Free UKMLA ear, nose and throat questions with explanations

A. Call senior anaesthetist for airway management

The clinical picture of high fever, drooling, muffled (hot potato) voice, tripod posture and stridor in a toxic child is classical acute epiglottitis, a life-threatening airway emergency where the priority is urgent senior anaesthetic (and ENT) involvement to secure the airway in a controlled setting such as theatre. Any distress, including examination, cannulation or lying the child flat, may precipitate complete airway obstruction.

E. Retropharyngeal abscess

Retropharyngeal abscess typically affects children aged 2–4 because of prominent retropharyngeal lymph nodes, presenting with neck stiffness, drooling, fever and a preference for neck extension. The lateral neck radiograph shows widened prevertebral soft tissue; after securing the airway, contrast CT confirms the collection; IV antibiotics are started, with surgical drainage for a large collection, airway compromise or failure to improve.

B. Streptococcus pyogenes

Quinsy is usually a polymicrobial infection, but group A beta-haemolytic streptococcus (Streptococcus pyogenes) is the organism most often isolated, reflecting its role as the commonest bacterial cause of the tonsillitis from which the abscess arises. Oral anaerobes, particularly Fusobacterium necrophorum and Prevotella species, are the next most frequent and are the reason metronidazole is often added to penicillin after drainage. Staphylococcus aureus and Haemophilus influenzae are recovered in a minority of cases. The practical consequence is that a penicillin remains the first-line antibiotic after drainage, with a macrolide or clindamycin for penicillin-allergic patients.

E. Referral for elective interval tonsillectomy

Recurrent peritonsillar abscess is an accepted indication for tonsillectomy, because a second quinsy carries a high chance of further episodes and each one risks deep neck spread. In UK practice this is done as an elective interval procedure around 6 weeks after the acute episode has settled, when the tissues are no longer inflamed and the haemorrhage risk is lower. Tonsillectomy during the acute infection (hot tonsillectomy) is occasionally used to drain an inaccessible abscess but is not the routine UK approach for a resolving episode. Prophylactic antibiotics do not remove the tonsillar crypts in which the infection begins and encourage resistance.

B. Admit for intravenous antibiotics

Acute mastoiditis is a suppurative infection of the mastoid air cells complicating otitis media and needs admission for intravenous antibiotics that cover Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae and Staphylococcus aureus; most uncomplicated cases settle within 48 hours. Oral antibiotics are inadequate once infection has spread beyond the middle ear into bone. Myringotomy is a useful adjunct to drain the middle ear and obtain culture, and cortical mastoidectomy is reserved for a subperiosteal abscess, intracranial complication or failure to improve on intravenous treatment.

A. Contrast-enhanced CT of the temporal bones and brain

Drowsiness, headache and vomiting in a child with mastoiditis signal an intracranial complication such as sigmoid sinus thrombosis, epidural or cerebral abscess, or meningitis, and contrast-enhanced CT of the temporal bones with the brain is the first-line urgent investigation because it shows bony erosion, subperiosteal or intracranial collections and a filling defect in a thrombosed sinus. Non-contrast bone-window CT defines the mastoid but misses abscesses and sinus thrombosis. MRI with venography is a valuable second study when CT is equivocal, but a focused non-contrast study of the internal auditory meati would not answer the question.

A. Referral to ENT for microscopic examination of the ear

Persistent unilateral offensive discharge with hearing loss and crust or debris in the attic, the upper part of the drum, is the presentation of cholesteatoma in adults, and the crust often hides a retraction pocket full of keratin. It cannot be diagnosed or treated in primary care: the ear needs cleaning and inspection under the microscope, followed by CT to plan surgery. Antibiotic drops may dry the discharge for a while but do not remove the keratin sac, and repeated courses delay the diagnosis while the disease erodes bone. Syringing is unsafe with a possible perforation, and waiting risks facial nerve palsy, labyrinthine fistula and intracranial infection.

C. Intranasal corticosteroid spray

Bilateral pale insensate swellings with hyposmia are nasal polyps, the hallmark of chronic rhinosinusitis with nasal polyps, a type 2 eosinophilic inflammatory disease of the sinus lining. First-line treatment is a daily intranasal corticosteroid with saline irrigation, which shrinks polyps and improves obstruction and smell with negligible systemic absorption; it is continued long term because polyps regrow when it stops. A short oral steroid course is added for severe obstruction or before surgery, and endoscopic surgery is reserved for failure of medical treatment and does not remove the need for ongoing topical steroid. Antihistamines help if there is coexisting allergic rhinitis, and antibiotics have no role without infection. Unilateral polyps, or polyps in a child, need a different approach because they raise the possibility of tumour or cystic fibrosis.

D. Labyrinthitis

Labyrinthitis is inflammation of the whole inner ear, usually after a viral upper respiratory infection, so it produces the acute vestibular syndrome of continuous vertigo, nausea and nystagmus lasting days together with cochlear symptoms: hearing loss and tinnitus on the affected side. Vestibular neuritis is the same viral process confined to the vestibular nerve and gives an identical vertigo but with normal hearing, so hearing loss is the discriminator between the two. Meniere's disease also combines vertigo with hearing loss and tinnitus but in recurrent attacks lasting minutes to hours with fluctuating low-frequency loss and aural fullness, not a single continuous episode after a cold. Treatment is short-term vestibular sedation then mobilisation.

A. Prochlorperazine

Acute Meniere's attacks are managed symptomatically with a vestibular sedative/antiemetic such as prochlorperazine (buccal, IM or oral) or cinnarizine to suppress the vertigo and nausea while the attack settles. These agents abort symptoms during the episode but are not used for long-term prevention because of sedation and the risk of delaying central compensation. UK practice reserves long-term and interventional measures for prophylaxis between attacks.