NRE Step 1 ENT MCQs

Answer: Nasal foreign body. A unilateral, foul-smelling, sometimes blood-stained nasal discharge in a young child is a foreign body until proven otherwise (beads, seeds, sponge). Remove it under good light — try the "parent’s kiss" first — and refer to ENT if it fails. Button batteries are an emergency because they cause tissue necrosis within hours.

• Adenoid hypertrophy: Adenoid hypertrophy causes bilateral blockage, snoring and mouth breathing, not one-sided foul discharge.
• Allergic rhinitis: Allergic rhinitis is bilateral, with clear watery discharge and itching.
• Acute sinusitis: Acute sinusitis usually follows a cold and is bilateral, not foul and unilateral in a well child.

Answer: Exostoses. Ear canal exostoses: multiple, bilateral, broad-based, smooth, hard bony swellings of the medial (bony) external canal caused by periosteal reaction to repeated cold water/wind exposure (surfers, swimmers, divers). They narrow the canal, trap water/wax/debris → recurrent otitis externa and conductive hearing loss. Prevention: ear plugs, neoprene hood, avoid cold water. Treatment: manage infections; canaloplasty (drill-out) when obstruction is significant. Osteomas are usually single, pedunculated, at the bony–cartilaginous junction. Furuncles are tender infected hair follicles in the outer cartilaginous canal. A painful, bleeding, ulcerated canal mass in an older person needs biopsy (SCC).

• Osteoma: An osteoma is single and pedunculated.
• Cholesteatoma: Cholesteatoma arises from the drum, not the canal walls.
• Furuncles: A furuncle is a tender infected hair follicle.

Answer: Mucosal CSOM. CSOM: persistent perforation with recurrent/chronic discharge. Mucosal ("safe", tubotympanic): central perforation of pars tensa (rim of drum remains), intermittent profuse mucoid odourless discharge, conductive loss; complications rare. Squamosal ("unsafe", atticoantral): attic or posterosuperior marginal perforation/retraction pocket with cholesteatoma — scanty, foul-smelling, continuous discharge, granulations, bone erosion, risk of intracranial and facial nerve complications → surgery. Management of mucosal disease: aural toilet, topical antibiotic drops (fluoroquinolones avoid ototoxicity), keep water out (cotton wool with Vaseline), treat nasal/sinus sources; surgical repair (myringoplasty/tympanoplasty) once dry to close the perforation and improve hearing. CSOM is common in Pakistan and a major cause of hearing loss.

• Squamosal CSOM: Squamosal disease has a foul discharge with attic retraction or cholesteatoma.
• Otitis externa: Otitis externa does not perforate the drum.
• Otitis media with effusion: In OME the drum is intact.

Answer: Perforation or patent grommet. Tympanometry measures middle-ear compliance as canal pressure is varied. Type A — normal peak at atmospheric pressure; As — shallow peak (stiff system: otosclerosis, tympanosclerosis); Ad — very high peak (ossicular discontinuity, flaccid drum); B — flat (no peak): interpret with ear canal volume — normal volume → middle-ear effusion (glue ear); large volume → perforation or patent grommet (the probe measures canal plus middle ear); small volume → wax occlusion or probe against canal wall; C — peak at negative pressure (Eustachian tube dysfunction, early/resolving effusion). Combine with otoscopy and audiometry (air–bone gap = conductive loss).

• Effusion with intact drum: Effusion with an intact drum gives a normal canal volume.
• Otosclerosis: Otosclerosis gives a type As trace.
• Negative pressure: Negative pressure gives a type C trace.

Answer: Not now — consider after 10 days. Acute rhinosinusitis: < 12 weeks of nasal blockage/discharge plus facial pain/pressure or reduced smell. Most are viral (common cold); bacterial infection (Strep pneumoniae, H. influenzae, Moraxella) is suggested by symptoms > 10 days, double sickening (worsening after initial improvement), severe local pain, fever > 38 °C, purulent discharge, raised CRP/ESR. Management: analgesia, saline irrigation, intranasal steroid (if > 10 days), decongestant short-term; antibiotics only for suspected bacterial cases or systemically unwell/high-risk. Red flags (urgent referral): periorbital oedema, displaced globe, diplopia, reduced vision, severe frontal headache, frontal swelling, meningism, neurological signs. Chronic rhinosinusitis: > 12 weeks.

• Immediately, because pus is present: Purulence alone does not mean bacterial infection.
• After 2 days: Two days is too early; most viral cases settle.
• Only if CT abnormal: Acute sinusitis is a clinical diagnosis.

Answer: Biopsy, ANCA, TB, VDRL. Septal perforation: anterior perforations cause whistling (small), crusting, epistaxis, obstruction; posterior ones are often asymptomatic. Causes: iatrogenic (septoplasty, cautery of both sides, nasal packing, nasogastric tubes), trauma/digital picking, septal haematoma/abscess, drugs (cocaine — vasoconstriction/necrosis, intranasal steroids/decongestants), granulomatous/inflammatory (GPA, sarcoidosis, TB, syphilis — bony septum, leprosy, lupus), malignancy (NK/T-cell lymphoma, SCC), occupational (chromium, arsenic). Investigations: history (drugs, surgery), FBC, ESR, ANCA, ACE, syphilis serology, TB tests, biopsy of the edge (avoid enlarging a benign perforation unnecessarily). Treatment: treat the cause, saline douches, emollients, septal button, surgical repair for symptomatic cases.

• Allergic rhinitis only: Allergic rhinitis does not perforate the septum.
• No investigation: A perforation may reflect systemic disease such as GPA, TB or syphilis.
• Nasal polyps: Polyps do not cause septal perforation.

Answer: Urgent cancer referral. Unilateral tonsillar enlargement in an adult, especially with ulceration, firmness, referred otalgia (glossopharyngeal/vagus), dysphagia, weight loss or neck nodes, needs urgent assessment for malignancy: squamous cell carcinoma (smoking, alcohol, and increasingly HPV-16 — HPV-positive oropharyngeal SCC occurs in younger non-smokers, often presenting with cystic neck nodes, and has better prognosis) or lymphoma. Investigations: endoscopy, biopsy/tonsillectomy, FNA of node, CT/MRI/PET. Isolated mild asymmetry without red flags in a young person can be observed. Referred otalgia with a normal ear examination in an adult → examine the upper aerodigestive tract.

• Antibiotics, review: Antibiotics delay diagnosis of a likely cancer.
• Reassure: A unilateral firm tonsil with otalgia and a node is a red flag.
• Quinsy — aspirate: This is not an acute abscess.

Answer: Laryngopharyngeal reflux. Laryngopharyngeal reflux (LPR, "silent reflux"): reflux of gastric contents (acid, pepsin) to the larynx and pharynx; heartburn is often absent. Symptoms: hoarseness, chronic throat clearing, globus, excess mucus/postnasal drip sensation, chronic cough, dysphagia. Signs: posterior laryngitis — interarytenoid oedema/erythema, pseudosulcus, granulomas (contact granuloma on vocal processes). Management: lifestyle and dietary changes, alginates (form a raft — reduce non-acid reflux), PPI trial (often twice daily for 8–12 weeks, though evidence is mixed), voice care; investigate further (pH-impedance) if refractory. Persistent hoarseness, especially in smokers, needs laryngoscopy to exclude malignancy; unilateral lesions or leukoplakia need biopsy.

• Laryngeal cancer: There is no mass on laryngoscopy.
• Bacterial laryngitis: This is not infective.
• Vocal cord palsy: The vocal folds move normally.

Answer: Inspiratory extrathoracic; expiratory intrathoracic. During inspiration, negative intraluminal pressure narrows the extrathoracic airway (collapse of floppy supraglottic structures) → inspiratory stridor (laryngomalacia, epiglottitis/supraglottitis, bilateral vocal cord palsy, laryngeal foreign body). Fixed lesions at the glottis/subglottis narrow the airway throughout the cycle → biphasic stridor (subglottic stenosis, subglottic haemangioma, croup — often inspiratory but can be biphasic, tracheal stenosis high in the neck). Intrathoracic airway narrows on expiration (positive pleural pressure) → expiratory noise (tracheomalacia, vascular rings, intrathoracic tracheal/bronchial foreign body, asthma wheeze). Stertor (snoring sound) arises above the larynx (pharynx/nose — adenotonsillar hypertrophy). Assess severity: recession, rate, colour, agitation, fatigue, SpO₂ (late fall).

• All stridor expiratory: Stridor is not always expiratory; extrathoracic lesions are inspiratory.
• No localising value: The phase of noise helps localise the level of obstruction.
• Inspiratory intrathoracic; expiratory extrathoracic: This reverses the rule.

Answer: MRI of internal acoustic meatus. Asymmetric sensorineural hearing loss or unilateral tinnitus needs MRI (gadolinium) of the internal acoustic meati/cerebellopontine angle to exclude vestibular schwannoma (acoustic neuroma — benign Schwann cell tumour of vestibular nerve). Larger tumours compress CN V (reduced corneal reflex — early sign), CN VII (late), cerebellum, and cause hydrocephalus. Bilateral → NF2. Management: observation, stereotactic radiosurgery or microsurgery.

• CT sinuses: CT sinuses does not image the IAM.
• Tympanometry only: Tympanometry is not diagnostic.
• Repeat audiogram in a year: Waiting delays diagnosis.

Answer: Submandibular gland. Salivary stones: ~80% in the submandibular gland (Wharton duct — long, upward course, alkaline mucous-rich saliva rich in calcium); meal-related pain and swelling (salivary colic). Diagnosis: ultrasound, sialography/CT. Treatment: hydration, sialogogues, massage; intraoral stone removal for distal duct stones; sialendoscopy; gland excision for recurrent proximal/intraglandular stones (risk to marginal mandibular, lingual and hypoglossal nerves). Acute sialadenitis → antibiotics.

• Parotid gland: Parotid stones are less common.
• Sublingual gland: Sublingual stones are rare.
• Minor salivary glands: Minor gland stones are rare and not palpable this way.

Answer: Nasopharyngeal carcinoma. Trotter triad (nasopharyngeal carcinoma arising in the fossa of Rosenmüller): conductive deafness (Eustachian tube obstruction — unilateral serous otitis media in an adult must prompt nasopharyngoscopy), mandibular nerve pain (perineural spread), palatal immobility. Other features: neck node (commonest presentation — upper deep cervical), epistaxis, nasal obstruction, cranial nerve palsies (V, VI). EBV associated; treatment radiotherapy ± chemotherapy.

• Glue ear with otalgia: Glue ear does not cause a palatal palsy in an adult.
• Trigeminal neuralgia: Trigeminal neuralgia does not cause effusion or palatal palsy.
• Peritonsillar abscess: Quinsy is acute with trismus and uvular deviation.