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MCQ TEST (20) - Answers

• Pressure over the tragus (Tragal sign / Fistula test positive) in CSOM indicates a perilymph fistula, most commonly of the lateral (horizontal) semicircular canal eroded by cholesteatoma.

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• Pseudomonas aeruginosa is responsible for >95% of cases of malignant (necrotizing) otitis externa, typically in elderly diabetics.

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• The earliest and most common presenting symptom is unilateral progressive SNHL, often accompanied by tinnitus. Facial palsy and vertigo are late features.

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• Unilateral, foul-smelling, purulent nasal discharge in a child is pathognomonic of a nasal foreign body until proven otherwise.

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• Pott's puffy tumour (subperiosteal abscess with osteomyelitis of the frontal bone) is a complication of frontal sinusitis.

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• Meniere's disease causes sensorineural (endolymphatic hydrops) hearing loss, NOT conductive. The classic triad is episodic vertigo + fluctuating SNHL + tinnitus.

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• Beta-2 transferrin (also called tau protein/beta-trace protein test) is the gold standard confirmatory test for CSF rhinorrhea. It is highly specific to CSF and not found in serum or nasal secretions.

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• This is the classic picture of otosclerosis: conductive HL with normal TM, absent stapedial reflex, paracusis Willisii (hearing better in noisy environments), and type As tympanogram.

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• Rinne positive = AC > BC, which is normal and also seen in SNHL. Rinne negative (BC > AC) is seen in conductive hearing loss and wax impaction.

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• Allergic rhinitis is an IgE-mediated (Type I / immediate hypersensitivity) reaction involving mast cell degranulation upon allergen exposure.

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• High-Resolution CT (HRCT) of the temporal bone is the investigation of choice for evaluating the extent of cholesteatoma, bony erosion, and surgical planning.

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• Paroxysmal sneezing is the hallmark symptom of allergic rhinitis, along with watery rhinorrhea, nasal congestion, and itching.

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• Tensor tympani is supplied by the medial pterygoid nerve, a branch of V3 (mandibular division of trigeminal nerve). Memory: "Tensor tympani = Trigeminal."

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• The pharyngeal end of the Eustachian tube opens into the lateral wall of the nasopharynx at the level of the inferior turbinate.

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• OAEs are generated by the outer hair cells (OHCs) of the cochlea and are the direct test of OHC function. Used in neonatal hearing screening.

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• Type B (flat) tympanogram indicates no movement of the tympanic membrane - classic for middle ear effusion (glue ear / OME). Also seen in TM perforation, but OME is the classic answer.

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• The cribriform plate of the ethmoid is the thinnest and most vulnerable part of the anterior skull base, making it the most common site of CSF rhinorrhoea.

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• Hennebert's sign = nystagmus and vertigo induced by pressure changes in the external ear canal (via tragus pressure or pneumatic otoscopy), classically associated with perilymph (labyrinthine) fistula. Also described in congenital syphilis.

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• Samter's triad (Aspirin Exacerbated Respiratory Disease / AERD) = Asthma + Nasal polyposis + Aspirin (NSAID) sensitivity.

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• Cottle's test: cheek is pulled laterally to open the nasal valve area. If breathing improves, the test is positive, indicating nasal valve stenosis/collapse.

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Quick Summary Table

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THIRD MBBS PART-2 ENT EXAMINATION

Total Marks: 50

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Q1. WRITE SHORT NOTES (ANY 2) — 10 Marks

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Q1.1 — 55-year-old hypertensive male, profuse right-sided epistaxis, BP 190/110, on aspirin

A. Probable Diagnosis and Causes (2 marks)

• Idiopathic (most common overall)
• Nasal trauma / digital trauma
• Septal spur

• Hypertension - BP 190/110 causes sustained high-pressure bleeding that does not stop with simple pinching (key in this case)
• Aspirin use - inhibits COX-1, impairs platelet aggregation (thromboxane A2 reduction), prolongs bleeding
• Arteriosclerosis (likely in a 55-year-old hypertensive)
• Coagulopathy secondary to antiplatelet therapy

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B. Blood Supply of Nasal Septum with Labelled Diagram (2 marks)

DIAGRAM (Lateral nasal wall - septal surface):
         Anterior ethmoidal a. ──┐
         Posterior ethmoidal a. ─┤
                                  ├── KIESSELBACH'S PLEXUS
         Sphenopalatine a. ──────┤    (Little's area - antero-inferior septum)
         Greater palatine a. ────┤
         Superior labial a. ─────┘

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C. Stepwise Management (2 marks)

• Sit patient upright, head slightly forward
• Pinch soft part of nose (Trotter's method) for 10-15 min
• IV access, blood investigations: CBC, PT/INR, BT/CT
• Control BP - IV labetalol / oral antihypertensives (critical in this patient)
• Stop aspirin / antiplatelet agents

• Nasal suction, good illumination
• If anterior bleeding point seen: Chemical cautery (silver nitrate) or electrical cautery

• BIPP (Bismuth Iodoform Paraffin Paste) ribbon gauze
• Remains for 24-48 hours
• Antibiotic cover to prevent sinusitis/toxic shock

• Brighton balloon / Foley catheter (12-14 Fr)
• Epistat balloon catheter
• Hospitalize, monitor vitals

• Endoscopic sphenopalatine artery ligation (gold standard for posterior epistaxis)
• Anterior ethmoidal artery ligation (for anterior/superior bleeds)
• Angiographic embolization (if surgical candidate is poor)

• Antihypertensive therapy (long-term)
• Haematology referral for coagulation workup
• Consider switching from aspirin if clinically feasible

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Q1.2 — 9-year-old boy, AOM not responding, painful swelling behind ear, pinna displaced forward and downward

A. Most Likely Diagnosis (1 mark)

• Incomplete treatment of AOM
• Post-auricular painful swelling with redness
• Pinna displaced forward and downward/outward (pathognomonic - due to subperiosteal abscess pushing the auricle)
• Fever, ear pain, purulent discharge

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B. Etiopathogenesis and Clinical Features (2 marks)

• Acute otitis media → infection spreads to mastoid air cells (mastoiditis always accompanies AOM) → inadequate treatment → coalescence of air cells (coalescent mastoiditis) → cortex eroded → pus collects under periosteum → Subperiosteal abscess

• High fever, toxicity
• Severe otalgia (earache)
• Purulent otorrhoea
• Decreased hearing
• Post-auricular pain and swelling

• Post-auricular swelling: red, tender, fluctuant
• Pinna pushed forward, downward, and outward (key sign)
• Post-auricular crease (sulcus) obliterated
• Sagging of postero-superior meatal wall
• Perforated TM with pulsatile discharge

• Bezold's abscess (via mastoid tip into neck)
• Meningitis, brain abscess
• Lateral sinus thrombosis
• Facial nerve palsy
• Labyrinthitis

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C. Investigation and Management (2 marks)

• HRCT Temporal bone - investigation of choice; shows coalescent mastoiditis, bone erosion, abscess
• Pure tone audiogram
• CBC, CRP, ESR
• Blood culture
• Ear swab for culture and sensitivity
• X-ray mastoid (Schuller's view) - shows haziness of air cells (less used now)

• Hospitalization, IV antibiotics: IV Amoxicillin-clavulanate or Cefotaxime + Metronidazole
• IV fluids, antipyretics, analgesics
• Myringotomy + grommet (ear tube) for drainage

• Cortical mastoidectomy (Schwartze operation) - definitive treatment
  • Post-auricular incision
  • Exenteration of all diseased mastoid air cells
  • Drainage of subperiosteal abscess
• If intracranial complications: modified radical mastoidectomy

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Q1.3 — 17-year-old male, progressive unilateral nasal obstruction, blood-stained discharge, cheek fullness, mass on endoscopy

A. Most Likely Diagnosis (1 mark)

• Young male (almost exclusively in adolescent males)
• Progressive unilateral nasal obstruction
• Recurrent blood-stained / epistaxis
• Mass in posterior nasal cavity on endoscopy
• Cheek fullness (extension into pterygopalatine fossa)
• Treated multiple times for "sinusitis" with no improvement

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B. Clinical Features and Investigations (2 marks)

• Progressive unilateral (later bilateral) nasal obstruction
• Recurrent severe epistaxis (hallmark)
• Nasal discharge (blood-stained)
• Headache, cheek fullness (pterygopalatine fossa extension)
• Proptosis (orbital extension)
• Diplopia, visual changes (advanced)
• Conductive hearing loss (Eustachian tube blockage)
• Nasal twang in voice

• Greyish-white/pink, smooth, firm, non-tender mass on endoscopy
• Arises from posterior nasal wall near sphenopalatine foramen
• DO NOT BIOPSY (risk of severe haemorrhage - highly vascular tumour)
• Holman-Miller sign on lateral X-ray: anterior bowing of posterior wall of maxillary sinus

• MRI with contrast - investigation of choice; shows "salt and pepper" appearance (due to flow voids + contrast enhancement); shows extent
• CT scan - shows bone erosion, Holman-Miller sign
• Angiography (DSA) - defines feeding vessels (mainly internal maxillary artery / sphenopalatine artery); also used for pre-operative embolization
• Biopsy is CONTRAINDICATED in clinic
• Sessons/Andrews staging on imaging

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C. Management (2 marks)

• Stage I: Limited to nasopharynx
• Stage II: Extension to paranasal sinuses / pterygopalatine fossa
• Stage III: Orbital / infratemporal fossa extension
• Stage IV: Intracranial extension

• Done 24-48 hours before surgery
• Reduces intraoperative blood loss significantly

• Endoscopic resection - preferred for Stage I and II (modern approach)
• Lateral rhinotomy / midfacial degloving - for Stage II-III
• Infratemporal fossa approach - for Stage III-IV
• Le Fort I osteotomy for large tumors

• Hormonal therapy (testosterone antagonists - flutamide): used in inoperable/recurrent cases
• Radiotherapy: for intracranial extension or recurrent inoperable disease (Stage IV)

• May spontaneously regress after puberty
• Recurrence rate: 20-25% (due to residual tumour at skull base)

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Q2. WRITE SHORT NOTES (ANY 4) — 20 Marks

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1. Atrophic Rhinitis (5 marks)

• Primary (Ozaena): Unknown etiology; more common in females, young adults, developing countries
• Secondary: Post-surgical (turbinate resection), post-infective, granulomatous diseases (syphilis, leprosy, sarcoidosis), irradiation

• Klebsiella ozaenae (primary causative organism in primary type)
• Nutritional deficiency (iron, Vitamin A, D)
• Endocrine factors (puberty, menstruation)
• Autonomic imbalance
• Hereditary / racial factors

• Nasal obstruction (paradoxical - despite wide nasal cavity, patient feels blocked due to absent air turbulence)
• Anosmia / Hyposmia
• Foul smell (ozaena) - patient unaware due to anosmia; friends/family notice
• Greenish-black dry crusts lining nasal cavity
• Epistaxis on crust removal
• Wide nasal cavity ("empty nose syndrome")
• Atrophic turbinates

• Nasal endoscopy: wide nasal cavity, atrophic turbinates, crusts
• CT PNS: shows widened nasal cavity, thinned turbinates
• Culture: Klebsiella ozaenae
• CBC, serum iron, Vitamin A levels

• Nasal irrigation with alkaline douche (sodium bicarbonate + sodium chloride + sodium biborate in warm water) - removes crusts
• 25% glucose in glycerine nasal drops - inhibits proteolytic organisms
• Oestrogen nasal drops / sprays
• Systemic antibiotics: Rifampicin, Ciprofloxacin (anti-Klebsiella)
• Iron supplementation, Vitamin A

• Young's operation: Closure of both nostrils by mucosal flaps for 6 months → reduces airflow → allows mucosal regeneration; nostrils re-opened later
• Submucosal injection of Teflon/paraffin to narrow nasal cavity
• Turbinate implants (cartilage, bone, fat)

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2. Ototoxic Drugs - Enlist and Describe One (5 marks)

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Detailed Description: Aminoglycoside Ototoxicity (Gentamicin)

• Aminoglycosides enter the cochlear outer hair cells (OHCs) via mechano-electrical transducer channels
• Generate reactive oxygen species (ROS) / free radicals → oxidative stress
• Damage the stria vascularis and outer hair cells of the basal turn (high-frequency region first)
• Gentamicin is primarily vestibulotoxic (vestibular hair cells preferentially)
• Streptomycin, Amikacin are primarily cochleotoxic
• Neomycin is most cochleotoxic (used topically only)

• Pre-existing renal impairment (reduced excretion → accumulation)
• High doses, prolonged use
• Concomitant loop diuretics (synergistic toxicity)
• Genetic susceptibility: mitochondrial mutation 1555A>G (12S rRNA gene)
• Age extremes (neonates, elderly)
• Prior noise exposure

• High-frequency SNHL (4000-8000 Hz first) → progressive
• Tinnitus (often the first symptom)
• Vertigo, imbalance, oscillopsia (gentamicin vestibulotoxicity)
• Dandy's syndrome (bilateral vestibular failure): oscillopsia + ataxia + SNHL

• Baseline and serial pure tone audiometry (PTA) - monitoring 8-12 kHz (ultra-high frequencies)
• Serum drug levels (trough/peak monitoring)
• Renal function tests

• Use lowest effective dose, shortest duration
• Once-daily dosing (less nephrotoxic and ototoxic than multiple daily doses)
• Avoid concurrent loop diuretics
• N-acetylcysteine / antioxidants (investigational)
• Genetic screening (1555A>G mutation) before aminoglycoside use

• Discontinue drug immediately on any sign of ototoxicity
• Cochlear implantation for severe bilateral SNHL
• Vestibular rehabilitation for gentamicin vestibulotoxicity
• Hearing aids

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3. Pure Tone Audiogram (5 marks)

• Air conduction thresholds elevated (>25 dB)
• Bone conduction thresholds normal (0-25 dB)
• Air-Bone Gap (ABG) ≥15 dB present
• Causes: Wax, CSOM, otosclerosis, OME

• Both air and bone conduction elevated equally
• No air-bone gap
• Causes: Noise-induced, presbyacusis, Meniere's, ototoxicity

• Both AC and BC elevated
• Air-bone gap present (BC better than AC)
• Causes: CSOM with labyrinthitis, otosclerosis with cochlear involvement

• Noise-induced HL: Characteristic notch at 4000 Hz (4kHz dip)
• Meniere's disease: Low-frequency SNHL (rising audiogram) early; flat later
• Otosclerosis: Carhart's notch at 2000 Hz on bone conduction
• Presbyacusis: High-frequency SNHL, bilateral, symmetrical (downsloping curve)

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4. Rhinosporidiosis (5 marks)

• Rhinosporidium seeberi
• Currently classified as a Mesomycetozoa (between fungi and animals; not a true fungus)
• Forms large sporangia (up to 300-350 μm) filled with endospores
• Cannot be cultured in vitro

• Endemic in South Asia: India (Tamil Nadu), Sri Lanka most commonly
• Rural populations, bathing in ponds/stagnant water
• More common in males; all age groups
• Transmission: inoculation through nasal mucosa while bathing in contaminated water

• Organism enters through microabrasion of nasal mucosa
• Forms large sporangia in subepithelial tissue
• Polypoidal granulomatous masses with sporangia at various stages
• Strawberry-like surface due to white dots (sporangia visible through mucosa)

• Unilateral nasal obstruction (progressive)
• Epistaxis (recurrent)
• Pink/red polypoidal mass hanging from nasal cavity (sometimes visible at nostril)
• Soft, friable, pedunculated, strawberry-like surface (white dots = sporangia)
• Nasal discharge

• Conjunctiva/lacrimal sac (second most common)
• Oropharynx, larynx, urethra, penis, vagina, skin

• Clinical appearance (strawberry polyp) is characteristic
• Histopathology - definitive diagnosis:
  • Large sporangia (200-350 μm) at various maturation stages
  • Mature sporangia contain thousands of endospores
  • Surrounding granulomatous reaction
• Nasal endoscopy: friable, pedunculated polyp
• CT/MRI: extent of disease

• Wide local excision with electrocautery of base - treatment of choice
• Diathermy of the base essential to destroy endospores and prevent recurrence
• Endoscopic removal preferred currently
• Recurrence rate: 10-15%

• Dapsone (50-100 mg/day) - inhibits sporangia maturation; used as adjuvant to prevent recurrence
• No proven curative medical therapy alone

• Recurrence (if base not adequately cauterized)
• Disseminated rhinosporidiosis (rare, immunocompromised)

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5. Bell's Palsy (5 marks)

• Idiopathic (by definition), but likely viral (HSV-1 reactivation) - most accepted theory
• Inflammation → edema → nerve compression within the bony fallopian canal → ischemia → demyelination
• Other associations: Herpes zoster (Ramsay Hunt - NOT Bell's), pregnancy, diabetes, hypertension

• Inability to close eye (Lagophthalmos) - most worrying feature (corneal exposure)
• Bell's phenomenon (upward rolling of eyeball on attempted eye closure)
• Flattening of nasolabial fold
• Drooping of angle of mouth
• Inability to raise eyebrow (distinguishes from UMN palsy)
• Asymmetrical smile, inability to whistle/puff cheeks

• Above geniculate ganglion: Loss of taste (anterior 2/3 tongue via chorda tympani) + hyperacusis (stapedius branch) + reduced lacrimation (greater petrosal nerve)
• Below stylomastoid foramen: Pure motor palsy only

• Grade I: Normal
• Grade VI: Complete paralysis, no movement

• Clinical diagnosis primarily
• Topognostic tests (Schirmer's, stapedial reflex, taste testing) - to localize level of lesion
• EMG/Nerve conduction studies - prognosis; done after 72 hours
• CT/MRI temporal bone (to rule out other causes)
• Blood: FBS, CBC (rule out diabetes, Lyme disease)

• Oral prednisolone (1 mg/kg/day for 10 days, then taper) - started within 72 hours of onset; improves recovery rate
• Acyclovir/Valacyclovir (if started within 72 hours): controversial as monotherapy; used with steroids in severe cases
• Eye care: Artificial tears (day), eye lubricant ointment (night), protective spectacles, taping eye shut at night (most important to prevent exposure keratitis)

• Facial exercises
• Electrical stimulation (controversial)

• Facial nerve decompression (for complete paralysis with poor prognostic EMG findings, within 14 days)
• Tarsorrhaphy (for corneal exposure not controlled medically)
• Nerve grafting (late cases)

• 80-85% recover completely without treatment
• Recovery begins within 3-6 months
• Poor prognostic signs: complete palsy, advancing age, hyperacusis, diabetes, no recovery by 3 weeks, denervation on EMG

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MCQ ANSWERS (20 marks - 1 mark each, No Negative Marking)

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Exam tip: For Q1, attempt the case with the most familiar topic first. For Q2, the five topics listed (atrophic rhinitis, ototoxics, PTA, rhinosporidiosis, Bell's palsy) are all high-yield standard ENT topics - attempt all 4 best ones. MCQs carry 1 mark each with no negative marking, so attempt all 20.