E-residency Weekly Test for EENT

1. A 26 year old patient, returning from a summer vacation at Dubai, attends the emergency
department with pain, blurred vision and light sensitivity in both eyes. She is normally fit and well,
on no regular medication. She denies any history of trauma / fever / GI symptoms. Her vitals are
unremarkable, VA by Snellen’s chart is 6/9 in both eyes. Her examination is significant for bilateral
photophobia, and conjunctival injection. Pupils are normal and reactive. You perform slit lamp
examination with fluorescein, with following findings. What is your advice to the patient?

a. Advise her that she has conjunctivitis that has extended into the cornea and prescribe
ciprofloxacin eye drops.

b. Advise her that she has uveitis and prescribe her cyclopentolate eye drops.

c. Advise her that she has ultraviolet keratitis, that is should typically resolve in 24-48 hours, and to
keep her eyes patched whenever possible. Prescribe cyclopentolate eye drops.

d. Advise her that she has superficial punctate keratitis and provide oral acyclovir course.

2. A 7 year old girl is brought to the emergency department by her mother, history provided by both.
The mother reports that her daughter has been scratching her right eye for two days, and this has
caused her eyelids to swell. She is known to have asthma and atopic dermatitis, which seem to have
a seasonal occurrence. The daughter confirms that she has been scratching her right eye. She
reports her vision as being normal. Visual acuity is 6/6 in both eyes. On examination you find the
following. What is your advice to the patient and mother?

a. She has blepharitis, advise careful daily cleansing of the edges of the eyelids and lashes. If it
doesn’t improve or gets worse in 48 hours to return for follow-up.

b. She has a stye that requires incision and drainage by an ophthalmologist.

c. She has a chalazion that requires incision and drainage by an ophthalmologist.

d. She has a stye that requires antibiotic eye drops and follow up with an ophthalmologist.
3. A 36 year old male is attending the emergency department because his left eye “started bleeding”
after a bout of cough. He takes citalopram for anxiety but is otherwise on no regular medications,
and is fit and well. He thinks he has the hantavirus and is going to die. He denies trauma, visual
disturbances, headache, GI complaints, RS complaints. He has no family history of bleeding
disorders. His vitals are unremarkable. His visual acuity is 6/6 in both eyes. You find the following on
examination. Your advice to him:

a. You understand his concerns, however, he does not have hantavirus, you will not do any tests as
he does not need them.

b. You tell him that this is an inappropriate use of hospital resources, and he should stop googling
medical symptoms.

c. You reassure him that his vitals being normal, and his examination being unremarkable are both
very good signs. Though it appears frightening, he has a subconjunctival haemorrhage which is quite
common, but not a threat to his vision or his life. It will get better over the next 10-14 days.

d. You tell him he has conjunctivitis, and prescribe 5 days of antibiotic eye drops, and advise him to
return if he develops visual disturbance.

4. A 46 year old female patient with a background history of ankylosing spondylitis, attends your
emergency department with complaints of pain in both eyes, but worse on the left with associated
redness, photophobia and blurred vision. She has no previous history of eye problems, trauma or
surgery. She takes regular paracetamol and naproxen for her long-standing back pain. Her vitals are
unremarkable. VA OD-6/9, OS 6/6 unaided. On examination, she has consensual photophobia in the
left eye, along with diffuse conjunctival injection, photophobia, miotic poorly reactive pupil. The left
eye appears unremarkable. Slit lamp examination reveals flare in the AC, with a small hypopyon.
Cornea appears normal on fluorescein staining. What is your diagnosis and advice to this patient?

a. She has uveitis, likely associated with her AS, and requires follow up with both ophthalmology and
rheumatology. You prescribe homatropine eye drops aiming for pain relief.

b. She has glaucoma, like associated with her AS, and requires an urgent ophthalmology consult for
laser iridotomy. You prescribe cyclopentolate eye drops aiming for pain relief.

c. She has severe keratitis, resulting in hypopyon, and requires antibacterial eye drops to control the
cause, and cyclopentolate eye drops to treat the pain. She will require ophthalmology follow up.

d. She has iritis, requiring antibiotic, antihistamine, and corticosteroid eye drops.

5. A 56 yo male patient attends the emergency department with facial injuries due to alleged assault.
You are happy with his airway, ventilation, chest, torso, pelvis. He is on no regular medication. He
states a punch glanced over his left eye. His vision went black for a few seconds but has since been
normal. His vitals are unremarkable. VA 6/6 both eyes. Examination reveals a V shaped laceration
with one limb being a full-thickness laceration over the lower eyelid, and the other limb overlying
the medial canthus. Your next steps:

a. You do not perform a slit lamp examination and refer this patient urgently to the ophthalmologist.

b. You perform a slit lamp examination with fluorescein and refer this patient to an ophthalmologist
or oculoplastic surgeon if available.

c. You perform a slit lamp examination with fluorescein, and with good local anaesthetic and
procedural sedation, carefully repair the laceration, follow up with ophthalmology.

d. Wound irrigation, tissue adhesive on the dermal surface of the laceration, and refer to
ophthalmology for further closure.

6. True or false: Blow-out fractures with normal initial eye examination in the ED do not require to
be referred to an ophthalmologist for an outpatient fully dilated exam.

a. True

b. False

7. True or false: Eye examination may be nearly normal after globe rupture form a tiny high-speed
projectile

a. True

b. False
8. A 41 year old patient with medical history significant for well controlled diabetes (on metformin),
attends with a painful left eye that has gradually worsened over the last 4 days with spreading
redness and swelling around the eye. He denies trauma and visual disturbances. He has felt
nauseated for 2 days and vomited earlier today. His vitals are as follows: T 38 C, P 98 bpm, BP
150/92 mmHg, RR 14/min, Bedside glucose: 4.5 mmol/L. You establish 2 large bore IV cannulas, and
obtain a full panel of bloods. You examination reveals a normal systems exam. Which of the
following features of an eye exam would be concerning?

a. Epiphora, redness, and itching

b. Blepharitis, internal hordeolum, and crusted discharge

c. Pain on moving the eyes, chemosis, ptosis

d. Itching, rhinitis, facial pressure

9. A 17 year old patient felt a foreign body sensation to his right eye while playing football. He is
otherwise well, with unremarkable vitals. On examining his right eye, aided by topical tropicaine
drops, you can see a corneal foreign body on naked eye examination. On fluorescein stained slit
lamp exam, you find that it is a full thickness foreign body. Your next steps:

a. With a 25 gauge needle, attempt foreign body removal under slit lamp exam.

b. First attempt removal with normal saline irrigation.

c. Attempt removal with a wet cotton tip applicator.

d. Full thickness laceration should be removed by an ophthalmologist

10. A cleaner splashed an unknown chemical cleaning agent into their right eye at work. She
immediately rinsed her eye with tap water. Her right eye is painful, red, with blurred vision. She is
systemically well, and normally with and well with no comorbidities. She does not use contact lenses
or glasses. After 30 minutes of eye irrigation initiated by the triage nurse, the litmus touchstrip pH is
6. Your next steps:

a. Stop to check visual acuity, then continue irrigation till pH is 7.5

b. Continue irrigation until pH remains neutral for 30 minutes after the last irrigation, then perform
an eye examination. If there is no corneal clouding/epithelial defect, prescribe phenylephrine for
cycloplegia.

c. Continue irrigation until pH remains neutral for 30 minutes after the last irrigation, then perform
an eye examination. Any patient with corneal clouding or an epithelial defect after irrigation should
receive prompt ophthalmology referral.

d. Continue irrigation until pH remains neutral for 1 hour. Patient with chemosis but no corneal
findings should be prescribed antibiotic ointment and ophthalmology outpatient follow-up after 72
hours.

11. Choose the correct pair:

b. Acute CN III palsy + dilated pupil < - > Horner’s syndrome

c. Pseudotumor Cerebri < - > cranial nerve VI palsy

d. Genu VII Bell’s palsy < - > Cranial nerve VII palsy (affecting ipsilateral upper and lower face) and
inability to adduct the ipsilateral eye

12. 64 yo male patient with background history of Type II DM poorly controlled by metformin and
short and long acting insulins, and hypertension on ramipril, attends with severe pain in the left ear,
with sticky yellow discharge and reduced hearing. He also reports reduced mouth opening with pain.
His vitals are within normal limits. On examination, he has a swollen, erythematous left external
auditory canal, trismus, and CN VII palsy. There are no apparent skin lesions. What is your suspected
diagnosis, and plan of management?

a. You diagnose Ramsay Hunt syndrome and start the patient on antivirals and corticosteroids.

b. You diagnose Malignant otitis externa, swab for C&S, administer antibiotics, CT Head with
contrast, refer to ENT

c. You diagnose Acute Suppurative Otitis Media associated with Bell’s Palsy. Start oral antibiotics and
refer to ENT outpatients.

d. Giant Cell Arteritis with associated acute mastoid osteomyelitis, admit for IV antibiotics, and high
dose steroids to gradually taper.

13. 72 yo male patient with a background of chronic heart failure with atrial fibrillation, on low dose
bisoprolol and furosemide, attends the emergency department with acute left sided facial swelling
and redness, lethargy and reduced oral intake. Vitals – T 37.5 C, P 90 bpm, RR 15/min, BP 101/64
mmHg, ECG – AF with no new changes compared to past ECGs. IV access established and bloods sent
to labs. Your examination is significant for left sided parotid region erythematous swelling and
trismus. You can express pus from Stenson’s duct. What is your leading diagnosis, and what are your
next steps?

a. Viral parotitis: usually self-limiting. Advise sialogogue (e.g. lemon drops), and discharge with safety
netting advice

b. Acute Suppurative parotitis: Obtain swab for C&S, admit for IV hydration and antibiotics, provide
sialogogues, massage and apply heat to affected gland

c. Sialolithiasis: Massage the gland and duct, provide analgesics in suspension form, provide
sialogogues and discharge with safety netting advice.

d. Preauricular lymphadenitis: Provide antibiotics, analgesia and book an outpatient ultrasound with
biopsy.

14. True or false: To reduce an anterior mandibular dislocation, one must apply pressure downward
and forward (toward clinician) with gloved thumbs in the patient’s mouth, over the occlusal surfaces
of the mandibular molars.

a. True
b. False

15. True or false: The most likely source of posterior epistaxis is the posterior ethmoidal artery.

a. False

b. True

16. A 39 year old male patient, normally fit and well on no regular medications, attends the
emergency department with nasal blockage and congestion, anosmia, facial pain (more on the left
side) worse on bending forward, and 11 days of progressively worsening nasal discharge. He denies
shortness of breath, wheezing, chest tightness, fever. He has tried nasal douching, steam inhalation,
and over the counter nasal decongestants with no relief. His vitals are within normal limits. His
examination reveals mild epiphora from the left eye, red nose, posterior nasal discharge,
mucopurulent discharge and crusting in both nasal vestibules. He has no known allergies.

a. You diagnose acute rhinosinusitis clinically and start the patient on tab amoxicillin 500mg tds x 7
days.

b. You suspect acute rhinosinusitis but require CT paranasal sinuses to aid with decision to use
antibiotics.

c. You suspect acute dacryocysitis, start the patient on coamoxiclav and refer to ophthalmology
urgently.

d. You suspect a viral URTI, recommend continuing nasal douching and steam inhalation, prescribe
oxymetazoline nasal spray, and suggest ENT follow up in 2 weeks. If symptoms persist, trial of
antibiotics.

17. A 52 year old male patient attends the ED with acute onset dysphagia and drooling, and dyspnea
worse in supine position. Vitals T 39 C, P 120 bpm, RR 16/min, BP 135/85 mmHg. ECG – sinus
tachycardia. Bedside glucose 4.5 mmol/L. Examination reveals right cervical adenopathy, and
anterior neck tenderness. You hear mild inspiratory strider. He was triaged as a sore throat
(Suspected tonsillitis), in a cubicle on a trolley, learning forward, taking measured breaths with his
mouth open. Your next steps:

a. History, vitals and examination are suggestive of peritonsillar abscess. Establish large bore iv
access, administer antibiotics and steroids, and perform Peritonsillar abscess drainage.

b. History, vitals and examination are suggestive of retropharyngeal abscess. Establish large bore iv
access, administer antibiotics and steroids, and order a lateral soft tissue neck x-ray. Refer to ENT.

c. History, vitals and examination are suggestive of epiglottitis. Transfer the patient to the
resuscitation room, establish large bore iv cannula, start antibiotics. Involve critical care and ENT.
Keep difficult airway trolley ready.

d. History, vitals and examination are suggestive of epiglottitis. Transfer the patient to resus,
establish large bore iv cannula. Administer benzodiazepine for anxiolysis and conduct careful
examination with good lighting and tongue depressor.
18. True or false: Most deep neck infections originate from an odontogenic source, usually maxillary
teeth.

a. True

b. False

19. 22 year old female attends ED with a sore throat and haemoptysis, 6 days post tonsillectomy.
She is not on anticoagulants. She has been using paracetamol and ibuprofen for pain. Her vitals are
within normal limits. On examination, you can see blood trickling from the left tonsillar bed. What
are you next steps?

a. Give the patient water to rinse and spit, and to drink. Sit them upright, leaning forwards. Refer to
ENT.

b. Keep the patient NPO, and in left lateral decubitus. Attach monitoring, send blood for crossmatch.
Administer IV tranexamic acid and monitor for 4 hours. If bleeding continues, refer to ENT.

c. Prepare a mouth wash with normal saline containing 1 g tranexamic acid and ask the patient to
hold orally for 10 seconds, and then rinse. If bleeding continues, apply direct pressure with
adrenaline-soaked gauze.

d. Consult ENT early. Keep the patient NPO and upright. Monitor with pulse ox, maintain adequate
IV access. Obtain CBC, Coag studies, type and crossmatch blood. Apply direct pressure to bleeding
bed with 4x4 gauze soaked in lignocaine + adrenaline.

20. True or false: If patients with tracheostomy present with massive bleeding through or around the
tracheostomy, the first manoeuvre is to hyperinflate the cuff to control brisk bleeding while planning
operative intervention.

a. True

b. False

21. Which of these structures is at risk of injury during aspiration or incision and drainage of a
peritonsillar abscess?

a. internal jugular vein

b. lingual artery

c. carotid artery

d. hypoglossal nerve

22. Which of the following is part of treatment of acute angle closure glaucoma?

a. Aspirin
b. topical cycloplegics

c. acetazolamide

d. lateral canthotomy

23. Which of the following is true about orbital cellulitis?

a. Aspergillus is a common causative agent

b. Sinusitis is an uncommon precipitant

c. Haematogenous spread of bacteria is common

d. Pain with extraocular movements is a characteristic feature.

24. Which of the following is the most common cause of Ludwig’s angina?

a. Dental disease

b. Facial fractures

c. Tongue piercings

d. Tongue-bite

25. A 26-year-old female patient presents with complaints of fever, headache, and blurred vision.
Your examination is significant for bilateral oculomotor paralysis, and mild proptosis. Imaging reveals
cerebral venous thrombosis. Which venous sinus is likely to be affected?

a. sphenoid sinus

b. cavernous sinus

c. straight sinus

d. sagittal sinus

1. c 2. a 3. c 4. a 5. b
6. b 7. a 8. c 9. d 10. c
11. c 12. b 13. b 14.b 15. a
16. a 17. c 18. b 19. d 20. a
21. c 22. c 23. d 24. a 25. b