Crisp and concise

Crisp and concise

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This is an ENT exam paper (M.B.B.S. 3rd Professional, Part-2, 2026). Here are all the answers - crisp and direct:

Section A - MCQ Answers

Q	Answer	Key Point
1	(d) Otosclerosis	Paracusis Willisii + Flamingo Flush (schwartze sign) = otosclerosis
2	(b) Congenital Cholesteatoma	Whitish mass behind intact TM, no discharge, no prior surgery
3	(c) Posterior Cricoarytenoid (PCA)	Only abductor of vocal cords - "safety muscle"
4	(b) Beta-2 Transferrin	Most specific biochemical test for CSF rhinorrhea
5	(d) Parapharyngeal space	Hot potato voice + drooling + trismus = parapharyngeal abscess
6	(d) Internal Laryngeal Nerve	Sensory above vocal cords (branch of superior laryngeal nerve)
7	(b) Pseudomonas aeruginosa	Malignant otitis externa in diabetic = Pseudomonas
8	(d) Lateral Sinus Thrombosis	Delta sign on CECT = filling defect in lateral/sigmoid sinus
9	(c) 4000 Hz	Carhart's notch = dip at 4000 Hz on bone conduction in otosclerosis
10	(c) Posterior Ethmoidal Artery	Kiesselbach's plexus = anterior ethmoidal + sphenopalatine + greater palatine + superior labial. Posterior ethmoidal does NOT contribute.
11	(d) Rhinosporidiosis	Unilateral fleshy mass bleeding on touch + hangs into oropharynx in a child
12	(d) Thrombophlebitis of the sigmoid sinus	Griesinger's sign = edema over mastoid due to emissary vein thrombosis
13	(c) Contrast CT/MRI with Angiography	Investigation of choice for JNA (highly vascular - no biopsy)
14	(d) Nasopharyngeal Carcinoma	Trotter's triad = conductive deafness + trigeminal neuralgia + palatal paralysis
15	(a) True vocal cords	Reinke's edema = fluid in Reinke's space (subepithelial space of true vocal cord)
16	(b) FESS	Treatment of choice for CRS not responding to medical therapy
17	(c) Incision and drainage with bolster suturing	Fluctuant auricular hematoma = I&D + through-and-through bolster sutures
18	(b) Meniere's Disease	Hennebert's sign (nystagmus on EAC pressure) positive without fistula in Meniere's
19	(d) Sleep Apnea/Obstructive symptoms	Absolute indication for tonsillectomy
20	(b) Meniere's Disease	Episodic vertigo + fluctuating SNHL + tinnitus = classic Meniere's triad

Section B - Short Answers

Q1. 55M, smoker, hoarseness 3 months, exophytic growth left vocal cord, fixed cord mobility, involves anterior commissure

(a) Provisional Diagnosis: Carcinoma of the larynx (Glottic carcinoma, left side with anterior commissure involvement and fixed cord)

(b) Clinical Staging (TNM):

T3 (fixed vocal cord) involving anterior commissure
Need to assess nodes (neck exam) and metastasis
Likely Stage III (T3 N0 M0) minimum; if anterior commissure involved, upstaged concern for subglottic extension

(c) Management:

Surgery: Total laryngectomy (fixed cord = not suitable for conservation surgery) + neck dissection if nodal disease
Radiotherapy: Post-op adjuvant RT if margins close/positive or nodal involvement
Concurrent chemoradiotherapy (cisplatin-based) is an organ-preservation option for selected T3
Pre-op workup: CT neck/chest, panendoscopy, biopsy, MDT discussion

Q2 Short Notes:

(a) Acute Mastoiditis

Complication of ASOM; mastoid air cells infected
Features: post-auricular pain, swelling, tenderness; ear pushed forward and downward; sagging of posterior meatal wall
Griesinger's sign (sigmoid sinus thrombosis), subperiosteal abscess
Treatment: IV antibiotics + cortical mastoidectomy if no response

(b) Epistaxis in 60-year-old hypertensive

Causes: hypertension (posterior bleeds common), arteriosclerosis, anticoagulants
Management: ABC, position (lean forward), local pressure 10 min
Anterior: cauterize Kiesselbach's plexus or anterior nasal pack
Posterior: Foley catheter/Bellocq's pack or endoscopic sphenopalatine artery ligation
Control BP, check coagulation

(c) Informed Consent - Laryngeal Cancer refusing surgery

Respect autonomy - patient has right to refuse even life-saving surgery
Ensure patient has full capacity (understands, retains, weighs info)
Clearly explain consequences of refusal (disease progression, palliative options)
Document refusal in detail
Offer alternative: chemoradiation as organ-preservation
Involve ethics committee if doubt about capacity; never coerce

(d) Fungal Sinusitis (Mucormycosis) in immunocompromised

Caused by Mucor/Rhizopus (angioinvasive)
Seen in diabetics (DKA), immunosuppressed (post-COVID, hematological malignancies)
Features: black eschar in nose/palate, periorbital swelling, proptosis, cranial nerve palsies
Diagnosis: KOH mount, biopsy (broad non-septate hyphae), CT/MRI
Treatment: Control underlying condition + IV Amphotericin B + aggressive surgical debridement

Q3 Very Short Notes:

(a) Carhart's Notch: Mechanical notch at 4000 Hz on bone conduction audiogram in otosclerosis; disappears after stapedectomy (not a true sensorineural loss)

(b) Bones of Nasal Septum: Bony part: Vomer (posteroinferiorly) + Perpendicular plate of ethmoid (superiorly); Cartilaginous: quadrilateral cartilage

(c) Griesinger's Sign: Edema and tenderness over the mastoid emissary vein area (posterior to mastoid) indicating thrombophlebitis of the sigmoid sinus

(d) Indications for Tracheostomy: (i) Acute upper airway obstruction (e.g., laryngeal edema, foreign body) (ii) Prolonged mechanical ventilation/respiratory failure

(e) Light Reflex of TM: Cone of light seen anteroinferiorly at 5 o'clock (right) and 7 o'clock (left); loss indicates middle ear pathology (effusion, retraction)

Section C - Long Answers

Q1. CSOM - Attico-antral (Unsafe) Type

Definition: Chronic irreversible inflammation of mucoperiosteal lining of middle ear cleft with persistent tympanic membrane perforation for >3 months.

Attico-antral (Unsafe): Involves the attic and antrum; associated with cholesteatoma - hence called "unsafe" due to risk of intracranial complications.

Pathology:

Marginal/attic perforation
Cholesteatoma: keratinizing squamous epithelium invades middle ear
Enzymatic bone erosion (collagenase) → ossicular destruction, tegmen, lateral sinus wall erosion

Clinical Features:

Scanty, foul-smelling (purulent/mucopurulent) discharge
Attic or posterosuperior marginal perforation
Conductive hearing loss
Cholesteatoma visible as white pearly mass

Complications:

Intratemporal: mastoiditis, facial nerve palsy, labyrinthitis, petrositis
Intracranial: meningitis, brain abscess, lateral sinus thrombosis, subdural abscess, extradural abscess

Surgical Management:

Modified Radical Mastoidectomy (MRM): Treatment of choice - removes cholesteatoma, creates a safe ear; preserves ossicular remnants if possible
Canal Wall Down (CWD) technique preferred for extensive cholesteatoma
Tympanoplasty (ossiculoplasty) for hearing reconstruction in second-stage surgery
Goal: safe dry ear first, hearing reconstruction second

Q2 Short Notes (Section C):

(a) Atrophic Rhinitis

Ozaena: progressive atrophy of nasal mucosa and turbinates
Causes: Klebsiella ozaenae, nutritional deficiency, post-surgical
Features: wide nasal cavity, green/brown crusts, paradoxical nasal obstruction (nose feels blocked despite wide cavity), anosmia, foetor
Treatment: nasal irrigation (saline douches), Young's operation (closure of nostrils 6 months), estrogen/KI drops, antibiotics for Klebsiella

(b) Tympanoplasty - Principles and Types

Principle: eradicate disease + reconstruct TM + ossicular chain to restore hearing
Wullstein's Classification:
- Type I (Myringoplasty): TM repair only, ossicles intact
- Type II: TM + malleus reconstruction
- Type III (Columella): TM grafted onto stapes head
- Type IV: TM onto mobile stapes footplate
- Type V: Fenestration of horizontal semicircular canal
Graft materials: temporalis fascia, perichondrium, fat

(c) Tonsillectomy - Indications and Complications

Indications:

Absolute: sleep apnea/OSA, recurrent febrile convulsions, suspected malignancy, peritonsillar abscess (>2 episodes), diphtheria carrier
Relative: >7 episodes/year (Paradise criteria), chronic tonsillitis, hypertrophy causing dysphagia

Complications:

Primary hemorrhage (within 24h)
Reactionary (6-8h, BP recovery)
Secondary hemorrhage (5-10 days, infection)
Others: anesthetic risk, velopharyngeal insufficiency, taste disturbance, nasopharyngeal stenosis

(d) Differential Diagnosis - Midline Neck Swelling

Thyroglossal cyst (moves up on swallowing AND tongue protrusion - most common)
Dermoid cyst (does not move with swallowing)
Submental lymph node
Thyroid isthmus swelling (moves with swallowing only)
Plunging ranula
Ludwig's angina (floor of mouth)
Lipoma

Q3 Very Short (Section C):

(a) Little's Area: Anteroinferior nasal septum where 5 arteries anastomose (Kiesselbach's plexus): anterior ethmoidal, superior labial, greater palatine, sphenopalatine, inferior ethmoidal. Most common site of anterior epistaxis.

(b) Meniere's Disease on PTA: (i) Low-frequency SNHL in early disease (ii) Flat or rising audiogram in later stages; recruitment present; characteristic "pike-shaped" or low-frequency dip

(c) Hennebert's Sign: Nystagmus produced by applying pressure to EAC (tragal pressure) in the absence of a fistula; seen in Meniere's disease due to hypermobile footplate or distended saccule

(d) Four Types of Nasal Polyps:

Ethmoidal polyps (bilateral, multiple, pale grey - most common)
Antrochoanal polyp (unilateral, single, from maxillary sinus)
Allergic polyps
Neoplastic/malignant polyps

(e) Quinsy (Peritonsillar Abscess): Accumulation of pus in peritonsillar space between the tonsillar capsule and the superior constrictor muscle; presents with trismus, muffled "hot potato" voice, uvular deviation to opposite side, drooling; treated with incision and drainage + IV antibiotics

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