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Iraqi Board ENT practice questions

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Question 1Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 35-year-old man has a central perforation of the pars tensa with a dry ear for 6 months. What is the most appropriate management?

  1. Tympanoplasty (myringoplasty) Correct answer.
  2. Observation with annual review
  3. Topical antibiotic drops
  4. Mastoidectomy

Explanation

A dry, stable central perforation with conductive hearing loss is best managed by tympanoplasty or myringoplasty to close the defect and improve hearing. Topical drops are for active infection, and mastoidectomy is reserved for cholesteatoma or uncontrolled disease.

Question 2Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

Which feature most reliably distinguishes cholesteatoma from simple chronic suppurative otitis media?

  1. Tympanic membrane perforation
  2. Mucopurulent discharge
  3. Conductive hearing loss
  4. Attic retraction pocket with keratin debris Correct answer.

Explanation

Cholesteatoma is defined by keratinizing squamous epithelium in the middle ear, typically seen as an attic or marginal retraction pocket containing keratin debris. Discharge, hearing loss, and perforation occur in both conditions and do not distinguish them.

Question 3Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A patient with chronic suppurative otitis media develops vertigo, nystagmus, and profound hearing loss. What complication should be suspected?

  1. Labyrinthine fistula Correct answer.
  2. Serous labyrinthitis
  3. Facial nerve palsy
  4. Subdural abscess

Explanation

Sudden vertigo with nystagmus and profound hearing loss in CSOM suggests erosion of the labyrinth, most often a labyrinthine fistula from cholesteatoma. The combination of vestibular symptoms and severe hearing loss points to inner ear involvement rather than isolated facial nerve disease.

Question 4Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

Which antibiotic is contraindicated for topical use in the middle ear because of ototoxicity?

  1. Gentamicin Correct answer.
  2. Ceftazidime
  3. Ciprofloxacin
  4. Ofloxacin

Explanation

Aminoglycosides such as gentamicin are potentially ototoxic when applied to the middle ear and are avoided if the round window is exposed. Fluoroquinolones and cephalosporins are safer topical choices.

Question 5Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 45-year-old woman has episodic vertigo lasting minutes to hours, with fluctuating hearing loss, tinnitus, and aural fullness. What is the most likely diagnosis?

  1. Vestibular neuritis
  2. Labyrinthitis
  3. Ménière disease Correct answer.
  4. Benign paroxysmal positional vertigo

Explanation

The tetrad of episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness is characteristic of Ménière disease. BPPV causes brief positional vertigo without hearing loss, and vestibular neuritis causes a single prolonged attack without auditory symptoms.

Question 6Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A patient reports brief vertigo triggered by rolling over in bed, lasting seconds. The Dix-Hallpike test reproduces vertigo with torsional nystagmus. What is the first-line treatment?

  1. Vestibular neurectomy
  2. Intratympanic gentamicin
  3. Epley canalith repositioning maneuver Correct answer.
  4. Betahistine

Explanation

The presentation is classic for posterior canal BPPV, and the Epley maneuver is the first-line treatment, offering rapid symptom relief by repositioning otoconia. Medications and surgical options are reserved for refractory cases.

Question 7Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

Which audiometric finding is most consistent with a conductive hearing loss?

  1. Bone conduction thresholds worse than air conduction
  2. Air-bone gap greater than 10 dB Correct answer.
  3. Absent otoacoustic emissions with normal audiogram
  4. Type A tympanogram

Explanation

A conductive hearing loss is characterized by an air-bone gap, typically defined as greater than 10 dB difference between air and bone conduction. Bone conduction thresholds worse than air conduction are not physiologic.

Question 8Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 30-year-old man has a sudden sensorineural hearing loss in the left ear noticed on waking. What is the most appropriate initial management?

  1. Reassurance and review in 3 months
  2. Topical antibiotic drops
  3. High-dose oral corticosteroids started promptly Correct answer.
  4. Immediate exploratory tympanotomy

Explanation

Idiopathic sudden sensorineural hearing loss is treated as an emergency, with high-dose corticosteroids started promptly to improve recovery. Delay in treatment reduces the chance of hearing recovery.

Question 9Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

Which nerve is most commonly affected by a complication of chronic suppurative otitis media involving the middle ear?

  1. Vagus nerve
  2. Optic nerve
  3. Facial nerve Correct answer.
  4. Hypoglossal nerve

Explanation

The facial nerve runs through the middle ear and is the most commonly affected cranial nerve in CSOM and cholesteatoma complications. The other listed nerves are anatomically remote from the middle ear.

Question 10Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A patient with cholesteatoma develops facial nerve palsy. What is the most appropriate management?

  1. Observation for 6 weeks
  2. Urgent surgical drainage and mastoidectomy Correct answer.
  3. Antiviral therapy
  4. Oral steroids alone

Explanation

Facial palsy complicating cholesteatoma requires urgent surgical management to remove the cholesteatoma and decompress the nerve. Delaying surgery risks permanent facial nerve damage.

Question 11Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

Which is the most common site of origin of acquired cholesteatoma?

  1. Marginal perforation of pars tensa
  2. Tympanic membrane trauma
  3. External auditory canal
  4. Pars flaccida retraction pocket Correct answer.

Explanation

Acquired cholesteatoma most commonly arises from a retraction pocket of the pars flaccida in the attic region. Pars tensa retraction and marginal perforations are less common sites.

Question 12Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 60-year-old man has a long-standing dry central perforation with a 30 dB conductive hearing loss. What is the expected benefit of myringoplasty?

  1. Improves hearing by closing the air-bone gap Correct answer.
  2. Prevents all future infections
  3. Eliminates sensorineural hearing loss
  4. Cures tinnitus permanently

Explanation

Myringoplasty closes the tympanic membrane defect, restoring the sound-conducting mechanism and reducing the air-bone gap. It does not affect sensorineural loss or guarantee permanent infection control.

Question 13Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

Which investigation is the imaging modality of choice for evaluating suspected cholesteatoma?

  1. Plain skull radiograph
  2. MRI of the brain
  3. Ultrasound of the neck
  4. High-resolution CT of the temporal bone Correct answer.

Explanation

High-resolution CT of the temporal bone demonstrates bony erosion and the extent of cholesteatoma, which is essential for surgical planning. Plain films lack detail, and MRI is used selectively for complications or soft tissue characterization.

Question 14Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A patient with chronic suppurative otitis media develops headache, fever, and neck stiffness. What complication is most likely?

  1. Meningitis Correct answer.
  2. Facial palsy
  3. Mastoiditis
  4. Otitis externa

Explanation

Headache, fever, and neck stiffness in a patient with CSOM suggest intracranial extension, most commonly meningitis. Urgent lumbar puncture and intravenous antibiotics are required.

Question 15Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

Which of the following is a recognized cause of sensorineural hearing loss in chronic suppurative otitis media?

  1. Ossicular fixation
  2. Middle ear effusion
  3. Toxin-mediated damage to the inner ear Correct answer.
  4. Tympanic membrane perforation

Explanation

Chronic infection can allow bacterial toxins to diffuse through the round window, causing sensorineural damage. Ossicular fixation, perforation, and effusion cause conductive loss.

Question 16Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

What is the most appropriate initial treatment for acute mastoiditis complicating CSOM?

  1. Oral antibiotics alone
  2. Topical drops only
  3. Observation
  4. Intravenous antibiotics with myringotomy Correct answer.

Explanation

Acute mastoiditis requires intravenous antibiotics and drainage, typically by myringotomy, with mastoidectomy if there is no response. Oral antibiotics alone are inadequate for this serious infection.

Question 17Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A patient has a positive fistula test with pressure-induced vertigo in the presence of cholesteatoma. What does this suggest?

  1. Ménière disease
  2. BPPV
  3. Vestibular schwannoma
  4. Labyrinthine fistula Correct answer.

Explanation

A positive fistula test in the setting of cholesteatoma suggests erosion of the bony labyrinth with a labyrinthine fistula. This is a surgical emergency requiring careful management to preserve hearing.

Question 18Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

Which of the following best describes the pathophysiology of Ménière disease?

  1. Endolymphatic hydrops Correct answer.
  2. Otoconia displacement
  3. Ischemia of the cochlea
  4. Viral inflammation of the vestibular nerve

Explanation

Ménière disease is characterized by endolymphatic hydrops, increased pressure in the membranous labyrinth. This explains the fluctuating hearing loss, tinnitus, and episodic vertigo.

Question 19Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 50-year-old man has unilateral progressive sensorineural hearing loss and tinnitus. What diagnosis should be excluded?

  1. Otosclerosis
  2. Presbycusis
  3. Vestibular schwannoma Correct answer.
  4. Noise-induced hearing loss

Explanation

Unilateral progressive sensorineural hearing loss with tinnitus warrants exclusion of vestibular schwannoma, typically with MRI. Otosclerosis is usually bilateral and conductive, while presbycusis and noise-induced loss are typically bilateral.

Question 20Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

Which of the following is a recognized risk of canal wall down mastoidectomy?

  1. Persistent cavity problems requiring regular cleaning Correct answer.
  2. Complete cure of all disease
  3. Elimination of the need for follow-up
  4. Improved hearing in all cases

Explanation

Canal wall down mastoidectomy creates an open cavity that requires lifelong cleaning and may cause discharge or debris accumulation. Hearing outcomes are variable and follow-up remains necessary.

Question 21Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

What is the most common cause of facial nerve palsy in a patient with a normal ear examination?

  1. Cholesteatoma
  2. Bell palsy Correct answer.
  3. Acoustic neuroma
  4. Otitis media

Explanation

Bell palsy is idiopathic facial nerve paralysis and is the most common cause when the ear examination is normal. Ear-related causes such as cholesteatoma and otitis media must be excluded.

Question 22Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

Which of the following is a characteristic feature of otosclerosis on audiometry?

  1. Air-bone gap at 4 kHz only
  2. Absent stapedial reflex with normal tympanogram
  3. Type B tympanogram
  4. Carhart notch at 2 kHz Correct answer.

Explanation

Otosclerosis shows a characteristic Carhart notch, an apparent bone conduction dip at 2 kHz, due to stapes fixation. Tympanometry is typically normal (type A).

Question 23Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A patient with chronic suppurative otitis media has a central perforation and a cholesteatoma in the attic. What is the most appropriate surgical approach?

  1. Myringotomy
  2. Observation
  3. Mastoidectomy with removal of cholesteatoma Correct answer.
  4. Tympanoplasty alone

Explanation

Cholesteatoma requires surgical removal, usually via mastoidectomy, with tympanoplasty for reconstruction. Tympanoplasty alone would leave the cholesteatoma behind.

Question 24Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

Which of the following is a recognized cause of recurrent vertigo after vestibular neuritis?

  1. Labyrinthine fistula
  2. BPPV
  3. Ménière disease
  4. Vestibular compensation failure Correct answer.

Explanation

After vestibular neuritis, incomplete central compensation can cause persistent or recurrent imbalance and vertigo. Vestibular rehabilitation is the mainstay of treatment.

Question 25Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

Which of the following best describes the role of a hearing aid in a patient with a large central perforation and mixed hearing loss?

  1. It cures the perforation
  2. It is contraindicated in all cases
  3. It can improve hearing but does not treat the perforation Correct answer.
  4. It prevents cholesteatoma

Explanation

A hearing aid amplifies sound and can improve communication in mixed hearing loss, but it does not close the perforation or treat middle ear disease. Surgical closure may be considered separately.

Question 26Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 45-year-old woman has a long-standing central perforation of the pars tensa with a dry ear. She now develops a painless, foul-smelling discharge that has persisted for three weeks. What is the most appropriate initial management step?

  1. Prescribe a course of oral antifungals and advise keeping the ear dry
  2. Immediately schedule tympanoplasty without any medical treatment
  3. Perform a mastoidectomy to eradicate the infection
  4. Obtain a swab for culture and sensitivity, then start topical antibiotic drops Correct answer.

Explanation

A change from a dry to a discharging ear in CSOM suggests active infection; culture-guided topical antibiotics are the first step. Tympanoplasty is elective and should be delayed until the ear is dry. Oral antifungals are not indicated unless fungal infection is proven, and mastoidectomy is reserved for complications or cholesteatoma.

Question 27Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 28-year-old man presents with a 6-month history of episodic vertigo lasting hours, left-sided fluctuating hearing loss, tinnitus, and a sensation of aural fullness. Audiometry shows a low-frequency sensorineural hearing loss in the left ear. What is the most likely diagnosis?

  1. Vestibular neuritis
  2. Ménière disease Correct answer.
  3. Benign paroxysmal positional vertigo
  4. Vestibular schwannoma

Explanation

The combination of recurrent spontaneous vertigo lasting minutes to hours, fluctuating sensorineural hearing loss, tinnitus, and aural fullness is classic for Ménière disease. Low-frequency sensorineural loss is typical early in the course. Vestibular schwannoma usually causes progressive, non-fluctuating hearing loss and does not cause episodic vertigo of this pattern.

Question 28Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 35-year-old woman reports a 3-month history of progressive right-sided facial weakness that started in the lower face and has gradually worsened. She also notices twitching of the right face. Otoscopy and audiometry are normal. What is the most important next step in management?

  1. Reassure and prescribe a course of oral corticosteroids
  2. Start antiviral therapy for presumed Bell's palsy
  3. Refer for urgent ENT and neurology evaluation for possible facial nerve tumour Correct answer.
  4. Perform a superficial parotidectomy for diagnosis

Explanation

Progressive facial palsy over weeks, especially with twitching and normal ear examination, is suspicious for a neoplasm such as a facial nerve schwannoma or a parotid malignancy. Urgent specialist referral for imaging and possible biopsy is required. Bell's palsy is acute in onset and does not progress beyond three weeks.

Question 29Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 40-year-old man has a history of recurrent left otorrhoea since childhood. Examination shows a retraction pocket in the pars flaccida filled with keratin debris. Audiometry shows a 25 dB conductive hearing loss. What is the most appropriate definitive treatment?

  1. Mastoidectomy with removal of cholesteatoma Correct answer.
  2. Tympanoplasty without mastoidectomy
  3. Observation with annual audiometry
  4. Long-term topical antibiotic drops

Explanation

A retraction pocket with keratin debris in the pars flaccida indicates cholesteatoma, which requires surgical removal, usually via mastoidectomy, to prevent complications. Topical antibiotics do not eradicate cholesteatoma. Tympanoplasty alone is inadequate because the disease extends into the attic and mastoid.

Question 30Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 55-year-old man with a 20-year history of bilateral chronic suppurative otitis media presents with progressive bilateral hearing loss. Audiometry shows a mixed hearing loss with a bone-conduction threshold of 50 dB and air-conduction threshold of 80 dB. What is the most appropriate rehabilitation option?

  1. Cochlear implant assessment
  2. No intervention as the loss is conductive
  3. Bilateral tympanoplasty alone
  4. Hearing aid evaluation Correct answer.

Explanation

The patient has a mixed hearing loss with a significant sensorineural component (bone conduction 50 dB), so surgery alone will not restore hearing. Hearing aids are the mainstay of rehabilitation for mixed loss when the sensorineural component is moderate. Cochlear implantation is reserved for severe-to-profound sensorineural loss.

Question 31Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 60-year-old woman with a history of treated cholesteatoma presents with a dead ear and recurrent vertigo. Examination reveals a positive fistula test. Imaging shows a defect in the lateral semicircular canal. What is the most appropriate management?

  1. Vestibular rehabilitation alone
  2. Intratympanic gentamicin injection
  3. Surgical repair of the labyrinthine fistula Correct answer.
  4. Conservative management with vestibular suppressants

Explanation

A labyrinthine fistula with a dead ear and recurrent vertigo is best managed by surgical repair to prevent further inner ear damage and meningitis. Conservative treatment may be used for small fistulas with serviceable hearing, but here the ear is dead and symptoms are recurrent. Gentamicin is for Ménière disease, not fistula.

Question 32Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 7-year-old boy is brought with a 2-day history of right ear pain and fever. Otoscopy shows a bulging, erythematous tympanic membrane with no perforation. What is the most appropriate initial antibiotic?

  1. Metronidazole
  2. Clarithromycin
  3. Ciprofloxacin
  4. Amoxicillin Correct answer.

Explanation

Amoxicillin is the first-line antibiotic for acute otitis media in children, covering the common pathogens Streptococcus pneumoniae and Haemophilus influenzae. Ciprofloxacin is not first-line and is used for chronic suppurative otitis media. Macrolides are reserved for penicillin allergy, and metronidazole covers anaerobes.

Question 33Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 50-year-old man with chronic suppurative otitis media develops sudden severe vertigo, nausea, and vomiting. Examination shows nystagmus and a positive fistula test. What is the most likely underlying pathology?

  1. Serous labyrinthitis
  2. Labyrinthine fistula Correct answer.
  3. Benign paroxysmal positional vertigo
  4. Vestibular neuritis

Explanation

A positive fistula test with acute vertigo in a patient with CSOM indicates a labyrinthine fistula, often due to cholesteatoma eroding the lateral semicircular canal. Serous labyrinthitis causes hearing loss and vertigo but the fistula test is typically negative. Vestibular neuritis and BPPV are not associated with CSOM or a positive fistula test.

Question 34Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 65-year-old man presents with a 6-month history of progressive right-sided hearing loss and tinnitus. He has no history of ear discharge. Audiometry shows a moderate sensorineural hearing loss in the right ear. What is the most appropriate next investigation?

  1. Pure tone audiometry repeat in 6 months
  2. Computed tomography of the temporal bone
  3. Tympanometry
  4. Magnetic resonance imaging of the internal auditory meatus Correct answer.

Explanation

Unilateral progressive sensorineural hearing loss in an adult raises suspicion of vestibular schwannoma, and MRI with gadolinium is the investigation of choice. CT scan is less sensitive for soft tissue lesions. Repeat audiometry delays diagnosis, and tympanometry assesses middle ear function, which is normal here.

Question 35Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 30-year-old woman presents with acute onset of severe vertigo, nausea, and vomiting that has lasted for 2 days. She has no hearing loss or tinnitus. Examination shows spontaneous horizontal nystagmus. What is the most likely diagnosis?

  1. Labyrinthitis
  2. Ménière disease
  3. Benign paroxysmal positional vertigo
  4. Vestibular neuritis Correct answer.

Explanation

Acute prolonged vertigo without hearing loss is typical of vestibular neuritis, which is thought to be viral inflammation of the vestibular nerve. Ménière disease causes recurrent episodes with hearing loss. Labyrinthitis includes hearing loss. BPPV causes brief positional vertigo.

Question 36Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 45-year-old man with a history of cholesteatoma presents with a 3-day history of right facial weakness. He cannot close his right eye. Otoscopy shows a retraction pocket with debris. What is the most appropriate management?

  1. Facial nerve stimulation
  2. Topical antibiotic drops and observation
  3. Oral corticosteroids and antiviral therapy
  4. Urgent surgical exploration and decompression of the facial nerve Correct answer.

Explanation

Facial palsy in the presence of cholesteatoma is a surgical emergency because the cholesteatoma is compressing or eroding the facial nerve. Urgent mastoidectomy with removal of cholesteatoma and nerve decompression is indicated. Medical therapy for Bell's palsy is inappropriate.

Question 37Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 55-year-old woman has a 10-year history of left-sided chronic suppurative otitis media with a central perforation. She now develops severe headache, fever, and neck stiffness. What is the most likely causative organism?

  1. Staphylococcus aureus
  2. Streptococcus pneumoniae
  3. Pseudomonas aeruginosa Correct answer.
  4. Haemophilus influenzae

Explanation

Meningitis complicating chronic suppurative otitis media is often caused by Pseudomonas aeruginosa, which is common in chronic ear infections. Streptococcus pneumoniae and Haemophilus influenzae are more typical of acute otitis media. Staphylococcus aureus is less common.

Question 38Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 40-year-old man with a history of bilateral chronic suppurative otitis media has a large central perforation in the right ear. He has a 30 dB conductive hearing loss. What is the expected outcome of tympanoplasty?

  1. Worsening of hearing due to ossicular damage
  2. Closure of the perforation but no change in hearing
  3. Persistent perforation requiring repeat surgery
  4. Closure of the perforation and improvement in hearing Correct answer.

Explanation

Tympanoplasty aims to close the perforation and improve hearing by restoring the sound-conducting mechanism. In a dry ear with a central perforation and intact ossicular chain, closure rates are high and hearing often improves. Persistent perforation or worsening hearing are complications, not expected outcomes.

Question 39Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 70-year-old man presents with a 1-year history of progressive hearing loss and tinnitus in the left ear. He also reports occasional unsteadiness. Audiometry shows a mild high-frequency sensorineural hearing loss. What is the most appropriate initial investigation?

  1. Electronystagmography
  2. Magnetic resonance imaging of the brain and internal auditory meatus Correct answer.
  3. Auditory brainstem response
  4. Computed tomography of the temporal bone

Explanation

Progressive unilateral sensorineural hearing loss with unsteadiness in an older adult warrants MRI to exclude vestibular schwannoma or other retrocochlear pathology. CT is less sensitive for soft tissue lesions. Electronystagmography and ABR are supportive tests but not first-line imaging.

Question 40Otology and Neurotology (chronic suppurative otitis media, cholesteatoma, hearing loss, vertigo, facial nerve)

A 25-year-old woman presents with a 2-day history of severe vertigo, nausea, and vomiting. She has no hearing loss. Examination shows horizontal nystagmus. What is the most appropriate initial treatment?

  1. Vestibular suppressants and antiemetics Correct answer.
  2. Oral corticosteroids
  3. Intratympanic gentamicin
  4. Vestibular rehabilitation exercises

Explanation

Acute vestibular neuritis is managed symptomatically with vestibular suppressants and antiemetics for the first few days. Corticosteroids may be considered but are not universally standard. Gentamicin is for Ménière disease, and vestibular rehabilitation is used after the acute phase.

Question 41Rhinology and Sinology (chronic rhinosinusitis, nasal polyposis, allergic rhinitis, epistaxis, endoscopic sinus surgery)

A 28-year-old man has recurrent left anterior epistaxis from Little's area. He is otherwise healthy and has no bleeding elsewhere. What is the most appropriate initial management?

  1. Packing of the posterior choana with a Foley catheter balloon
  2. Digital pressure over the alar cartilages with the head tilted forward for 10–15 minutes Correct answer.
  3. Systemic tranexamic acid with admission for observation
  4. Ligation of the ipsilateral external carotid artery

Explanation

Most anterior epistaxis arises from Kiesselbach's plexus on the anterior nasal septum and stops with correct technique: firm pinching of the soft part of the nose, head forward, for at least 10 minutes without release. Posterior packing and arterial ligation are reserved for bleeding that fails conservative and endoscopic measures. Systemic antifibrinolytics are not first-line for a simple anterior bleed in an otherwise healthy patient.

Question 42Rhinology and Sinology (chronic rhinosinusitis, nasal polyposis, allergic rhinitis, epistaxis, endoscopic sinus surgery)

Which anatomical structure is the primary arterial supply to the anterior nasal septum in Kiesselbach's plexus?

  1. Superior labial artery of the facial artery Correct answer.
  2. Anterior ethmoidal artery
  3. Sphenopalatine artery
  4. Ascending pharyngeal artery

Explanation

Kiesselbach's plexus on the anterior septum is formed by branches of the anterior ethmoidal, sphenopalatine, greater palatine and superior labial arteries. The superior labial branch of the facial artery supplies the anteroinferior part of the septum and nasal floor. The sphenopalatine artery dominates the posterior and lateral nasal wall, while the anterior ethmoidal artery supplies the roof.

Question 43Rhinology and Sinology (chronic rhinosinusitis, nasal polyposis, allergic rhinitis, epistaxis, endoscopic sinus surgery)

A 45-year-old woman has bilateral nasal polyps, asthma and aspirin sensitivity. Which diagnosis best fits this triad?

  1. Samter's triad (aspirin-exacerbated respiratory disease) Correct answer.
  2. Wegener's granulomatosis
  3. Unilateral antrochoanal polyp
  4. Allergic fungal rhinosinusitis

Explanation

The combination of nasal polyposis, asthma and aspirin or NSAID sensitivity is Samter's triad, also called aspirin-exacerbated respiratory disease. It typically presents in adulthood with diffuse polypoid disease and is managed with avoidance of NSAIDs, topical corticosteroids and sometimes aspirin desensitisation. Allergic fungal rhinosinusitis and granulomatosis have different clinical and radiological features.

Question 44Rhinology and Sinology (chronic rhinosinusitis, nasal polyposis, allergic rhinitis, epistaxis, endoscopic sinus surgery)

What is the most common cause of bilateral nasal obstruction with clear rhinorrhoea and sneezing in a 20-year-old during spring?

  1. Allergic rhinitis Correct answer.
  2. Chronic rhinosinusitis with polyps
  3. Choanal atresia
  4. Inverted papilloma

Explanation

Seasonal sneezing, clear rhinorrhoea, itching and bilateral obstruction in a young adult during a defined pollen season is the classic picture of allergic rhinitis. Diagnosis is supported by skin-prick testing or specific IgE. Structural and neoplastic causes do not produce this seasonal, allergen-triggered symptom pattern.

Question 45Rhinology and Sinology (chronic rhinosinusitis, nasal polyposis, allergic rhinitis, epistaxis, endoscopic sinus surgery)

Which symptom is most characteristic of chronic rhinosinusitis with nasal polyps compared with chronic rhinosinusitis without polyps?

  1. Reduced or absent sense of smell Correct answer.
  2. Facial pressure worse on bending
  3. Purulent anterior discharge
  4. Postnasal drip

Explanation

Olfactory dysfunction is markedly more prominent and more severe in chronic rhinosinusitis with nasal polyps than without polyps. Polyps obstruct the olfactory cleft and are associated with type 2 inflammation that damages olfactory epithelium. Facial pressure, postnasal drip and purulent discharge occur in both phenotypes.

Question 46Rhinology and Sinology (chronic rhinosinusitis, nasal polyposis, allergic rhinitis, epistaxis, endoscopic sinus surgery)

What is the recommended first-line medical treatment for chronic rhinosinusitis with nasal polyps?

  1. A short course of oral antibiotics
  2. Daily intranasal corticosteroid spray with saline irrigation Correct answer.
  3. Long-term oral decongestant spray
  4. Systemic antihistamine as monotherapy

Explanation

Guidelines recommend daily intranasal corticosteroids, often combined with saline irrigation, as first-line therapy for chronic rhinosinusitis with nasal polyps. They reduce polyp size and improve symptoms and are continued for at least 8–12 weeks before assessing response. Antibiotics are reserved for confirmed bacterial exacerbations.

Question 47Rhinology and Sinology (chronic rhinosinusitis, nasal polyposis, allergic rhinitis, epistaxis, endoscopic sinus surgery)

A patient has a nosebleed that continues despite correct anterior pressure and anterior nasal packing. The bleeding appears to run down the posterior pharynx. Which vessel is the most likely source?

  1. Sphenopalatine artery Correct answer.
  2. Greater palatine artery
  3. Superior labial artery
  4. Anterior ethmoidal artery

Explanation

Posterior epistaxis most often arises from branches of the sphenopalatine artery in the posterior nasal cavity, particularly the woodruff plexus area. Blood runs posteriorly into the pharynx and anterior packing often fails. Endoscopic sphenopalatine artery ligation or cautery is the definitive treatment when packing fails.

Question 48Rhinology and Sinology (chronic rhinosinusitis, nasal polyposis, allergic rhinitis, epistaxis, endoscopic sinus surgery)

Which finding on CT of the paranasal sinuses best supports a diagnosis of chronic rhinosinusitis?

  1. Isolated concha bullosa without mucosal disease
  2. Mucosal thickening or opacification of the ostiomeatal complex and sinuses Correct answer.
  3. Widened pterygopalatine fossa
  4. Thinning of the frontal bone

Explanation

The radiological hallmark of chronic rhinosinusitis is mucosal thickening or opacification centred on the ostiomeatal complex and paranasal sinuses. CT is used to confirm disease extent and to plan endoscopic sinus surgery after failed medical therapy. Incidental anatomical variants alone do not establish the diagnosis.

Question 49Rhinology and Sinology (chronic rhinosinusitis, nasal polyposis, allergic rhinitis, epistaxis, endoscopic sinus surgery)

A 35-year-old woman has 12 weeks of nasal obstruction, thick discharge and facial pain. Endoscopy shows bilateral diffuse polyps. What is the most appropriate next step in management?

  1. A course of intranasal corticosteroids and saline irrigation with review Correct answer.
  2. Immediate endoscopic sinus surgery
  3. Reassurance and discharge
  4. Systemic antifungal therapy

Explanation

Chronic rhinosinusitis with polyps is first treated medically with intranasal corticosteroids and saline irrigation, usually for at least 8–12 weeks. Surgery is considered when symptoms persist despite adequate medical therapy. Antifungal therapy is not indicated for ordinary polypoid disease.

Question 50Rhinology and Sinology (chronic rhinosinusitis, nasal polyposis, allergic rhinitis, epistaxis, endoscopic sinus surgery)

Which feature on history most strongly suggests a diagnosis of allergic rhinitis rather than non-allergic rhinitis?

  1. Symptoms triggered only by temperature change
  2. Unilateral obstruction with blood-stained discharge
  3. Perennial symptoms with crusting and foul smell
  4. Symptoms confined to specific seasons with itching and sneezing Correct answer.

Explanation

Seasonal timing with prominent itching, sneezing and clear rhinorrhoea suggests an IgE-mediated allergic cause. Non-allergic rhinitis is more often perennial, triggered by irritants or temperature, and lacks itching. Unilateral bloody symptoms should raise concern for a neoplastic or structural cause.