---

ENT OSCE Cases — Medical Student (Finals Level)

---

CASE 1 — Acute Otitis Media (Ear)

Scenario

---

History to Elicit

---

Examination Findings

• Otoscopy: Moderate-to-severe bulging, opaque, erythematous right tympanic membrane (TM) with loss of normal light reflex
• Pneumatic otoscopy: Reduced TM mobility — confirms middle ear effusion (MEE)
• Temperature: 38.5°C
• No mastoid tenderness (rules out mastoiditis at this stage)

Diagnosis: Acute Otitis Media (AOM)

---

Investigations

• Usually a clinical diagnosis — no routine investigations needed
• Tympanometry: flat type B curve (no TM movement) confirms MEE
• If recurrent / treatment failure: culture if perforation with otorrhea

---

Management

---

Examiner Questions

• Q: What are the 3 most common bacterial causes of AOM? S. pneumoniae (25–40%), H. influenzae (10–30%), M. catarrhalis (2–15%)
• Q: What distinguishes AOM from OME? AOM has acute symptoms (fever, pain) + bulging TM; OME is painless with fluid behind the TM, no acute inflammation
• Q: What is the most common cause of eustachian tube dysfunction? Abnormal tubal compliance + delayed tensor veli palatini innervation; commonly triggered by viral URTI

---

CASE 2 — Epistaxis (Nose)

Scenario

---

History to Elicit

---

Examination Findings

• Sit patient upright, leaning forward, pinching the soft part of the nose
• Visualise with bright light + nasal speculum: bleeding from anterior septum (Kiesselbach's plexus in most cases)
• Posterior epistaxis (>65 yr, hypertensive): bleeding not visible anteriorly, blood in oropharynx
• Check BP (170/100 mmHg → needs treatment), HR, SpO₂
• Examine for signs of coagulopathy: bruising, petechiae, hepatosplenomegaly

Most likely: Anterior epistaxis from Kiesselbach's (Little's) area

---

Kiesselbach's Plexus — Blood Supply

1. Anterior ethmoidal artery
2. Posterior ethmoidal artery
3. Septal branch of sphenopalatine artery
4. Greater palatine artery
5. Branch from the superior labial artery

---

Investigations

• FBC (anaemia, thrombocytopenia)
• PT / INR (warfarin — check supratherapeutic?)
• APTT, group & save if severe
• IV access if haemodynamically compromised

---

Management

1. Sit forward, pinch soft nose for 10–15 minutes — patient/carer can do this at home
2. Topical vasoconstrictor + local anaesthetic (e.g. co-phenylcaine spray)
3. Silver nitrate cautery to visible bleeding point (if identifiable)
4. Anterior nasal packing (BIPP ribbon gauze or Merocel pack) — pack for 24–48 hrs
5. Posterior epistaxis: Foley catheter or posterior pack; ENT admission
6. Reverse anticoagulation if INR supratherapeutic; withhold antiplatelet if safe to do so
7. Refractory cases: sphenopalatine artery ligation or embolisation

---

Examiner Questions

• Q: What is Kiesselbach's plexus? Rich arterial anastomosis at the anteroinferior nasal septum; site of 90% of anterior nosebleeds
• Q: What makes epistaxis posterior? Bleeding from posterior two-thirds of nasal cavity; often heavy, bilateral, blood visible in oropharynx; more common in elderly hypertensive patients
• Q: What rare diagnosis must be excluded in a young male with recurrent epistaxis and nasal obstruction? Juvenile nasopharyngeal angiofibroma — benign but locally aggressive vascular tumour

---

CASE 3 — Peritonsillar Abscess (Quinsy) (Throat)

Scenario

---

History to Elicit

---

Examination Findings

• Trismus (difficulty opening mouth — spasm of pterygoid muscles)
• Uvular deviation away from the affected side
• Peritonsillar bulge: Unilateral soft palate swelling, displaced tonsil medially
• Erythema, oedema of soft palate
• Ipsilateral tender cervical lymphadenopathy
• Check for airway patency — is the patient in respiratory distress?

Diagnosis: Peritonsillar Abscess (Quinsy)

---

Investigations

• Clinical diagnosis primarily
• FBC (leukocytosis), CRP
• Throat swab (Group A β-haemolytic Streptococcus most common)
• Monospot / EBV serology if suspected glandular fever (can mimic quinsy)
• Neck USS or CT if parapharyngeal/deep space extension suspected

---

Management

1. Surgical drainage — needle aspiration (first line) or incision & drainage under LA
2. IV antibiotics: Co-amoxiclav OR Benzylpenicillin + Metronidazole
3. IV fluids + analgesia (IV paracetamol, NSAID)
4. Steroids (IV dexamethasone) — reduce oedema, shorten hospital stay
5. Admit for monitoring; ENT team management

• ≥7 episodes in 1 year, or ≥5/year for 2 years, or ≥3/year for 3 years
• Previous peritonsillar abscess
• Airway obstruction / obstructive sleep apnoea

---

Potential Complications

---

Examiner Questions

• Q: How does peritonsillar abscess differ clinically from severe tonsillitis? Quinsy has trismus, uvular deviation, peritonsillar bulge, and "hot potato" muffled voice — all absent in simple tonsillitis
• Q: What organism most commonly causes quinsy? Group A β-haemolytic Streptococcus (GABHS)
• Q: What life-threatening complication can occur if the abscess extends to the parapharyngeal space? Lemierre syndrome (septic thrombophlebitis of the internal jugular vein) → septic emboli to lungs; or mediastinitis (descending necrotising mediastinitis)

---

CASE 4 — Sudden Sensorineural Hearing Loss (SSNHL) (Ear)

Scenario

---

History to Elicit

---

Examination Findings

• Rinne test (affected ear): AC > BC (sensorineural pattern — normal bone conduction still better reference but AC > BC maintained in SNHL)
• Weber test: Lateralises to the normal (right) ear — away from the lesion
• Otoscopy: Normal tympanic membrane (distinguishes from conductive loss)
• Full cranial nerve exam — particularly VII, VIII
• Cerebellar signs (rule out acoustic neuroma / posterior fossa lesion)

Diagnosis: Sudden Sensorineural Hearing Loss (SSNHL) — idiopathic until proven otherwise

---

Investigations

---

Management

• ENT emergency — refer same day
• High-dose oral corticosteroids (prednisolone 1 mg/kg/day for 7–14 days) — mainstay treatment; improves recovery when given within 2 weeks of onset
• Intratympanic steroid injection if systemic contraindicated or as salvage
• Treat underlying cause if identified (antiviral for Ramsay Hunt; penicillin for syphilis)
• Hearing aid if residual deficit
• If acoustic neuroma found → MDT discussion (surveillance, radiosurgery, or surgery)

---

Examiner Questions

• Q: What are the 4 types of hearing loss? Conductive (CHL), sensorineural (SNHL), mixed, and central hearing loss
• Q: How do you differentiate CHL from SNHL on tuning fork tests? Rinne: CHL → BC > AC (abnormal); SNHL → AC > BC (normal Rinne, but reduced overall). Weber: CHL → lateralises to affected ear; SNHL → lateralises to unaffected ear
• Q: What is the commonest cause of conductive hearing loss in an adult with no trauma or infection history? Otosclerosis — autosomal dominant, fixation of stapes footplate; treated with stapedectomy (>95% success)

---

CASE 5 — Benign Paroxysmal Positional Vertigo (BPPV) (Ear)

Scenario

---

History to Elicit

---

Examination — Dix-Hallpike Manoeuvre

Diagnosis: BPPV — posterior semicircular canal (most common type)

---

Peripheral vs Central Vertigo

---

Investigations

• Clinical diagnosis — Dix-Hallpike is diagnostic
• Audiogram if hearing loss present
• MRI brain if central cause suspected
• Electronystagmography (ENG) / vestibular function tests if diagnosis uncertain

---

Management

1. Epley manoeuvre (canalith repositioning) — first-line; highly effective (>80%)
2. Brandt-Daroff exercises — home vestibular rehabilitation
3. Betahistine (limited evidence in BPPV; used for Ménière's)
4. Short-term vestibular suppressants (prochlorperazine) for acute severe nausea — avoid long-term
5. Refer to ENT / audiovestibular medicine if treatment fails or atypical features

---

Examiner Questions

• Q: What is the anatomical mechanism of BPPV? Otoliths (calcium carbonate crystals) detach from the utricle and enter the posterior semicircular canal (canalolithiasis), causing abnormal endolymph movement with head position change
• Q: What distinguishes Ménière's disease from BPPV? Ménière's: triad of episodic vertigo (>20 min), fluctuating sensorineural hearing loss, and tinnitus/aural fullness; attacks last hours, not seconds
• Q: What is the Epley manoeuvre? Series of 4 head position changes to move the displaced otolith out of the posterior canal back into the utricle

---

CASE 6 — Acute Rhinosinusitis (Nose/Sinus)

Scenario

---

History to Elicit

---

Examination Findings

• Nasal endoscopy / anterior rhinoscopy: Mucosal oedema, purulent discharge from middle meatus
• Facial tenderness: Maxillary sinuses (under eyes) ± frontal sinuses (above eyes, on brow)
• Transillumination (limited use) — dullness of maxillary sinus
• Check for orbital signs (lid swelling, proptosis, restricted eye movement, reduced vision) → orbital complication

Diagnosis: Acute bacterial rhinosinusitis (bacterial if ≥10 days duration + purulent discharge + facial pain)

---

Differentiating Bacterial vs Viral Sinusitis

---

Investigations

• Usually clinical diagnosis — no imaging for uncomplicated cases
• CT sinuses: for chronic/recurrent sinusitis, surgical planning, or complications
• CT with contrast if orbital or intracranial complication suspected (emergency)

---

Management

1. Intranasal saline irrigation (first line)
2. Intranasal corticosteroids (mometasone, fluticasone) — reduce mucosal oedema
3. Oral amoxicillin 500 mg TDS for 5–7 days (or amoxicillin-clavulanate if severe/failed amoxicillin)
4. Analgesia (NSAIDs) for facial pain
5. Nasal decongestants (oxymetazoline) short-term (≤3 days) — avoid rebound rhinitis

• Orbital cellulitis / abscess → IV antibiotics, CT, ophthalmology + ENT
• Meningitis / intracranial abscess → neurosurgery + ENT emergency
• Frontal osteomyelitis (Pott's puffy tumour) → neurosurgical emergency

---

Examiner Questions

• Q: Which sinus is most commonly affected in sinusitis and why? Maxillary sinus — largest, most dependent (ostium drains superiorly making drainage against gravity), frequently obstructed at the ostiomeatal unit
• Q: What is the ostiomeatal unit? Functional drainage pathway of the anterior ethmoid, maxillary, and frontal sinuses converging into the middle meatus; blockage here causes rhinosinusitis
• Q: What are the intracranial complications of frontal sinusitis? Meningitis, epidural/subdural empyema, brain abscess, cavernous sinus thrombosis, Pott's puffy tumour (frontal bone osteomyelitis)

---

Quick-Reference Summary Table

---