding from his right nostril. He also
states that the right nostril seems to be
perpetually blocked for the last 6 months
in spite of all the decongestants he has
bought off the counter. On examination,
right maxillary prominence is noted.
Anterior rhinoscopy reveals a fleshy
mass obstructing the right nasal cavity.
He has associated unilateral diplopia on
the right side.

Correct

A 12-year-old boy hit his head on a pole

on the school playground. His nurse sent
him to Accident and Emergency
department as he had a small nasal bleed
that stopped spontaneously. In the
intervening 2 hours, he has noticed a
watery discharge from his nose. On
examination there is considerable
bruising on his nose and forehead.

Correct
Epistaxis or nasal bleed is a very common condition. Causes for epistaxis, like most
conditions, could be classified into: Traumatic fractures of the nasal bones, maxilla,
and floor of the cranial cavity or soft tissue injury around the nasal cavity. Nose
picking is the commonest cause of epistaxis in children. Neoplastic include both
benign (angiofibroma of nasal cavity) and malignant (maxillary or other Para nasal
sinus carcinoma, Kaposi sarcoma). Nasal polyps are a common cause of epistaxis but
these are generally produced by mucosal hypertrophy rather than true hyperplasia and
so are not strictly Neoplastic. Infective are rare causes of epistaxis. However
severely congested conchae could bleed with very trivial trauma. Orf is one infective
cause of infective epistaxis. Ulcers due to sexually transmitted disease are also
described. Systemic illnesses a variety of systemic illnesses could give rise to nasal
bleed. The common ones for a spontaneous epistaxis are hypertension, bleeding
diathesis including haematological malignancies. Miscellaneous these include
medications including anticoagulants. The gentlemans symptoms, his occupation and
the examination findings of fleshy mass, maxillary lump and unilateral diplopia point

to the obvious cause of his epistaxis. Ethmoid bone fracture is the only traumatic
cause in this list of differentials provided and so is the cause of epistaxis in the boy.

Differential diagnosis of hearing loss.

AAcoustic neuroma
BAcute otitis media
CBarotrauma
DOtotoxicity
EPetrous temporal bone fracture
FWax impaction
Select the most appropriate diagnosis for
the following patients who present with
hearing loss:

A 58-year-old woman presented to her

general practitioner with gradually
worsening deafness in her right ear. She
also reports some postural imbalance and
occasional headaches. On examination,
she has decreased hearing in the left ear
which is decreased for air and bone
conduction and Webers test lateralises to
her left ear. There is also a reduction of
the corneal reflex on the right eye.

Correct

A 20-year-old male presents with hearing

loss after a fall from his horse and
sustained head injury. He complains of a
dead left. On examination, his ears are
normal but he has a bruise on the left
temporal region.

Correct

Explanation: Deafness could result when there is impediment to conduction of sound

waves from exterior to the brain or conductive lesions could be in the auditory
canal, middle ear or sensory neural lesions of inner ear (cochlear) and acoustic
nerve. Clinical examination includes tuning fork tests which assess air conduction
(AC) and bone conduction (BC) in the individual compared to that of the examiner
(presuming his hearing is normal). The common tests used are Rhinnes test and
Webbers test. Rhinnes test has two components first where the AC of the Examiner
and the patient are compared. The second part helps differentiate conductive deafness
and sensory neural deafness. In normal individuals, the AC > BC. But, in conductive
deafness, BC > AC. If a person is found to be deaf by Rhinnes 1 and has a normal AC
BC relation, he has sensory neural deafness. Webbers test compares BC on both sides
and lateralizes to the normal side. The features of decreased hearing (VIII nerve) and
reduced corneal reflex (V nerve) suggest a posterior fossa lesion and is suggestive of
an acoustic neuroma. These lesions of the VIII nerve may with enlargement also
affect the V and VII nerves. They are associated with other conditions such as
phaeochromocytoma and are best visualized with MRI. Fractures of the petrous
temporal bone may occur in the longitudinal or transverse axis of the petrous ridge.
These are seen in 1% of children hospitalized for treatment of head injury.
Longtitudinal fractures occur as a result of a blow to the side of the head and run in
the long axis of the petrous bone, typically from the squamous part of the temporal
bone along the roof of the external and middle ear cavities and then along the anterior
aspect of the petrous ridge towards the foramen lacerum. The facial nerve is at risk of
injury either at the geniculate ganglion or in its second intratympanic part. Ossicular
chain injury, either dislocation or fracture, may also occur causing conductive hearing
loss. Transverse fractures are less common but may be more severe and occur as a
result of a blow to the front or back of the head. These usually run from the jugular
fossa across the internal auditory meatus and/or the labyrinth. Facial nerve injury and
sensorineural deafness secondary to disruption of the labyrinth may occur. Clinically
these fractures may be suspected if a haemotympanum or CSF otorrhoea or
rhinorrhoea is present after head injury. Conductive deafness may be temporary and
caused by bleeding into the middle ear cavity, however, if it persists, an ossicular
chain injury should be suspected.
Differential diagnosis of Neck Swellings
ACervical rib
BCystic hygroma
CGoitre
DJugular glomus tumour
ELaryngomalacia
FPharyngeal pouch
GSubclavian artery aneurysm
HThyroglossal cyst
Select the most probable diagnosis to suit
the following presentations:
A 28-year-old man presents with a
pulsatile swelling in the lower part of the

neck at the base of the

sternocleidomastoid. On questioning, he
gives a history of intermittent
claudication particularly when working
with his arm above his head.

Correct

A 25 yr-old man presents with a lump in

the lower neck he noticed on casual
palpation. There is no pain associated
with the lump. He reports tingling along
the inner aspect of his forearm. The lump
is situated in the supra-clavicular fossa.
It is hard, rounded and seems to be
attached to the 7th cervical vertebra.

Correct

A 10-year-old girl presents with a

swelling in the lower part of the inferior
constrictor. Her mother reports that as an
infant the girl was troubled by
regurgitation and has always had
problems swallowing. This lump in her
neck increases after eating and the girl
reports that on pressing the swelling she
feels food in her throat again. There is
cough impulse on examination.

Correct

A 30-year-old female has noticed a

swelling in the front of neck. She has lost
significant weight in preparation for her
wedding. She doesnt remember having
the lump before. The lump is not painful

and is not associates with any other

symptoms. On examination, there is a
1.5 cm diameter smooth cystic lump
about 2cm above the thyroid cartilage in
the midline. This moves with deglutition
and protrusion of tongue.

Correct

Neck swellings are usually classified on

their location into: Anterior Triangle
swellings (anterior to the sternomastoid
muscle) and Posterior Triangle swellings
(posterior to sternocleidomastoid).
Typically, swellings in the posterior
triangle are lymph nodes. There are more
diverse origins for anterior triangle
swellings. Common differentials are
lymph nodes and thyroid swellings.
Swellings could be classified as midline
swellings and lateral swellings. There are
certain characteristic features associated
with certain swellings. For example,
thyroid swellings move with deglutition
but not with protrusion of tongue. Other
swellings that move with deglutition are
Thyroglossal cyst, hyoid bursa and
median / pyramidal lobe of thyroid.
These also move with protrusion of
tongue in contrast to thyroid swellings.
Swellings with cough impulse are
pharyngeal and laryngeal pouches /
diverticula and cystic hygroma. It is true
cough impulse in the former conditions
while the latter is an ill-defined sac
resulting from remnants of an
undeveloped lymph sac and the cough
impulse is transmitted. Lymph node
swellings are generally found along
veins. They are divided into 6 levels
mainly to stage metastatic disease and
standardize surgical procedures by the
digastric muscle, sternomastoid muscle

A 24 year-old man is evaluated for facial

pain and fever lasting four days.
Symptoms began with an upper
respiratory tract infection accompanied
by purulent nasal discharge; he then
began to have pain over the right cheek
and developed a fever of 38.4o C.
On examination he has a purulent nasal
discharge and tenderness over the right
maxilla. CT shows right maxillary
sinusitis.
Which of the following is the most
effective antibiotic treatment for this
patient?
(Please select 1 option)

Cefuroxime
Flucloxacillin
Co-amoxiclav
Ciprofloxacin
Amoxicillin Correct
Acute bacterial sinusitis usually occurs
following an upper respiratory infection
that results in obstruction of the
osteomeatal complex, impaired
mucociliary clearance and
overproduction of secretions. Sinusitis
can be treated with antibiotics,
decongestants, steroid drops or sprays,
mucolytics, antihistamines, and surgery
as (lavage). Studies have shown that
70% of cases of community-acquired
acute sinusitis in adults and children are
caused by Streptococcus pneumoniae
and Haemophilus influenzae. Most
guidance favours amoxicillin as 1st line
treatment. There seems to be little
evidence base for this, however. BMJs
clinical evidence website found 3 RCTs
which showed no difference between
amoxicillin and placebo (in patients
without bacteriological or radiological
evidence of sinusitis). However, there

were no RCTs examining the effects of

co-trimoxazole, cephalosporins,
azithromycin and erythromycin. Second
line therapies include ciprofloxacin and
co-amoxiclav. First and second
generation cephalosporins are not
generally favoured
and hyoid bone. In the above questions,
history, the anatomical situation and
examination findings point to the
answers.
History, sites and clinical examination of
neck swellings...
A 18-year-old woman attends
her General Practitioner's
surgery because of an insect which had
lodged in her right ear. What is the most
appropriate approach to remove this?

(Please select 1 option)

Instill 70% alcohol ear drops

Remove the insect with a hook
Syringe the ear with warm water Correct
Use a magnet
Under general anaesthesia
Syringing the ear is an option for many
foreign bodies providing the tympanic
membrane is not perforated. Suction,
which is not listed, under microscopy
would be useful if syringing fails. Use of
a general anaesthetic for this sort of
incident is too risky. Use of a hook may
push the insect further inwards and
magnets are used to aid remove of
foreign bodies made of iron.

A 6-year-old boy presents with fever,

throat and ear pain of 3 days duration.
This began with coryza, but the next day

he developed pain on swallowing, which

has gradually worsened. Born at term
weighing 3.9kg, he is fully immunised
and FH/SH are unremarkable.
On examination he looks uncomfortable,
with painful swallowing. His
temperature is 38.9C, and he is flushed.
Respiratory rate is 15/min and pulse
100/min. His chest is clear. Eardrums are
normal, but his tonsils look red with
scanty exudate. Cervical nodes are
enlarged and tender.
What is the most likely diagnosis?
(Please select 1 option)

Glandular fever Incorrect answer selected

Group A streptococcal pharyngitis This is the correct answer
Hand, foot and mouth disease
Primary herpes infection
Tonsillar abscess
The history suggests an acute
pharyngitis. Most are viral, though
Streptococcus Group A is an important
cause. It is not possible to discriminate
between these clinically. EBV may be
associated with a florid exudate and rash,
which may be precipitated by
prescription of Amoxicillin. Penicillin V
may be given if bacterial infection is
suspected

A 12-year-old girl presents with left ear

pain and fever, worsening over the past 3
days. Today mother has noted a whitish
creamy discharge from the ear canal. She
was born at 38/40 gestation weighing
3.8kg and there were no neonatal
problems. She is fully immunised. She
trains regularly in a swimming team.
On examination she has a temperature of
38.2C and has a red left tragus. This is

exquisitely tender, and examination of

the drum is impossible because of the
pain and creamy thin discharge. She has
shotty tender posterior cervical glands.
What is the most likely diagnosis?
(Please select 1 option)

Group A streptococcal pharyngitis

Mastoiditis
Otitis externa Correct
Otitis media, acute
Otitis media, recurrent
The history suggests an acute otitis
externa. The tight adherance of skin to
the underlying perichondrium and
periostium make the pain worse than the
degree of inflammation would suggest.
An ear swab culture should be sent and
neomycin and colistin/polymixin ear
drops commenced. This covers the
common gram positive and gram
negative usually responsible.
A 6-year-old girl presents with cervical
lymphadenopathy of 3 months standing,
which has increased progressively in
size. She has been off colour with a
chronic cough and hoarse voice. Full
term normal delivery, no neonatal
problems. Immunisations up to date. No
family or social history of note.
On examination the temperature is
36.8C, respiratory rate 20/min and pulse
85/min. Looks unwell and thin. 3rd
centile for weight, 25% for height.
Massive rubbery enlargement of right
cervical glands, which are non-tender.
No overlying erythema. Otherwise well.
What is the most likely diagnosis?
(Please select 1 option)

HIV
Infectious mononucleosis
Kawasaki disease

Lymphoma Correct
Mycobacterial adenitis
The progressive enlargement of nodes
over several months without associated
inflammation suggests malignant
infiltration. The abnormal voice suggests
involvement of the recurrent laryngeal
nerve. Assessment will require chest Xray and MRI or CT of neck and thorax,
and lymphnode biopsy. Prognosis will
depend on staging and histology
(including molecular tests).
A 9-year-old boy presents with a history
of headache and persistent green nasal
discharge. At night he has a cough and
snores loudly. The headache is
exacerbated by leaning forwards.
On examination he is apyrexial, but has a
persistent nasal obstruction and nasal
speech. He is tender over the maxillae
and forehead.
What is the most likely diagnosis?
(Please select 1 option)

Allergic rhinitis
Cluster headache
Cystic fibrosis
Nasal polyp
Sinusitis Correct
The picture is one of upper airways
obstruction associated with nasal
discharge, most likely due to sinusitis. In
this case the maxillary and frontal
sinuses are most likely to be involved.
A 7-year-old girl presents with high fever
and severe left-sided throat pain. She has
had difficulty in swallowing over the last
2 days, and has been finding it
increasingly uncomfortable to open her
mouth. Her voice is muffled and she
dribbles saliva. She was born at 41/40

gestation weighing 4.0kg and there were

no neonatal problems.
On examination she looks ill. Her
temperature is 40.2C (tympanic), RR
15/min and HR 100/min. ENT
examination shows left tonsillar
enlargement and exudate, with a uvula
deviated to the right.
What is the most likely diagnosis?
(Please select 1 option)

Atypical tuberculosis
Cervical lymphangitis
Foreign body aspiration
Peritonsillar abscess Correct
Retropharyngeal abscess
The history suggests a peritonsillar
abscess (quinsy) on the left side, a
complication of Group A Strep. sore
throat. A fever greater than 39.4C is
associated with severe disease, and
treatment is by surgical drainage.
57-year-old smoker gives a three month
history of persistent hoarseness. On
direct questioning he admits to rightsided earache. On examination he is
hoarse and has mild stridor. Examination
of his ears is normal. Endoscopy of his
upper airway shows an irregular mass in
the larynx.
What is the most likely diagnosis?
(Please select 1 option)

Laryngeal lymphoma
Carcinoma of the larynx Correct
Laryngeal papillomatosis
Laryngeal tuberculosis
Thyroid carcinoma
This patient is a heavy smoker,his
symptoms are of laryngeal pathology,
and an irregular mass is noted on nasal

endoscopy, these features point to a

diagnosis of laryngeal carcinoma.
A 14-year-old girl presents with a history
of cough and breathlessness on exercise.
She has seasonal rhinitis, and admits to
have started smoking. Clinical
examination is unremarkable.
What is the most likely diagnosis?
(Please select 1 option)

Allergic rhinitis
Asthma Correct
Cystic fibrosis
Gastroesophageal reflux
Sinusitis
A typical history of asthma in later
childhood, with exercise-induced
symptoms and a general deterioration on
commencement of smoking.
Unfortunately this is all too common
these days.
A 17 month old boy has been completely
well and playing with his toys. Mother
hears him coughing and choking and
rushes next door. She finds him gagging
and retching, drooling and red in the
face. He was born at 37+3/40 weighing
3.7kg and there were no neonatal
problems.
On examination his temperature is
36.9C, Respiratury rate 30/min, heart
rate 130/min. He looks slightly cyanosed
with an O2 saturation of 85% in air. He
has marked stridor and moderate
recession.
What is the most likely diagnosis?
(Please select 1 option)

Anaphylaxis
Croup
Foreign body aspiration Correct

Peritonsillar abscess
Retropharyngeal abscess
The history suggests aspiration of a
foreign body. Small objects, such as toys,
are the commonest offenders. They can
give rise to acute obstruction, or there
may be a latent period when symptoms
settle before inflammation around the
object gives rise to symptoms.
Assessment requires a chest X-ray,
which will locate radioopaque objects,
and bronchoscopy to remove the object.
A 3-year-old boy is goes to a children's
party and eats some peanuts. Almost
immediately he spits them out, and runs
to his mother saying his mouth hurts.
She notes a rapidly developing raised
itchy rash over his face, and that his
eyes, lips and tongue are swelling. He
begins to have marked difficulty in
breathing with audible stridor. An
ambulance is called.
On the arrival of the paramedics he has
collapsed and appears unconscious. He
has shallow breathing at 10/min, HR
160/min (thready pulse), and is
responding only to pain.
What is the most likely diagnosis?
(Please select 1 option)

Acute severe asthma

Anaphylaxis Correct
Croup
Foreign body aspiration
Trauma
The history is of anaphylactic shock in
response to peanuts. After attention to
airway and breathing he requires IM
adrenaline, then IV steroids and
antihistamines and nebulised salbutamol.
Fortunately anaphylactic shock is rare.