ENT OSCE Complete Answer Key

1. Acute Otitis Media (AOM)

A. What is your diagnosis?
●​ Acute Otitis Media (AOM) of the right ear (specifically, the Stage of Suppuration
characterized by a highly congested and bulging tympanic membrane with a loss of
landmarks).

B. Mention the sign.

●​ Cartwheel sign (radial vascular congestion along the handle of the malleus and the pars
tensa) and Bulging of the Tympanic Membrane (loss of the cone of light and landmarks
like the lateral process of the malleus).

C. What are the most common organisms responsible for it?

1.​ Streptococcus pneumoniae (most common bacterial pathogen)
2.​ Non-typeable Haemophilus influenzae
3.​ Moraxella catarrhalis
4.​ Streptococcus pyogenes (Group A Strep)

D. What are the stages?

According to the Shambaugh/Scott-Brown classification:
1.​ Stage of Tubal Occlusion: Eustachian tube is blocked, resulting in negative pressure.
TM is retracted, handle of malleus is horizontal, mild earache, and conductive hearing
loss.
2.​ Stage of Pre-suppuration: Capillary engorgement occurs. TM shows radial congestion
(cartwheel appearance). Severe throbbing pain, fever, and constitutional symptoms start.
3.​ Stage of Suppuration: Pus forms in the middle ear cavity under pressure. TM bulges
outwards (donut or nipple-like projection). Pain becomes excruciating, high-grade fever,
and vomiting may occur.
4.​ Stage of Resolution/Perforation: TM ruptures, leading to purulent/blood-stained ear
discharge (otorrhea) and a sudden drop in pain and fever.
5.​ Stage of Coalescence: If resolution fails, middle ear infection spreads to mastoid air
cells, causing mastoiditis.

E. How will you treat the patient?

●​ Medical Management (First-line):
1.​ Systemic Antibiotics: Oral Amoxicillin (high-dose: 80–90 mg/kg/day in children)
for 7–10 days. If beta-lactamase resistance is suspected, switch to
Amoxicillin-Clavulanate (Co-amoxiclav).
 2.​ Analgesics & Antipyretics: Paracetamol (Acetaminophen) or Ibuprofen for relief
of severe otalgia and fever.
3.​ Decongestants: Nasal decongestant drops (e.g., Oxymetazoline 0.025% or
Xylometazoline) and systemic decongestants to open the Eustachian tube.
4.​ Dry Local Heat: Warm compresses over the ear to soothe pain.
●​ Surgical Management:
○​ Myringotomy: An incision in the posteroinferior quadrant of the TM to drain pus
under tension. Indicated if medical therapy fails, or if complications (e.g., facial
nerve palsy, labyrinthitis, meningitis) arise.

2. Otitis Media with Effusion (OME)

A. What is your diagnosis?
●​ Otitis Media with Effusion (OME) (also known as Secretory Otitis Media, Serous
Otitis Media, or "Glue Ear").

B. Mention the finding.

●​ Presence of air-fluid levels and air bubbles behind a dull, yellow/amber-colored,
retracted tympanic membrane. The lateral process of the malleus is prominent, and the
handle of the malleus is foreshortened.

C. What are the clinical features?

1.​ Conductive hearing loss (CHL): The most common symptom, often presenting in
children as school inattentiveness, turning up the television volume, or speech delay.
2.​ Feeling of ear fullness or blockage: Often fluctuating in nature.
3.​ Autophony: Hearing one's own voice louder or sounding echoey.
4.​ Popping or clicking sounds: Heard in the ear during swallowing or yawning as air tries
to enter the middle ear.
5.​ Mild, intermittent discomfort: Usually painless, unlike acute otitis media.

D. How will you investigate?

1.​ Pneumatic Otoscopy: Demonstrates a sluggish or completely immobile tympanic
membrane (the most reliable clinical diagnostic test).
2.​ Impedance Audiometry (Tympanometry): Typically shows a Type B (flat)
tympanogram indicating fluid behind an intact drum, or occasionally a Type C
tympanogram showing high negative middle ear pressure.
3.​ Pure Tone Audiometry (PTA): Demonstrates Conductive Hearing Loss with an
air-bone gap of 20 to 40 dB.
4.​ Acoustic Reflexometry: Absent acoustic reflexes in the affected ear.

E. What is the treatment?

●​ Conservative / Watchful Waiting: Up to 3 months of active surveillance, as 90% of
 cases in children resolve spontaneously.
●​ Medical Management:
1.​ Auto-inflation of the Eustachian tube (e.g., Valsalva maneuver or Otovent balloon).
2.​ Treatment of predisposing conditions: nasal saline douching, intranasal
corticosteroids for allergic rhinitis/adenoid hypertrophy.
●​ Surgical Management (Indicated if effusion persists > 3 months bilaterally, or is
accompanied by severe hearing loss/structural TM changes):
1.​ Myringotomy with Grommet (Tympanostomy Tube) Insertion: Placed in the
anteroinferior quadrant to ventilate the middle ear.
2.​ Adenoidectomy: Often performed concurrently in children to relieve physical
obstruction of the Eustachian tube orifice.

3. Tympanosclerosis
A. Name the condition seen on the tympanic membrane.
●​ Tympanosclerosis (specifically Myringosclerosis when localized purely to the tympanic
membrane). It is characterized by chalky-white, crescent-shaped, calcified plaques within
the lamina propria of the TM.

B. Enumerate three causes for it.

1.​ Recurrent episodes of Acute Otitis Media (AOM) or chronic middle ear infections.
2.​ Prior insertion of ventilation tubes (grommets) (iatrogenic micro-trauma).
3.​ Chronic Otitis Media with Effusion (OME) or direct mechanical trauma/rupture of the
tympanic membrane.

4. Chronic Otitis Media (COM) - Mucosal Type

A. What is your diagnosis from the image shown above?
●​ Chronic Otitis Media (COM) - Mucosal Type (formerly termed Tubotympanic type or
"Safe" type CSOM), currently in a dry/quiescent phase.

B. What is a central perforation?

●​ A central perforation is a defect in the pars tensa of the tympanic membrane where an
intact margin of the fibrocartilaginous annulus is preserved all around the perforation (i.e.,
it does not touch the bony sulcus/annulus at any point).

C. What will be the clinical features of this patient?

1.​ Ear Discharge (Otorrhea): Profuse, mucoid or mucopurulent, odorless, painless,
non-offensive, and typically intermittent (precipitated by upper respiratory tract infections
or accidental water entry into the ear).
2.​ Hearing Loss: Conductive hearing loss, the severity of which correlates directly with the
size and location of the perforation and the integrity of the ossicular chain.
 3.​ Tinnitus: Mild, intermittent low-pitched ringing.

D. How will you investigate?

1.​ Examination Under Microscope (EUM): To assess the exact margins of the perforation,
the status of the middle ear mucosa (dry, edematous, or congested), and to check for
ossicular continuity.
2.​ Pure Tone Audiometry (PTA): To confirm and quantify the degree of Conductive Hearing
Loss.
3.​ Ear Discharge Culture and Sensitivity (C&S): If active discharge is present, to identify
pathogens (such as Pseudomonas aeruginosa or Staphylococcus aureus) and direct
targeted antibiotic therapy.
4.​ Tuning Fork Tests (256/512/1024 Hz): Rinne negative in the affected ear, Weber
lateralized to the diseased ear, and Absolute Bone Conduction (ABC) normal.

E. What is the treatment?

●​ Conservative / Medical Management (for active discharge):
1.​ Keep the ear strictly dry (e.g., using cotton plugs with Vaseline during bathing).
2.​ Aural Toilet: Micro-suctioning or dry-mopping of middle ear secretions.
3.​ Topical Antibiotic Drops: Non-ototoxic ear drops like Ciprofloxacin or Ofloxacin.
Avoid aminoglycoside drops if a perforation exists.
●​ Surgical Management (Definitive Treatment once the ear has been dry for 4–6
weeks):
1.​ Myringoplasty: Surgical closure of the tympanic membrane perforation using a
graft (commonly temporalis fascia or tragal perichondrium).
2.​ Tympanoplasty (Type I): Reconstructive surgery of the tympanic membrane,
ensuring the ossicular chain is intact and mobile.

5. Grommet (Tympanostomy Tube)

A. What is the white structure shown in the picture?
●​ Grommet (also known as a Tympanostomy Tube or Ventilation Tube).

B. Name the condition of the ear in which it is used.

●​ Otitis Media with Effusion (OME) (refractory to medical treatment), recurrent Acute
Otitis Media, or severe Eustachian Tube Dysfunction with tympanic membrane
atelectasis.

C. Which quadrant of the tympanic membrane is it placed in?

●​ Anteroinferior quadrant (to avoid injury to the postero-superiorly located ossicles and
the chorda tympani nerve, and because it is the quadrant with the least risk of long-term
attic retraction/cholesteatoma).
D. Name the instrument used for this surgical picture.
1.​ Myringotomy Knife (to perform the radial incision).
2.​ Grommet Inserter / Introducer (or fine alligator forceps).

E. What are the complications?

1.​ Persistent perforation of the TM after the grommet extrudes.
2.​ Post-grommet otorrhea (chronic ear discharge).
3.​ Tympanosclerosis (calcification of the TM membrane around the site).
4.​ Early extrusion or bony intrusion/blockage of the grommet.
5.​ Cholesteatoma formation (due to squamous epithelial migration through the incision
site).

6. Noise-Induced Hearing Loss (NIHL)

A. What is the diagnosis?
●​ Noise-Induced Hearing Loss (NIHL) (bilateral, symmetrical high-frequency
sensorineural hearing loss).

B. What is the classic finding being marked with the arrow?

●​ Acoustic notch at 4000 Hz (also referred to as the 4 kHz dip or "Boilermaker's
Notch"), where both air and bone conduction thresholds drop at 4 kHz with partial
recovery at 8 kHz.

C. Is it preventable? Yes or No.

●​ YES.

D. What are the clinical features?

1.​ Bilateral progressive high-frequency sensorineural hearing loss (SNHL).
2.​ Difficulty in speech discrimination, particularly in environments with background noise
(e.g., cock-tail party effect).
3.​ High-pitched, continuous tinnitus.
4.​ History of prolonged exposure to industrial/occupational noise (e.g., railway machinery,
factories) or recreational noise (e.g., firearms, loud music).

E. How will you treat this patient?

●​ Preventive Measures (Most Crucial):
1.​ Strict use of Personal Protective Equipment (PPE) like earplugs or earmuffs.
2.​ Noise reduction at the source and routine annual audiometric monitoring.
●​ Rehabilitative Measures:
 1.​ Bilateral Hearing Aids (digital program-controlled to amplify higher frequencies
selectively).
2.​ Tinnitus Retraining Therapy (TRT) or white noise maskers if tinnitus is disabling.
3.​ Counseling on vocal safety and background noise minimization.

7. Otosclerosis
A. What is the diagnosis?
●​ Otosclerosis (specifically clinical stapedial otosclerosis).

B. What is the type of hearing loss being shown?

●​ Conductive Hearing Loss (or mixed hearing loss if it is advanced cochlear otosclerosis).

C. What is the classic finding being marked with the arrow?

●​ Carhart's Notch (a mechanical dip in the bone conduction threshold at 2000 Hz by about
15 dB).

D. Give 2 probable diagnoses from the audiogram above.

1.​ Stapedial Otosclerosis
2.​ Congenital Stapes Fixation (or Ossicular Chain Fixation)

E. What is the treatment?

●​ Surgical Treatment (Treatment of Choice): Stapedotomy (or stapedectomy) with
placement of a Teflon/Platinum piston prosthesis.
●​ Medical Treatment: Oral Sodium Fluoride (useful in active spongiotic phase to arrest
progression and cochlear otosclerosis).
●​ Non-surgical Rehabilitation: Hearing Aid amplification (highly effective option for
patients who decline surgery).

8. Ramsay Hunt Syndrome (Herpes Zoster Oticus)

A. Name the syndrome.
●​ Ramsay Hunt Syndrome (Herpes Zoster Oticus / Ramsay Hunt Syndrome Type II).

B. Name the causative organism.

●​ Varicella Zoster Virus (VZV) (reactivation of latent virus in the geniculate ganglion of the
facial nerve).

C. Name the other areas where rashes can be seen in this syndrome.
 ●​ Pinna (concha), External Auditory Canal (EAC), postauricular sulcus, lateral pharyngeal
wall, soft palate, and the anterior two-thirds of the tongue.

D. Name the various eye care procedures which should be followed in

treating the patient.
(Due to lagophthalmos from facial nerve paralysis, preventing exposure keratopathy is critical):
1.​ Frequent use of artificial tears/lubricating eye drops during the daytime.
2.​ Ophthalmic ointment (e.g., Lacri-Lube) at bedtime.
3.​ Eye taping or patching shut at night to protect the cornea.
4.​ Wearing protective moisture chambers or sunglasses during the day to prevent debris
entry and wind drying.

E. What is the treatment?

1.​ Systemic Antivirals: Oral Acyclovir (800 mg 5 times daily) or Valacyclovir (1 g 3 times
daily) for 7–10 days.
2.​ Systemic Corticosteroids: Oral Prednisolone (1 mg/kg/day tapered over 10–14 days) to
decrease facial nerve edema.
3.​ Analgesics: For severe neuropathic pain (e.g., Gabapentin, Pregabalin, or Amitriptyline).

9. Siegle's Pneumatic Speculum

A. Name the instrument.
●​ Siegle's Pneumatic Speculum.

B. Name its uses.

1.​ Pneumatic Otoscopy: To evaluate the mobility of the tympanic membrane (e.g.,
restricted in OME, hypermobile in monomeric/flaccid segments).
2.​ Fistula Test: To check for a labyrinthine fistula (positive pressure causes
nystagmus/vertigo if a fistula exists in the horizontal semicircular canal).
3.​ Magnified Examination (2.5x magnification): For detailed inspection of attic retraction
pockets, tiny perforations, and fluid bubbles.
4.​ Delivering Topical Medications: Pumping the bulb helps drive topical antibiotic drops
through a TM perforation into the middle ear.
5.​ Aural Toilet: Allows controlled cleaning of ear debris under magnification.

10. Otomycosis
A. Describe the lesion.
●​ A wet-paper-like or cotton-wool-like fungal mass in the external auditory canal covered
with black-pepper-like spores (conidiophores) or velvety white/gray filaments. The
underlying canal skin is erythematous, edematous, and tender.
B. What could be the probable diagnosis?
●​ Otomycosis (Fungal Otitis Externa).

C. What could be the causative organism?

1.​ Aspergillus niger (presents with black spores/conidia).
2.​ Candida albicans (presents with a white, curd-like creamy discharge).
3.​ Aspergillus fumigatus (presents with green or gray filaments).

D. What will be the clinical features?

1.​ Intense itching (pruritus) in the ear (most common symptom).
2.​ Ear pain (otalgia) and tenderness (especially on tragal tug or pulling the pinna).
3.​ Ear blockage / Fullness and Conductive hearing loss (due to canal occlusion by
debris).
4.​ Watery, musty, or foul-smelling ear discharge.

E. What is the treatment?

1.​ Thorough Aural Toilet: Complete suction clearance of fungal debris and spores under a
microscope. (Syringing should be avoided).
2.​ Topical Antifungal Agents: Clotrimazole (1% drops or cream), Ketoconazole, or Nystatin
drops for 10–14 days.
3.​ Strict Dry Ear Precautions: Prevent any water entry during bathing.
4.​ Analgesics for pain relief.
5.​ Avoid steroid drops unless severe secondary bacterial edema is present.

11. Comment on the Ear Drum

A. Comment on the ear drum.
●​ (Note: Based on standard ENT curriculum slides, this typical finding shows a Retracted
Tympanic Membrane):
○​ Findings:
1.​ Prominent lateral process of the malleus (appears like a sharp peg).
2.​ Handle of the malleus is foreshortened, more horizontal, and pulled medially.
3.​ Distortion, loss, or displacement of the cone of light.
4.​ Sagginess/retraction of the pars flaccida and pars tensa.

12. Middle Ear Anatomy & Retracted Ear Drum

A. Name the structures numbered.
●​ (Assuming a standard labeled tympanic membrane/middle ear diagram):
○​ 1. Pars Flaccida (Shrapnell's membrane)
 ○​ 2. Lateral Process of Malleus
○​ 3. Handle of Malleus
○​ 4. Umbo
○​ 5. Pars Tensa
○​ 6. Cone of Light (Anteroinferior)

B. Write down the possible causes of bilateral retracted ear drum.

(Causes of chronic Eustachian Tube Dysfunction):
1.​ Adenoid Hypertrophy (most common cause in children).
2.​ Chronic Rhinosinusitis or Allergic Rhinitis causing mucosal congestion.
3.​ Nasopharyngeal Mass / Carcinoma (must always be ruled out in adults).
4.​ Cleft Palate (due to paralysis/dysfunction of the tensor veli palatini muscle).
5.​ Deviated Nasal Septum (DNS) or nasal polyps blocking the postnasal Eustachian
orifices.

13. Chronic Otitis Media - Atticoantral Type

A. Comment on the ear discharge of this patient.
●​ The discharge is foul-smelling (highly offensive), scanty, purulent, and occasionally
blood-stained (indicative of bone destruction and granulation tissue associated with
cholesteatoma).

B. What could be the possible diagnosis?

●​ Chronic Otitis Media (COM) - Squamosal / Atticoantral Type (formerly known as
"Unsafe" type CSOM with active Cholesteatoma).

14. Acute Otitis Media - Suppurative Stage

A. Name the diagnosis.
●​ Acute Otitis Media (Right Ear) - Stage of Suppuration.

B. Name the various stages of this disorder.

1.​ Stage of Tubal Occlusion
2.​ Stage of Pre-suppuration
3.​ Stage of Suppuration
4.​ Stage of Perforation / Resolution
5.​ Stage of Coalescence

C. Name the surgery performed in this patient.

●​ Myringotomy (with or without Grommet/Ventilation tube insertion).
D. Indication for surgery.
1.​ Excruciating otalgia unresponsive to maximal medical analgesics.
2.​ Persistent high fever and systemic toxicity (vomiting, meningismus).
3.​ Impending or early intracranial/extracranial complications (e.g., facial palsy,
labyrinthitis, mastoiditis).
4.​ Failure of resolution despite 48–72 hours of appropriate high-dose antibiotics.

15. Swelling Behind the Pinna - Differential Diagnosis

A. Differential diagnosis of this lesion.
(Assuming a postauricular swelling over the mastoid region):
1.​ Mastoid Abscess (secondary to Acute Mastoiditis/cholesteatoma).
2.​ Post-auricular Lymphadenitis (inflamed, reactive lymph node).
3.​ Infected Sebaceous Cyst or Furuncle of the posterior canal wall causing post-mastoid
edema.
4.​ Post-auricular Dermoid Cyst.

16. Postauricular Swelling with Chronic Otorrhea

A. What differential diagnosis you can offer?
1.​ Mastoid Abscess (postauricular subperiosteal abscess) complicating Chronic Otitis
Media (unsafe/squamosal type).
2.​ Infected Post-auricular Lymph Node secondary to active CSOM/scalp infection.
3.​ Post-auricular Fistula with infected cholesteatoma debris.
4.​ Osteomyelitis of the temporal bone.

17. Acute Otitis Externa (Furuncle)

A. Enumerate otoscopic findings.
1.​ Localized, erythematous, extremely tender pustular swelling (furuncle) in the cartilaginous
part of the external auditory canal.
2.​ Significant narrowing (stenosis) of the external auditory canal.
3.​ Scanty purulent discharge.
4.​ Exquisite tenderness on moving the pinna or pressing the tragus (tragal tug test positive).

B. Mention the possible diagnosis.

●​ Acute Localized Otitis Externa (Furunculosis of the EAC).

C. Mention in brief the pathophysiology of this disorder.

 ●​ It is a localized staphylococcal infection of a hair follicle in the cartilaginous part of the
external auditory canal. It is often initiated by localized trauma (such as aggressive
cleaning with cotton buds, keys, or hairpins) or water exposure (which softens the canal
skin), allowing entry of Staphylococcus aureus into the hair follicle, leading to
micro-abscess formation and intense pain due to the tight adherence of the skin to the
underlying perichondrium.

18. Congenital Pinna Deformity

A. Name the type of pinna seen here.
●​ Microtia (grades I to IV) or Anotia (complete congenital absence of the pinna).

B. Name some drugs which when ingested during pregnancy would

cause this condition.
1.​ Thalidomide
2.​ Isotretinoin (Retinoic acid / high-dose Vitamin A)
3.​ Alcohol (Fetal Alcohol Syndrome)
4.​ Anticonvulsants (e.g., Phenytoin, Sodium Valproate)

19. Swelling over Pinna (Pseudocyst / Hematoma)

A. Name the possible pathology.
●​ Pseudocyst of the Pinna (accumulation of serous fluid within the intracartilaginous
plane) or Hematoma Auris (subperichondrial accumulation of blood following minor blunt
trauma).

B. How will you manage this condition?

1.​ Aspiration under strict aseptic conditions to evacuate the fluid or blood.
2.​ Immediate pressure dressing (using bolster sutures, dental rolls, plaster of Paris, or a
custom compression splint) to keep the perichondrium adhered to the cartilage and
prevent re-accumulation.
3.​ Prophylactic Systemic Antibiotics (to prevent transition to perichondritis).
4.​ If recurrent: Surgical incision and drainage with a small window excision of the cartilage.

20. External Auditory Canal Stenosis / Exostosis

A. Why is the external auditory canal narrow?
●​ Due to multiple benign bony overgrowths (exostoses) arising from the tympanic bone
projecting into the canal, or chronic diffuse inflammatory edema.
B. What could be the cause?
●​ Repeated exposure to cold water (classically seen in swimmers/surfers, termed
"Surfer's Ear"), which stimulates periosteal bone growth.

C. What could be the clinical problems faced by this patient?

1.​ Conductive hearing loss (when the bony growths enlarge to completely block the canal
or trap wax/debris).
2.​ Recurrent Otitis Externa (due to water and keratin trapping behind the exostoses).
3.​ Difficulty in clearing ear wax/discharge.

D. What surgery should be performed in this patient?

●​ Canalplasty (bony drilling of the exostoses to widen the external auditory canal under a
microscope).

21. Attic Retraction Pocket & Incus Necosis

A. What is yellow arrow?
●​ Attic Retraction Pocket (or pars flaccida cholesteatoma).

B. What is white arrow?

●​ Granulation tissue over the postero-superior quadrant (or eroded long process of the
Incus).

C. What is the treatment of white arrow?

●​ Aural toilet and topical antibiotic-steroid ear drops for localized granulation tissue. If
secondary to cholesteatoma/COM, the definitive treatment is Tympanomastoid Surgery
(Mastoidectomy with Tympanoplasty).

22. Preauricular Sinus

A. What is this condition?
●​ Preauricular Sinus (a congenital ear anomaly).

B. How will you manage this patient?

●​ Asymptomatic: No intervention or treatment required.
●​ Acute Infection/Abscess: Systemic antibiotics (e.g., Co-amoxiclav) and incision &
drainage if a fluctuant abscess forms.
●​ Recurrent Infection (Definitive Treatment): Surgical excision of the sinus tract and
 its complete ramification (supra-auricular approach / "islands" technique) after the acute
infection has resolved.

23. Allergic Rhinitis

A. What is your diagnosis?
●​ Allergic Rhinitis (seasonal or perennial).

B. What is your management?

1.​ Allergen Avoidance: Minimize exposure to known triggers (dust mites, pollen, mold, pet
dander).
2.​ Pharmacotherapy:
○​ Intranasal Corticosteroid Sprays (e.g., Fluticasone, Mometasone) – first-line and
most effective treatment.
○​ Second-generation Oral Antihistamines (e.g., Cetirizine, Loratadine,
Fexofenadine) – non-sedating.
○​ Leukotriene Receptor Antagonists (e.g., Montelukast).
3.​ Nasal Saline Irrigation (Douching): To clear allergens and thick mucus.
4.​ Allergen Immunotherapy (Desensitization): For patients refractory to medical
management.

24. Laryngeal Carcinoma

A. What is the most common type of laryngeal cancer?
●​ Squamous Cell Carcinoma (SCC) (accounts for over 95% of cases).

B. Give two predisposing factors.

1.​ Cigarette/Tobacco Smoking (highest relative risk factor).
2.​ Chronic Alcohol Consumption (has a synergistic carcinogenic effect with tobacco).

C. Suggest two other complaints.

1.​ Dysphagia or Odynophagia (common in supraglottic tumors).
2.​ Referred Otalgia (ear pain mediated by the vagus/Arnold's nerve).
3.​ Dyspnea and Stridor (in advanced glottic or subglottic tumors causing airway
obstruction).
4.​ Neck lump (metastatic lymphadenopathy).

25. Unilateral Conductive Hearing Loss

A. Mention 4 possible causes of deafness in this patient.
(With negative Rinne's in the left ear indicating a Conductive Hearing Loss on the left):
1.​ Impacted Cerumen (Ear Wax) or foreign body in the left canal.
2.​ Left-sided Tympanic Membrane Perforation (traumatic or chronic mucosal COM).
3.​ Left-sided Otitis Media with Effusion (OME) (glue ear).
4.​ Otosclerosis involving the left stapes footplate.
5.​ Left-sided Ossicular Discontinuity (post-traumatic).

26. Tonsillar Hypertrophy

A. What is your diagnosis?
●​ Bilateral Tonsillar Hypertrophy (Grade IV / "Kissing Tonsils") causing Obstructive
Sleep Apnea (OSA).

B. What is your management?

●​ Surgical Tonsillectomy (with or without Adenoidectomy, depending on the status of the
adenoid tissue).

C. Give 2 indications for your management.

1.​ Obstructive Sleep Apnea (OSA), sleep-disordered breathing, or daytime somnolence
due to mechanical airway obstruction.
2.​ Recurrent Acute Tonsillitis (Paradise Criteria: \ge 7 episodes in 1 year, \ge 5
episodes/year for 2 consecutive years, or \ge 3 episodes/year for 3 consecutive years).
3.​ Peritonsillar Abscess (Quinsy) unresponsive to drainage, or recurrent in nature.
4.​ Suspected malignancy (unilateral hypertrophy or atypical enlargement).

27. Sinus Anatomy

A. What is (a)?
●​ Middle Turbinate (concha media).

B. What is (b)?
●​ Inferior Turbinate (concha inferior).

C. Where does ethmoidal sinus drain?

●​ Anterior Ethmoidal Sinus: Drains into the Middle Meatus (via the ethmoidal
infundibulum/middle meatal hiatus semilunaris).
●​ Posterior Ethmoidal Sinus: Drains into the Superior Meatus.

28. Foreign Body in Esophagus (Coin)

A. What is your diagnosis?
●​ Foreign Body Esophagus (Coin at the level of the Cricopharyngeal sphincter).
(Note: A coin in the esophagus appears "en face" / circular in the AP view of an X-ray,
whereas in the trachea it appears on edge).

B. What is your management?

●​ Emergency Rigid Esophagoscopy and foreign body extraction under General
Anesthesia with endotracheal intubation.

C. Give two complications to this condition.

1.​ Esophageal Perforation leading to life-threatening Mediastinitis or deep neck space
abscess.
2.​ Tracheoesophageal Fistula or mucosal ulceration/stricture if retained chronically.
3.​ Airway compression/asphyxia due to direct mechanical pressure on the soft posterior
tracheal wall.

29. Neck Mass - Branchial Cyst

A. Give two differential diagnoses.
(For a neck mass anterior to the sternocleidomastoid muscle):
1.​ Branchial Cyst (typically located at the junction of upper and middle third of the SCM
muscle).
2.​ Cervical Lymphadenopathy (Tuberculous, reactive, lymphoma, or metastatic).
3.​ Carotid Body Tumor (Paraganglioma).
4.​ Cold Abscess (Tuberculous).

B. Give two investigations.

1.​ Fine Needle Aspiration Cytology (FNAC): To rule out lymphoma/metastasis and identify
cholesterol crystals (hallmark of branchial cyst).
2.​ Contrast-Enhanced CT (CECT) of the neck: To delineate the anatomical cystic margins
and its relation to the carotid sheath and internal/external carotid arteries.
3.​ Ultrasound of the neck.

30. Tuning Fork Test - Left Conductive Hearing Loss

A. What is the diagnosis?
●​ Left Conductive Hearing Loss (CHL) (normal hearing in the right ear).

B. Give differential diagnosis.

1.​ Left-sided impacted wax or foreign body.
 2.​ Left-sided Otitis Media with Effusion (OME).
3.​ Left-sided Tympanic Membrane Perforation.
4.​ Left-sided Otosclerosis.

C. What does Rinnes positive mean.

●​ Rinne positive means that Air Conduction is better than Bone Conduction (AC > BC).
This indicates either normal hearing in that ear or a sensorineural hearing loss (since
both air and bone pathways are equally reduced, the air conduction pathway remains
more efficient).

31. Tuning Fork Test - Right Sensorineural Hearing

Loss
A. What is the inference?
●​ Right Sensorineural Hearing Loss (SNHL) (Rinne is positive bilaterally, but Weber
lateralizes to the left, and Absolute Bone Conduction is reduced on the right, confirming a
right-sided sensory/neural deficit).

B. Give differential diagnosis for unilateral sensorineural hearing loss.

1.​ Acoustic Neuroma (Vestibular Schwannoma) (vital to rule out in any unilateral SNHL).
2.​ Meniere's Disease (presents with fluctuating unilateral low-frequency SNHL, vertigo, and
tinnitus).
3.​ Sudden Sensorineural Hearing Loss (SSNHL) (idiopathic, viral, or vascular).
4.​ Labyrinthitis (secondary to CSOM or viral infection).
5.​ Labyrinthine trauma/temporal bone fracture.

C. What is the ideal frequency of tuning fork that is used in these

tests?
●​ 512 Hz (provides the ideal compromise: it has a slow decay time, is audible without
producing strong tactile vibrations like the 256 Hz fork, and does not fade too rapidly like
the 1024 Hz fork).

32. Cauliflower Ear (Hematoma Auris)

A. What is the diagnosis?
●​ Cauliflower Ear (the chronic end-stage deformity resulting from untreated Hematoma
Auris / Boxer's ear).

B. What are the causes?

●​ Blunt trauma or shear injury to the pinna (commonly sustained in contact sports like
 boxing, rugby, or wrestling). This shears the perichondrium away from the underlying
cartilage, severing blood vessels and creating a subperichondrial hematoma.

C. What are the clinical features?

●​ Acute Stage: Fleshy, fluctuant, red, painful, and tender swelling over the anterior aspect
of the pinna, obliterating its normal contours.
●​ Chronic Deformed Stage: Hard, nodular, painless, and irregular fibrotic masses
resembling a cauliflower (due to cartilage necrosis, subsequent fibrous tissue
replacement, and irregular neocartilage formation/calcification).

D. How will you manage this patient?

1.​ Aspiration or Incision & Drainage (I&D) under strict aseptic conditions to evacuate the
hematoma or serous fluid.
2.​ Compression suture/bolster dressing (using buttons, dental rolls, or plaster of Paris) to
re-approximate the perichondrium to the cartilage.
3.​ Systemic Antibiotic coverage (effective against Pseudomonas, e.g., Ciprofloxacin) to
prevent perichondritis.

33. Preauricular Sinus

A. Spot the diagnosis.
●​ Preauricular Sinus (indicated by the small punctum at the anterior border of the
ascending limb of the helix).

B. What is the embryological defect?

●​ Incomplete fusion of the six auditory hillocks of His (derived from the first and second
branchial arches) during the development of the pinna.

C. How will you manage?

●​ Asymptomatic: No active treatment required; educate patient to avoid squeezing or
picking the site.
●​ Infected: Oral broad-spectrum antibiotics. If an abscess forms, perform localized incision
and drainage.
●​ Recurrent Infections: Surgical excision of the sinus tract and its tract branches
(using the post-auricular or supra-auricular approach under microscopic control, often
using methylene blue dye to outline the tract) once the acute infection has completely
subsided.

34 & 35. Facial Nerve Palsy (Lower Motor Neuron)

A. What is the condition being shown here?
 ●​ Lower Motor Neuron (LMN) Facial Nerve Palsy (Bell's Palsy).
○​ Clinical signs visible in image: Loss of forehead wrinkles on the affected side,
inability to close the eye (lagophthalmos), drooping of the angle of the mouth,
flattening of the nasolabial fold, and deviation of the mouth to the healthy side on
smiling.

B. Which is the drug to be given in case the above condition is due to

an idiopathic cause?
●​ Systemic Corticosteroids (Oral Prednisolone) – 1 mg/kg/day (typically 60 mg daily for
5 days, then tapered over the next 5 days), ideally started within 72 hours of symptom
onset.

C. Which is the narrowest segment of the nerve involved in the photo

above?
●​ Labyrinthine Segment of the facial nerve within the fallopian canal (measuring only 0.68
mm in diameter, making it the most vulnerable site for compression and ischemia due to
edema).

36. Otosclerosis & Carhart's Notch

A. What is the inference?
●​ Otosclerosis (demonstrating Carhart's Notch on the bone conduction curve).

B. What is Carhart’s notch?

●​ A pseudo-sensory dip in the bone conduction threshold at 2000 Hz (by
approximately 15 dB) in patients with stapes fixation. It is a mechanical artifact caused by
the loss of the inertial contribution of the stapes ossicle to bone conduction and
characteristically reverses/disappears after successful stapes surgery.

C. How will you manage this condition?

1.​ Surgical: Stapedotomy or stapedectomy with insertion of a micro-piston.
2.​ Hearing Aid: Excellent alternative for patients who decline surgery or are medically unfit.
3.​ Medical: Sodium Fluoride therapy to stabilize active otospongiosis (Schwartze sign
positive) and protect the cochlea.

37. Cochlear Implant

A. What is the procedure?
●​ Cochlear Implantation (surgical placement of an active electronic medical device to
restore hearing in profound sensorineural deafness).
B. Parts of the device.
●​ External Parts:
1.​ Microphone: Receives acoustic sounds.
2.​ Speech Processor: Filters and digitizes sound into coded signals.
3.​ Transmitter Coil: Transmits the coded signals across the skin via electromagnetic
induction.
●​ Internal Parts:
1.​ Receiver-Stimulator: Placed in a surgically created bony well in the skull; decodes
the signal.
2.​ Electrode Array: Inserted directly into the scala tympani of the cochlea to
stimulate the auditory nerve fibers.

C. Indications for the procedure.

1.​ Bilateral profound sensorineural hearing loss (SNHL) (thresholds \ge 90\text{ dB}).
2.​ Lack of significant benefit from an optimal trial of conventional hearing aids over 3 to 6
months.
3.​ Pre-lingually deafened children (optimal implantation age is 9–18 months) or
post-lingually deafened adults.

D. Surgical approach?
●​ Cortical Mastoidectomy and Posterior Tympanotomy (Facial Recess Approach) to
access the round window of the cochlea.

E. Complications of the procedure.

1.​ Facial nerve injury (during posterior tympanotomy).
2.​ Meningitis or post-operative wound infection.
3.​ Electrode extrusion or misplacement.
4.​ Chorda tympani nerve damage (causing temporary taste alteration).
5.​ Flap necrosis or device failure.

38. Presbycusis
A. Identify the type and degree of hearing loss shown in the picture.
●​ Bilateral symmetrical high-frequency sloping Sensorineural Hearing Loss (SNHL),
moderate to severe (falling from 50 dB to 75 dB). This is the classic audiometric profile of
Presbycusis (age-related hearing loss).

B. How will you manage this patient?

1.​ Bilateral digital programmable Hearing Aids with high-frequency amplification.
2.​ Use of Assistive Listening Devices (ALDs) (e.g., FM systems, TV loops).
 3.​ Auditory Rehabilitation: Counseling on lip-reading, face-to-face communication, and
reducing background environmental noise.

39. CSF Rhinorrhea

A. What is the probable diagnosis?
●​ Cerebrospinal Fluid (CSF) Rhinorrhea (unilateral, clear, watery nasal discharge that
increases on bending forward – Bow sign).

B. Name two investigations which will help us to clinch the

diagnosis?
1.​ Beta-2 Transferrin assay of the nasal fluid (the gold standard, highly specific
biochemical marker for CSF).
2.​ High-Resolution CT (HRCT) of the paranasal sinuses and skull base (to localize the
osseous defect).
3.​ CT / MR Cisternography (to identify the active site of the dural leak).
4.​ Glucose estimation (CSF glucose is typically >30\text{ mg/dl}, though less specific than
Beta-2 transferrin).

40. Caldwell-Luc Surgery

A. Identify the surgical procedure pictured above?
●​ Caldwell-Luc Surgery (Anterior Antrostomy of the Maxillary Sinus via a sublabial
approach).

B. Mention two indications for this procedure.

1.​ Removal of recurrent or extremely large Antrochoanal Polyps.
2.​ Removal of a displaced tooth root or foreign body from the maxillary sinus cavity.
3.​ Approach to the pterygopalatine fossa for internal maxillary artery ligation (for severe
epistaxis) or V2 nerve block.
4.​ Biopsy or excision of suspected benign/malignant maxillary sinus tumors.
5.​ Maxillary sinus orbital decompression (in Graves' ophthalmopathy).

C. Mention one complication of this procedure.

1.​ Cheek and upper lip numbness/paresthesia (due to trauma to the infraorbital nerve).
2.​ Injury to the roots of the upper teeth (leading to dental pain/loss of tooth vitality).
3.​ Oroantral fistula formation.

41. Killian's Nasal Speculum

A. Identify the instrument.
●​ Killian's Nasal Speculum (long-bladed speculum, often with a self-retaining screw
mechanism).

B. In which surgery is it used?

●​ Septoplasty or Submucous Resection (SMR) of the nasal septum, and transsphenoidal
hypophysectomy.

C. What is the advantage of using this instrument?

●​ The long blades keep the mucoperichondrial or mucoperiosteal flaps retracted on both
sides, providing excellent visibility of the deeper osteomeatal septum while leaving both of
the surgeon's hands free.

42. Surgical Mallet & Septal Chisel/Gouge

A. Identify the instruments.
●​ Surgical Mallet (upper image) and Ballenger's / Killian's Septal Chisel or Gouge
(lower image).

B. In which surgery is it used?

●​ Submucous Resection (SMR) / Septoplasty (to remove bony septal spurs, the maxillary
crest, or thick vomer bone) and cortical mastoidectomy.

C. What is the advantage of using this instrument?

●​ It allows the clean, controlled removal of dense bone (such as a septal spur) without
fracturing adjacent delicate skull base bones (such as the cribriform plate of the ethmoid).

43. Unilateral Nasal Mass (Antrochoanal Polyp)

A. Write two differential diagnosis for unilateral nasal mass.
1.​ Antrochoanal Polyp (most common in young individuals; grows posteriorly towards the
choana).
2.​ Inverted Papilloma (common in middle-aged males; arises from the lateral nasal wall,
locally aggressive and premalignant).
3.​ Meningoencephalocele (congenital, pulsatile, expansile on crying / Furstenberg test
positive).
4.​ Nasal Rhinosporidiosis or nasal malignancy (e.g., Squamous Cell Carcinoma).

B. Write the surgical treatment for ethmoidal polyposis.

 ●​ Functional Endoscopic Sinus Surgery (FESS) with ethmoidectomy and polypectomy.

44. Acute Tonsillitis (Membranous)

A. Spot the diagnosis.
●​ Acute Membranous / Follicular Tonsillitis (showing severely enlarged tonsils with
coalescing yellow-white exudative patches).

B. What are the different types?

1.​ Acute Catarrhal (Superficial) Tonsillitis: Associated with generalized upper respiratory
viral infection.
2.​ Acute Parenchymatous Tonsillitis: The entire tonsil tissue is uniformly congested and
enlarged.
3.​ Acute Follicular Tonsillitis: Exudate collects in the crypts, appearing as separate yellow
spots.
4.​ Acute Membranous Tonsillitis: Follicular exudates coalesce to form a non-adherent
membrane over the tonsillar surface.

45. Vocal Nodules

A. Spot the diagnosis.
●​ Bilateral Vocal Nodules (also called "Singer's Nodes" or "Screamer's Nodes"). They
are symmetric, mucosal thickening at the junction of the anterior 1/3 and posterior 2/3 of
the vocal cords (the point of maximum vibratory amplitude).

B. Who are more prone for this?

●​ Individuals with high vocal demand or chronic vocal abuse (e.g., professional singers,
teachers, lecturers, children who shout, and public speakers).

C. How will you manage?

1.​ Speech and Voice Therapy (Mainstay): Retraining the patient in proper vocal hygiene,
breath control, and reducing hard glottal attacks.
2.​ Proton Pump Inhibitors (PPIs): To treat concurrent laryngopharyngeal reflux (LPR).
3.​ Voice Rest: Short-term absolute or relative voice rest.
4.​ Microlaryngeal Surgery (MLS): Excision of nodules using cold micro-instruments,
reserved only for large, fibrotic nodules that fail intensive voice therapy over 3–6 months.

46. Beckmann's Adenoid Curette

A. Name the instrument.
 ●​ Beckmann's Adenoid Curette (with cage).

B. Mention its use.

●​ Adenoidectomy (to shave off and excise the hypertrophied adenoid tissue from the
nasopharynx).

C. What are the types?

1.​ Curettes with a cage (retains the sliced adenoid tissue to prevent aspiration).
2.​ Curettes without a cage.
3.​ Sized from 1 to 5 (depending on the width of the nasopharynx).

47. Thyroglossal Duct Cyst

A. What is the diagnosis?
●​ Thyroglossal Duct Cyst (a midline cystic neck mass that classically moves upward both
on deglutition and on protrusion of the tongue).

B. What are the differential diagnosis?

1.​ Sublingual Dermoid Cyst.
2.​ Plunging Ranula.
3.​ Ectopic Thyroid (Lingual Thyroid).
4.​ Submental Lymphadenitis.

C. How will you treat this patient?

●​ Sistrunk’s Operation: Complete surgical excision of the cyst, the entire thyroglossal tract
up to the foramen caecum, and the central portion of the hyoid bone (essential to
reduce recurrence rate to <1\%).

48. Vocal Cord Polyp

A. What is the diagnosis?
●​ Vocal Cord Polyp (typically a unilateral, smooth, pinkish, or reddish polypoid mass at the
free edge of the true vocal cord).

B. What is the treatment?

●​ Microlaryngeal Surgery (MLS) with micro-flap excision using cold micro-instruments
or CO2 laser under microscope.

C. What precaution must the patient follow in the immediate post op

period?
1.​ Absolute Voice Rest for 7–10 days (no talking, including whispering, which strains the
vocal cords).
2.​ Refrain from throat clearing and coughing.
3.​ Hydration and avoidance of voice irritants (e.g., tobacco smoke, dust, caffeine, alcohol).

49. Eve's Tonsillar Snare

A. Identify the instrument.
●​ Eve's Tonsillar Snare.

B. In which surgery is it used?

●​ Tonsillectomy (dissection method, used at the final step to crush the inferior tonsillar
pedicle and detach the tonsil).

C. What is the advantage of using this instrument?

●​ The wire loop crushes the tonsillar vessels before cutting them, which stimulates
thromboplastin release and promotes hemostasis, significantly reducing intra-operative
bleeding from the lower pole.

50. Tuning Fork Preference

A. Which tuning fork will you prefer?
●​ 512 Hz Tuning Fork.

B. Give 2 reasons for your preference.

1.​ It does not produce strong bone-conducted tactile vibrations (unlike the 256 Hz fork,
which patients can "feel" rather than "hear", leading to false-positive results).
2.​ It has a slower decay time (stays vibrating longer than the 1024 Hz fork) and represents
the frequency of normal human speech.

C. Name 4 causes of Conductive Hearing Loss.

1.​ Impacted Ear Wax (Cerumen) or canal foreign body.
2.​ Otitis Media with Effusion (OME).
3.​ Tympanic Membrane Perforation (chronic or traumatic).
4.​ Otosclerosis (Stapes fixation).

51. Juvenile Laryngeal Papillomatosis

A. What is the most probable diagnosis?
●​ Juvenile-Onset Recurrent Respiratory Papillomatosis (RRP).

B. Name two investigations you will do to confirm the diagnosis.

1.​ Direct Laryngoscopy (to visualize the characteristic pink, exophytic, "cauliflower-like"
masses).
2.​ Biopsy of the lesion for histopathological examination.
3.​ PCR of the biopsy tissue to identify Human Papillomavirus (HPV Types 6 and 11).

C. What is the surgical treatment for the above condition? What is the
prognosis?
●​ Surgical Treatment: Surgical debulking of papillomas using a microdebrider or CO2
laser under microscopic guidance. (Tracheostomy must be avoided as it can seed
papillomas into the lower trachea).
●​ Prognosis: Guarded and unpredictable. It is a benign disease but highly recurrent,
often requiring dozens of surgeries. It frequently regresses spontaneously after puberty.

52. Adenoid Hypertrophy ("Adenoid Facies")

A. What is your most probable diagnosis?
●​ Adenoid Hypertrophy causing bilateral Eustachian tube dysfunction and secondary
Otitis Media with Effusion (OME).

B. Name 2 investigations which will help you to confirm the diagnosis.

1.​ Lateral Radiography of the Nasopharynx (Soft tissue neck): Shows soft tissue
shadow narrowing the postnasal air space.
2.​ Diagnostic Nasal Endoscopy (DNE): Direct visualization of hypertrophied adenoid
tissue blocking the posterior choanae.
3.​ Tympanometry (to document middle ear effusion; usually Type B).

C. What is the surgical management?

●​ Adenoidectomy (by curettage, microdebrider, or coblation), often performed in
conjunction with myringotomy and grommet insertion if persistent middle ear effusion
is present.

53. Ethmoidal Polyposis

A. What is your diagnosis?
●​ Bilateral Ethmoidal Polyposis (associated with Allergic Rhinitis).
B. Name 4 differences between nasal polyp and turbinate.
Feature Nasal Polyp Nasal Turbinate
Color Pale, translucent, grape-like Pinkish-red, opaque
Sensitivity Insensitive to touch/probing Highly sensitive to touch
Mobility Highly mobile on probing Fixed, immobile
Bleeding Does not bleed on probing Bleeds easily on touch
Response to Decongestant Does not shrink with Shrinks significantly
vasoconstrictor
C. Name 2 drugs that may relieve the patient symptoms.
1.​ Intranasal Corticosteroids (e.g., Fluticasone propionate or Mometasone furoate spray).
2.​ Oral Corticosteroids (Prednisolone) – short course to "medically de-bulk" the polyps.
3.​ Oral Antihistamines and Montelukast.

54. Nasopharyngeal Carcinoma (NPC)

A. What is the most probable diagnosis?
●​ Nasopharyngeal Carcinoma (NPC) (presenting as cervical lymph node metastasis and
Eustachian tube obstruction causing unilateral tinnitus/OME – Trotter's Triad).

B. Name 2 appropriate investigations to confirm the diagnosis.

1.​ Endoscopy-guided biopsy of the nasopharyngeal mass (typically from the Fossa of
Rosenmüller).
2.​ FNAC of the neck swelling to document metastatic carcinoma.
3.​ Contrast-Enhanced CT / MRI of the head, skull base, and neck to evaluate primary
tumor margins and intracranial extension.

C. What is the treatment of choice?

●​ Concurrent Chemoradiotherapy (CCRT) or Radiotherapy (RT) alone for early stage
(since NPC is highly radiosensitive and surgical access is extremely limited).

55. Otogenic Intracranial Complication (Brain

Abscess)
A. What is the probable diagnosis?
●​ Otogenic Brain Abscess (Temporal lobe or Cerebellar abscess) or Otogenic Meningitis
secondary to Chronic Otitis Media (cholesteatoma / unsafe type).

B. Give 2 appropriate investigations to confirm the diagnosis.

 1.​ Contrast-Enhanced CT (CECT) of the brain and temporal bone: Reveals a
"ring-enhancing" lesion in the temporal lobe or cerebellum, alongside mastoid bone
erosion.
2.​ MRI of the Brain with contrast: Higher sensitivity for early cerebritis and dural venous
sinus thrombosis.

C. Name 2 types of brain abscess.

1.​ Temporal Lobe Abscess (most common cerebral site).
2.​ Cerebellar Abscess (most common cerebellar site).

56. Anterior Nasal Packing & Epistaxis

A. Name the type of nasal packing.
●​ Anterior Nasal Packing (using ribbon gauze lubricated with liquid paraffin/antibiotic
ointment, or compressed expander sponges like Merocel).

B. Name 2 important causes of epistaxis in elderly patients.

1.​ Systemic Hypertension (usually blood vessels in the posterior septum - Woodruff's
plexus).
2.​ Atherosclerosis of the nasal arteries (prevents contraction of injured vessels).
3.​ Use of anticoagulant or antiplatelet drugs (e.g., Aspirin, Clopidogrel, Warfarin).

C. Name the 4 arteries that form the Kiesselbach’s plexus.

(Little's Area on the anterior-inferior nasal septum):
1.​ Anterior Ethmoidal Artery (from Internal Carotid system).
2.​ Sphenopalatine Artery (from External Carotid system).
3.​ Greater Palatine Artery (from External Carotid system).
4.​ Septal branch of the Superior Labial Artery (from Facial Artery).

57. Tympanometry (Type C)

A. Identify this investigation.
●​ Tympanometry (Impedance Audiometry).

B. What is the finding?

●​ Type C tympanogram (normal static compliance, but the peak is shifted to significant
negative pressure, typically \le -150\text{ daPa}). This is diagnostic of Eustachian Tube
Dysfunction.

C. Name 2 otoscopic findings you can expect in this patient.

 1.​ Retraction of the tympanic membrane (horizontal malleus, prominent lateral process).
2.​ Congestion along the handle of the malleus.
3.​ Air bubbles or a thin amber fluid level behind the drum (early stage OME).

58. Myringoplasty Indications

A. What is your diagnosis?
●​ Chronic Otitis Media - Mucosal Type (dry/quiescent phase), presenting with a dry
central tympanic membrane perforation.

B. What is the surgical treatment for this condition?

●​ Myringoplasty (Type I Tympanoplasty).

C. Name two contraindications for the above surgical procedure.

1.​ Active middle ear discharge (relative contraindication; the ear should ideally be
completely dry for 4–6 weeks before grafting).
2.​ Uncontrolled Eustachian Tube Dysfunction (causes graft retraction and high failure
rates).
3.​ Active Upper Respiratory Tract Infection (URI) or acute nasal/sinus infection.
4.​ Active external otitis.

59. Perichondritis of Pinna

A. What is your probable diagnosis?
●​ Acute Perichondritis of the Right Pinna (secondary to infected hematoma auris or
trauma).

B. How will you treat it?

1.​ Intravenous (IV) Antibiotics: Must cover Pseudomonas aeruginosa (e.g., Ceftazidime,
Piperacillin-Tazobactam, or Ciprofloxacin).
2.​ Incision and Drainage (I&D): If fluctuant pus/necrosis is present, make an incision,
evacuate pus, and debride necrotic cartilage.
3.​ Aseptic pressure dressing with bolster/through-and-through sutures.
4.​ Analgesics and anti-inflammatory drugs.

C. What is the complication likely to occur if untreated?

●​ Cauliflower Ear Deformity (widespread cartilage necrosis and subsequent fibrotic
collapse of the pinna framework).
60. Nasopharyngeal Carcinoma with Abducens Palsy
A. What is the most probable diagnosis?
●​ Nasopharyngeal Carcinoma (NPC) with Abducens (6th Cranial) Nerve Palsy
(extending through the skull base/cavernous sinus, causing lateral rectus palsy and
diplopia).

B. Name 2 relevant investigations that will confirm the diagnosis?

1.​ Endoscopy-guided biopsy of the primary postnasal mass.
2.​ Contrast-Enhanced MRI of the head, skull base, and neck (to evaluate primary extent
and cavernous sinus invasion).
3.​ FNAC of cervical lymph node (if present).

C. What is the treatment of choice?

●​ Concurrent Chemoradiotherapy (CCRT) or Radiotherapy (RT) alone.

61. Indirect Laryngoscopy (IDL)

A. Name the procedure done using this instrument.
●​ Indirect Laryngoscopy (IDL) using an Indirect Laryngeal Mirror.

B. Name 4 structures visualised by this instrument.

1.​ Epiglottis (and glossoepiglottic folds/valleculae).
2.​ True Vocal Cords and False Vocal Cords (vestibular folds).
3.​ Arytenoid Cartilages (and aryepiglottic folds).
4.​ Pyriform Fossae (bilateral) and Posterior Pharyngeal Wall.
5.​ Base of the tongue.

C. What separates the oral cavity from the oropharynx?

●​ The palatoglossal arches (anterior tonsillar pillars), junction of the hard and soft
palate superiorly, and the circumvallate papillae of the tongue inferiorly.

62. Weber's Tuning Fork Test

A. Identify this test.
●​ Weber's Test (performed by placing a vibrating tuning fork on the midline of the forehead,
vertex, or chin).
B. Why 512 frequency preferred in otology?
●​ Because it provides the best clinical compromise: it has a slow decay rate, does not
produce tactile vibration sensations like the 256 Hz fork, and is in the middle of human
speech frequencies (unlike the 1024 Hz fork, which decays too quickly).

C. Why does Weber lateralize to deafer ear in conductive deafness?

1.​ Masking Effect: Ambient room noise is blocked from entering the cochlea in the
conductive deaf ear, leaving its cochlea more sensitive to bone-conducted sounds.
2.​ Phase differences and lack of sound escape/dissipation from the obstructed middle ear
cavity.

63. Eustachian Tube

A. Identify the marked structure.
●​ Eustachian Tube (Pharyngotympanic Tube).

B. Name 2 functions of this structure.

1.​ Ventilation / Pressure Equalization: Keeps middle ear pressure equal with atmospheric
pressure.
2.​ Mucociliary Clearance / Drainage: Drains secretions and debris from the middle ear into
the nasopharynx.
3.​ Protection: Protects the middle ear from nasopharyngeal sound pressure and ascending
secretions.

C. Name 4 conditions that can arise by malfunction of this structure.

1.​ Otitis Media with Effusion (OME / Glue Ear).
2.​ Atelectasis of the Tympanic Membrane (retraction pockets).
3.​ Barotrauma (middle ear barotrauma during diving/flying).
4.​ Acute Otitis Media (AOM) or Patulous Eustachian Tube Syndrome.

64. Acute Tonsillitis (Follicular)

A. What is your diagnosis?
●​ Acute Follicular Tonsillitis (marked tonsillar hypertrophy with yellow follicular exudative
points).

B. Name 2 relevant investigations you ask for this case.

1.​ Throat Swab for Culture and Sensitivity: To test for Group A Beta-Hemolytic
Streptococcus (GABHS).
 2.​ Complete Blood Count (CBC): Shows leukocytosis with a neutrophilic predominance.

C. Name 2 drugs that you will prescribe for this boy.

1.​ Antibiotic: Oral Penicillin V or Amoxicillin (or Azithromycin if penicillin-allergic) for 10
days.
2.​ Analgesic/Antipyretic: Paracetamol (Acetaminophen) or Ibuprofen.

65. Le Fort I Maxillary Fracture

A. What type of fracture is this?
●​ Le Fort I Fracture (Low-level Maxillary / Guérin's Fracture).

B. Name one synonym for this type of fracture.

●​ Horizontal Maxillary Fracture or Guérin's Fracture.

C. What is the status of palate in this patient?

●​ "Floating Palate" (the hard palate, upper alveolar arch, and pterygoid plates are mobile
and separated from the rest of the facial skeleton).

D. Management.
1.​ Airway maintenance and hemorrhage control (anterior/posterior nasal packing if needed).
2.​ Open Reduction and Internal Fixation (ORIF): Surgical fixation using miniplates and
screws along the nasomaxillary and zygomaticomaxillary buttress lines.
3.​ Intermaxillary Fixation (IMF) to restore normal dental occlusion.

E. Enumerate complications.
1.​ Dental Malocclusion.
2.​ Facial deformity (cosmetic shortening or flattening).
3.​ Chronic maxillary sinusitis.
4.​ Non-union or mal-union of the fracture segments.

66. Thyroid Goiter (Multinodular / Colloid)

A. What could be the possible differential diagnosis?
(For a midline neck mass moving on swallowing):
1.​ Multinodular Goiter (MNG) or Colloid Goiter.
2.​ Thyroid Adenoma.
3.​ Thyroid Carcinoma (e.g., Papillary, Follicular).
4.​ Hashimoto's Thyroiditis.
B. Name the clinical tests you would do in this patient.
1.​ Swallowing Test: Ask the patient to swallow; thyroid swellings characteristically move
upward due to their suspension within the pretracheal fascia.
2.​ Tongue Protrusion Test: Differentiates from a Thyroglossal Cyst (which moves upward
on tongue protrusion; thyroid goiters do not).
3.​ Pemberton's Sign: Assess for retrosternal goiter extension (facial congestion/dyspnea
when both arms are raised).

C. How will you investigate?

1.​ Thyroid Function Tests (TFTs): Serum T3, T4, and TSH levels.
2.​ Ultrasound of the Neck: To evaluate gland volume and nodules (cystic vs. solid,
microcalcifications).
3.​ Fine Needle Aspiration Cytology (FNAC): Under ultrasound guidance for dominant
nodules (gold standard to exclude malignancy).

D. Management.
●​ Euthyroid asymptomatic colloid goiter: Reassurance and annual ultrasound follow-up.
●​ Symptomatic (compressive symptoms) or malignant goiter: Surgical
Thyroidectomy (Hemithyroidectomy, Subtotal, or Total Thyroidectomy).

67. Deep Neck Space Infection (Ludwig's Angina)

A. What is the probable diagnosis?
●​ Ludwig’s Angina (bilateral cellulitis/infection of the submandibular, sublingual, and
submental spaces, commonly odontogenic in origin).

B. Management.
1.​ Secure the Airway (Highest Priority): Immediate preparation for tracheostomy or awake
fiberoptic intubation (blind nasal/oral intubation is highly contraindicated).
2.​ Intravenous (IV) Antibiotics: Empirical high-dose broad-spectrum IV antibiotics covering
aerobes and anaerobes (e.g., Ceftriaxone + Metronidazole).
3.​ Surgical Decompression: Incision and drainage via a bilateral submandibular approach
to release tissue tension and evacuate any pus collection.
4.​ Strict diabetic control with insulin therapy.

C. What are the complications?

1.​ Airway obstruction and Asphyxia (most common cause of death).
2.​ Descending Necrotizing Mediastinitis (spread via the retropharyngeal space).
3.​ Septicemia and Septic Shock.
4.​ Internal Jugular Vein Thrombophlebitis (Lemierre’s Syndrome) or carotid blowout.
D. What are the boundaries of submental triangle.
●​ Apex: Symphysis menti.
●​ Base: Hyoid bone.
●​ Lateral sides: Anterior bellies of the digastric muscles (right and left).
●​ Floor: Mylohyoid muscle.

68. Contact Granuloma

A. What could be the possible diagnosis?
●​ Contact Granuloma / Contact Ulcer of the larynx (located on the vocal process of the
arytenoid cartilage).

B. Layers of vocal cord?

(From superficial to deep):
1.​ Epithelium (stratified squamous).
2.​ Lamina Propria:
○​ Superficial layer (Reinke's Space).
○​ Intermediate layer (elastic fibers).
○​ Deep layer (collagen fibers). (Intermediate + Deep layers form the Vocal Ligament).
3.​ Thyroarytenoid (Vocalis) Muscle.

C. Probable etiology?
1.​ Gastroesophageal Reflux Disease (GERD) / Laryngopharyngeal Reflux (LPR).
2.​ Vocal abuse (excessive throat clearing, hard glottal attacks).
3.​ Prior endotracheal intubation trauma.

D. Management?
1.​ High-dose Proton Pump Inhibitors (PPIs) (e.g., Esomeprazole twice daily) for 3–6
months to treat reflux.
2.​ Speech therapy to eliminate glottal strain and throat clearing.
3.​ Botulinum toxin injection into the vocalis muscle (in refractory cases).
4.​ Surgical excision (MLS) is avoided unless malignancy is suspected, as recurrence rates
are extremely high.

69. Lingual Thyroid

A. What could be the probable differential diagnosis?
(For a midline mass at the base of the tongue/foramen caecum):
1.​ Lingual Thyroid (embryological failure of thyroid descent).
2.​ Thyroglossal Duct Cyst.
 3.​ Lingual Tonsil Hypertrophy.
4.​ Lingual Hemangioma.

B. How will you investigate this patient?

1.​ Technetium-99m or Iodine-123 Thyroid Scan: To document the presence of thyroid
tissue at the base of the tongue and confirm if there is a normally located thyroid in the
neck.
2.​ Ultrasound of the Neck: To check for a thyroid gland in its normal position.
3.​ Thyroid Function Tests (TFTs).

C. How will you treat this patient?

●​ Asymptomatic: Observation.
●​ Symptomatic (Mild dysphagia): Thyroid hormone replacement therapy (L-thyroxine) to
suppress TSH and shrink the lingual thyroid mass.
●​ Severe obstruction: Surgical excision of the lingual mass, ONLY after ensuring there is
a normal cervical thyroid gland, or prepared for life-long post-operative thyroid
replacement.

70. Ear Syringing

A. What is the procedure being done?
●​ Ear Syringing (for removal of impacted ear wax or non-hygroscopic foreign bodies).

B. What complication can it lead to after performing?

1.​ Tympanic Membrane Perforation (if the water stream is aimed directly at the drum or
high pressure is used).
2.​ Otitis Externa (if the canal is lacerated or water is retained).
3.​ Vertigo, nausea, and vomiting (due to caloric stimulation if the water temperature is not
at body temperature, 37°C).
4.​ Tinnitus or temporary hearing loss.

71. Battle's Sign

A. What is your diagnosis from the image?
●​ Battle's Sign (extravasation of blood over the mastoid process).

B. What is Battle sign?

●​ Ecchymosis over the mastoid region indicating a fracture of the base of the skull
(specifically, a middle cranial fossa fracture involving the petrous/mastoid temporal bone).
C. Name one condition in which the post aural groove is obliterated?
●​ Acute Mastoiditis / Mastoid Abscess (unlike furunculosis, where the postauricular
groove is typically preserved).

72. Tympanometry (Type B)

A. What is the type of audiogram shown above?
●​ (Note: This is a Tympanogram or Impedance Audiogram, not a pure tone audiogram).

B. Identify the curve.

●​ Type B tympanogram (flat curve with no compliance peak, indicating a highly stiffened
middle ear system).

C. Name 2 conditions in which this type of curve is seen.

1.​ Otitis Media with Effusion (OME) (with a normal physical ear canal volume).
2.​ Tympanic Membrane Perforation or patent grommet (with a abnormally large physical
ear canal volume).

73. Danger Area of the Face (Furuncle)

A. What is this condition called?
●​ Nasal Furunculosis (local abscess of a hair follicle in the nasal vestibule).

B. What is this area known as?

●​ Danger Area of the Face (bounded by the nasal bridge and the corners of the mouth).

C. Why is it called so?

●​ Because the veins draining this area (facial and ophthalmic veins) are valveless.
Retrograde spread of thrombophlebitis from a nasal furuncle can travel directly into the
Cavernous Sinus, leading to a life-threatening Cavernous Sinus Thrombosis.

74. Cold Spatula Test

A. What is the test being shown?
●​ Cold Spatula Test (a qualitative clinical test for nasal patency).
B. How is this test interpreted?
●​ A polished cold metal spatula is held horizontally below the nostrils while the patient
exhales gently. The size and symmetry of the condensation/fogging patterns formed on
the spatula represent the patency of each nasal airway. Reduced or absent fogging on
one side indicates unilateral nasal airway obstruction.

75. Cottle's Test

A. What is the test being shown?
●​ Cottle’s Test (used to evaluate nasal valve patency).

B. Improvement in nasal airway suggest test is positive True or False.

●​ TRUE (lateral retraction of the cheek cheek pulls the lateral nasal wall, opening the nasal
valve; improvement in breathing confirms a positive test).

C. This test checks which anatomical area of nose?

●​ Internal Nasal Valve (the narrowest anatomical region of the nasal airway, formed by the
septum, upper lateral cartilage, and the anterior end of the inferior turbinate).

76. Indirect Laryngoscopy

A. What is the test being performed here?
●​ Indirect Laryngoscopy (IDL).

B. Draw and label the structures seen in this test.

(Key landmarks to represent in a sketch):
●​ Anteriorly: Base of the tongue and Epiglottis (with vocal process pointing down/inverted
mirror view).
●​ Posteriorly: Interarytenoid fold.
●​ Laterally: Aryepiglottic folds and Pyriform Fossae.
●​ Midline: True Vocal Cords (white, glistening, forming a V-shape pointing anteriorly) and
False Vocal Cords (red, lateral to true cords).

77. Frontal Mucocele

A. What is the most probable diagnosis?
●​ Frontal / Fronto-Ethmoidal Sinus Mucocele (presenting as a painless, fluctuant,
slow-growing swelling in the forehead and superomedial orbit, displacing the globe
 downwards and outwards).

B. What is the most common sinus to be involved in this entity?

●​ Frontal Sinus (followed by the ethmoid sinus).

C. What is the treatment you will do?

●​ Endoscopic Frontal Sinusotomy (Draf I-III procedure) to marsupialize the mucocele
and restore drainage into the nasal cavity.

78. Nasolabial Cyst

A. What is the most probable diagnosis?
●​ Bilateral Nasolabial Cysts (extra-osseous developmental cysts appearing as soft tissue
swellings in the floor of the nasal vestibule and nasolabial fold).

B. What are the causes?

●​ Arises from embryonic epithelial remnants of the nasolacrimal duct, or from trapped
ectoderm during the fusion of the maxillary, lateral nasal, and medial nasal processes.

C. What is the treatment of choice?

●​ Complete surgical excision via a transoral sublabial approach (without entering the
nasal mucosa).

79. Rhinosporidiosis
A. What is the diagnosis shown in this picture?
●​ Rhinosporidiosis (characterized by a friable, painless, vascular, "strawberry-like" nasal
polypoid mass covered with white dots – sporangia).

B. Name the pathogen causing it.

●​ Rhinosporidium seeberi (now classified as an aquatic protist within the clade
Mesomycetozoea, previously thought to be a fungus).

C. What is the treatment of choice?

●​ Wide surgical excision of the mass with electrocoagulation (diathermy) of its
mucosal base to minimize local recurrence. (Optionally supplemented with oral
Dapsone).
80. Ranula
A. What is the diagnosis?
●​ Ranula (a translucent, bluish, cystic swelling in the floor of the mouth, representing a
mucous extravasation cyst of the sublingual salivary gland).

B. What is the treatment of choice?

●​ Surgical excision of the ranula along with the offending sublingual salivary gland
(to ensure zero recurrence). Marsupialization can be done for very small, simple ranulas.

C. What is it known as when the lesion extends into the neck?

●​ Plunging Ranula (occurs when the mucus extravasation herniates through the
mylohyoid muscle into the submandibular and cervical neck spaces).

81. Aphthous Ulcer

A. What is the diagnosis?
●​ Aphthous Ulcer (Recurrent Aphthous Stomatitis - minor type). Typically presents as a
small, painful, shallow, round/oval ulcer with a grey-yellow necrotic center and an
erythematous halo.

B. What is the treatment?

1.​ Topical Corticosteroids (e.g., Triamcinolone acetonide in oral paste) – reduces
inflammation and speeds healing.
2.​ Topical Anesthetic gel (e.g., Lidocaine 2%) – applied before meals for symptomatic pain
relief.
3.​ Antiseptic mouthwash (Chlorhexidine gluconate).
4.​ Supplementation with Iron, Vitamin B12, and Folate (if deficiencies are documented).

82. Vocal Cord Positions

A. What are the various positions of the cords shown in the diagram
from 1-5 and mention the distance of each from the midline?
1.​ Median Position: 0\text{ mm} (true midline, adopted during phonation).
2.​ Paramedian Position: 1.5\text{ mm} (adopted in isolated recurrent laryngeal nerve
palsy).
3.​ Intermediate (Cadaveric) Position: 3.5\text{ mm} (adopted in combined recurrent and
superior laryngeal nerve palsy).
4.​ Gentle (Quiet) Respiration Position: 7\text{ mm} (sub-maximal abduction).
 5.​ Deep (Forced) Inspiration Position: 13.5\text{ mm} (maximal abduction).

B. Which is the position adopted by the cords in paralysis of both

recurrent and superior laryngeal nerves?
●​ Intermediate (Cadaveric) Position (Position 3).

C. Which is the position adopted by the cords in quiet respiration?

●​ Gentle Respiration Position (Position 4).

83. Indirect Laryngoscopy Mirror Preparation

A. What is the procedure being performed?
●​ Indirect Laryngoscopy.

B. Draw a labelled diagram of the structures seen in this procedure.

(Refer to the labels provided in Question 76B).

C. What is the instrument being used called?

●​ Indirect Laryngeal Mirror.

D. How is it prepared before performing the test?

●​ The mirror is warmed by holding it over a spirit lamp flame (or dipping it in warm
water) to prevent condensation of moisture from the patient's breath. The temperature
must be checked on the back of the examiner’s hand first to ensure it is warm and safe
before entering the patient's mouth.

84. Ludwig's Angina Secondary to Caries Tooth

A. What is the diagnosis from the photo being shown?
●​ Ludwig’s Angina (odontogenic deep neck space infection, presenting with severe
bilateral submandibular/sublingual swelling and upward displacement of the tongue).

B. What is the treatment you will give?

1.​ Airway Security: Keep tracheostomy set ready at the bedside; prioritize fiberoptic nasal
intubation.
2.​ High-dose Intravenous Antibiotics: Ceftriaxone + Metronidazole.
3.​ Surgical Decompression: Incision and drainage of submandibular spaces.
4.​ Identification and extraction of the offending carious tooth.
C. Mention 3 complications that can occur.
1.​ Acute Airway Obstruction / Asphyxiation.
2.​ Descending Necrotizing Mediastinitis.
3.​ Septic Shock and Multi-organ dysfunction.
4.​ Cavernous Sinus Thrombosis.

85. Cuffed Portex Tracheostomy Tube

A. What is the name of the instrument?
●​ Cuffed Portex Tracheostomy Tube (made of medical-grade PVC/polyvinyl chloride).

B. What is its advantage over the metallic tubes?

1.​ It is flexible and soft, causing far less friction/trauma to the tracheal mucosa.
2.​ It has an inflatable cuff which seals the airway, making it vital for patients requiring
positive pressure mechanical ventilation and preventing the micro-aspiration of
saliva/blood.
3.​ It is radiopaque (visible on X-rays) and does not need to be removed during radiation
therapy (metal causes scatter).

C. What is the part marked with arrow known as and its use?
●​ Inflatable Cuff (or Pilot Balloon).
○​ Use: The cuff is inflated to seal the airway. The pilot balloon remains external and
indicates the pressure and inflation status of the cuff inside the trachea.

86. Fenestrated Jackson's Metallic Tracheostomy

Tube
A. What is the name of the instrument?
●​ Jackson’s Fenestrated Metallic Tracheostomy Tube (double-cannula metallic tube).

B. What is its use?

●​ Used for decannulation trials and to facilitate speech (phonation). When the outer
opening of the tube is blocked (finger-occluded), air passes through the fenestration
(hole) in the outer cannula upwards through the larynx, allowing the patient to speak
naturally.