Otorhinolaryngology – Head and Neck Surgery: Clinical Decision-Making (Part II Oral Exam)
What Part II tests
The oral exam presents undifferentiated cases and asks for safe, prioritised decisions: red flags, focused examination, appropriate investigation, differential diagnosis, definitive management, and communication. It tests whether you can act before the diagnosis is certain.
Core rules
- Start with airway, bleeding, and sepsis. Stridor or a rapidly expanding neck haematoma outranks diagnostic completeness.
- Persistent hoarseness for more than three weeks, especially in a smoker, requires flexible laryngoscopy-not an empirical trial of antireflux therapy.
- Unilateral nasal obstruction with epistaxis, facial numbness, or orbital symptoms needs nasoendoscopy and imaging for sinonasal malignancy.
- A neck lump in an adult is malignant until proven otherwise. Do not excise it before imaging, fine-needle aspiration, and panendoscopy.
- Paediatric stridor is age-patterned: laryngomalacia is inspiratory and positional; croup is barking and febrile; tracheomalacia is expiratory; foreign body is sudden-onset.
- Document smoking, alcohol, voice use, and prior radiotherapy because they alter risk, staging, and reconstruction.
Worked example
A 64-year-old smoker has 10 weeks of hoarseness and otalgia. Flexible nasoendoscopy shows a fixed left vocal cord with a bulky supraglottic mass. Reasoning: this is laryngeal squamous cell carcinoma until biopsy proves otherwise. T3 is likely because the cord is fixed. Contrast-enhanced CT neck assesses cartilage, pre-epiglottic space, and nodes. Assess the airway before biopsy; perform biopsy under general anaesthesia with panendoscopy to map second primaries. Take the case to multidisciplinary team review: surgery or chemoradiotherapy depends on stage, pulmonary reserve, and patient preference.
Traps
- Treating persistent hoarseness as reflux without visualising the larynx.
- Excising an adult neck lump before excluding a head and neck primary.
- Omitting panendoscopy and missing a second primary.
- Forgetting airway assessment in a large laryngeal tumour.