ENT QUESTIONS WITH EXPLANATIONS

FOR MIST MCQ BOOK ( 2020)

TOTAL NUMBER OF QUESTIONS – 140

4 SECTIONS

A. EAR 50 QUESTIONS
B. LARYNX 35 QUESTIONS
C. NOSE & SINUSES 35 QUESTIONS
D. PHARYNX 20 QUESTIONS
EAR

1. The most common site of cholesteatoma in middle ear is

a. Epitympanum

b. Mesotympanum

c. Hypotympanun

d. Prussak’s space

Cholesteatoma is skin in middle ear cleft. It is pearly white in colour

The most common cause of cholesteatoma is retraction pockets( primary

acquired chlesteatoma).

Prussak’s space in epitympanum is the commonest site of cholesteatoma

formation in middle ear.

Boundaries of Prussak’s space:

Superior – Fibers of lateral malleolar fold
Inferior –lateral process of Malleus
Lateral – Shrapnell’s membrane
Medial: neck of malleus
2.Identify the prosthesis given in the picture used in treatment of serous
otitis media

a. Ossicular Prosthesis

b. Partical repositioning manoeuvre

c. Microwick assisted transtympanic Gentamicin Injection

d. Grommet

In glue ear, grommet= middle ear ventilation tube is placed in tympanic

membrane after doing myringotomy in anteroinferior quadrant.

Glue ear= (serous otitis media= secretory otitis media)

Is accumulation of non purulent serous fluid in the middle ear.

Its Incidence highest in School going children due to ET blockage due to

adenoid hypertrophy

symptoms

- conductive Hearing loss

- Delayed speech development

- heaviness in the ear

Otoscopy :-Tympanic membrane

- dull Retracted TM with

- Air fluid level behind / bubbles

INVESTIGATIONS

• Pure tone audiometry : Conductive Hearing loss (10-40 dB)

• Impedance audiometry : Type B curve.

TREATMENT . Myringotomy and grommet insertion in the anteroinferior

quadrant of tympanic membrane. Also, adenoidectomy is an important part of
Treatment
 3. What type of tympanogram is seen in glue ear ( given in the picture)?

a. Type A curve

b. Type B Curve

c. Type C Curve

d. Type AD curve

Tympanometry = Impedance audiometry curves

Type A--- Normal

Type B-- Glue Ear ( it is a flat curve)

 Type C--- Negative middle ear pressure/ retracted TM

Type Ad---- ossicular dislocation

Type As----- otosclerosis

4.A patient of right unsafe CSOM has presented with history of

diplopia and pain behind the right eye. What is the name of this
entity?

a. Gradinego Syndrome

b. Malignant Otitis externa

c. Lateral sinus thrombosis

d. Trotter’s Triad

Gradinego syndrome= petrositis is a triad of ear discharge, retroorbital pain( V

nerve) and diplopia due to VI nerve involvement. It is a complication of CSOM.

Trotter’s triad is a feature of Nasopharyngeal carcinoma. It has temporoparietal

pain, palatal palsy and unilateral conductive hearing loss.

5.Which statement is False regarding Bell’s palsy?

a. Forehead muscles are not paralysed
b. Hyperacusis is seen in these cases
c. Oral Steroids are used for treatment
d. There are 85 % chances of recovery of facial function

Bell’s palsy is idiopathic sudden onset lower motor neuron facial palsy. It is
mostly unilateral.

In lower motor neuron facial palsy, forehead muscles are also involved .
(Supranuclear spares the forehead).
 Herpes simplex is being postulated as an aetiology for Bell’s palsy. Steroids
are the main stay of management. A patient who reports within first three
days should be given acyclovir as well. Care of the eye is a very important
part of management to prevent exposure keratopathy. Chances of recovery in
Bell’s palsy are 85% and above.

6.Patient has the complaint of right sided hearing loss and left ear hearing
is normal.

 Tuning fork tests show that Rinne is Negative on right side and
positive on left side.

 Weber test is lateralised towards right ear.

 Absolute bone conduction (ABC) test is normal on both sides

What is the interpretation?
a. Right conductive hearing loss
b. Right sensorineural hearing loss
c. Normal hearing on both sides
d. Right mixed hearing loss

Tuning Fork Test

Tuning fork of 512Hz is ideal. Forks of lower frequency produce sense of bone
vibration while those of higher frequency have a shorter decay time

To test AC - A vibratory fork is placed vertically about 2cm away from the
opening of EAM
AC tests the function of both conducting mechanism & the cochlea. Normally,
hearing through air conduction is louder & heard twice as long as through bone
conduction route.
To test BC - Footplate of vibratory fork is placed firmly on the mastoid bone.
Cochlea is stimulated directly by vibrations conducted through skull bone. BC is a
measure of the cochlear function only

1. Rinnie Test : In this AC. of the ear is compared with its BC. It is +ve when AC >
BC ( normal / SN HL ). It is negative Rinne when
BC > AC which is seen in conductive deafness

2. Weber Test : Normally, it is heard equally in both ear

Lateralised to the worse ear in conductive deafness. Lateralised to the better ear
in SN deafness

3. Absolute bone conduction (ABC) test ABC is poor in SNHL.

7.What is Cupula in inner ear?

a. Sensory end organ of Utricle and saccule

b. Sensory end organ of semicircular canals
c. gelatinous layer around Macula
d. gelatinous layer around Crista

crista is the sensory end organ of semicircular canals . it is lying in the ampulla of
canals. It is surrounded by a gelatinous layer called cupula.

Macula is the sensory end organ of utricle and saccule. It has otoconia or otoliths
which are calcium carbonate crystals in the gelatinous layer of macula. They are
concerned with the function of linear balance.

8. A child is born with deformed pinna. ( see picture)

What is the name of this deformity?

a. Bat ear
b. Cauliflower ear
c. Tropical ear
d. Surfer ear

Bat ear is a cosmetic deformity in which antihelix is poorly developed. The plastic
reconstruction is done after 6 years of age because pinna grows fully by that
time.

Cauliflower ear= boxer ear is due to post traumatic necrosis of pinna cartilage

Tropical ear = swimmer ear is diffuse otitis externa.

Surfer ear is exosteosis of external auditory canal which is hyperplasia of bony

EAC.

9. Which membrane separates Scala Vestibuli and Scala Media?

 a. Basilar membrane
b. Reissner’s membrane
c. Tectorial membrane
d. Sharpnell’s membrane

Basilar membrane separates Scala Media and Scala Tympani

Reissner’s membrane separates Scala Vestibuli and Scala media

Tectorial membrane covers Organ of corti

Sharpnell’s membrane= pars flaccida

Secondary tympanic membrane= round window membrane

10.Wet Newspaper’ like appearance in external auditory canal is a feature

of
a. Localised otitis externa
b. Otomycosis
c. Exosteosis
d. Diffuse otitis externa

This kind of appearance is seen in otomycosis. This is the appearance of fungal

mass in the EAC which appears as wet piece of paper. Most common fungus to
cause it is Aspergillus niger.

11.One of the following is a feature of meniere’s disease

a. Presbyacusis
b. Paracusis
c. Diplacusis
d. Hyperacusis
Diplacusis : patient is able to perceive same sound in two different frequencies. It
is seen in meniere’s disease patient.

Paracusis Willisi … patient hears better in noisy areas. It is a feature of

otosclerosis.

Hyperacusis …intolerance to loud sound.. it is seen in Bell’s palsy.

Presbyacusis is age related hearing loss.

12.Name the audiological investigation In which this type of ear probe is

used to record echoes from cochlear outer hair cells.

a. Cortical evoked response audiometry

b. Brainstem evoked response audiometry
c. Pure tone Audiometry
d. Otoacoustic emissions

Otoacoustic emissions are cochlear echoes emitted by outer hair cells on acoustic
stimulation. This is ideal hearing screening investigation for neonates.

Brainstem evoked response audiometry ( BERA) is the electrical activity

produced in auditory pathway on acoustic stimulation. This is used for hearing
assessment in children and malingerers.

Pure tone audiometry is subjective method of assessment of hearing thresholds

in air conduction and bone conduction in 250 to 8000 Hz frequency.

13. A 50 year old male patient presenting with hearing loss complaint
on left side was subjected to audiometry. His audiogram is shown
below
 What is the most possible diagnosis?
a. Sensorineural hearing loss (SNHL)
b. Normal Hearing
c. Conductive hearing loss
d. None of the above

Both air conduction and bone conduction are poor , hence this audiogram is
depicting sensorineural hearing loss.

If in audiogram , AC is poor and BC is normal and there is AB gap which is

indicative of conductive hearing loss.

14.What is Bill’s bar?

a. A landmark for Mastoid Antrum

b. A landmark for endolymphatic sac
c. A Vertical bony septum in Internal Auditory meatus
d. A horizontal crest on medial wall of middle ear
Bill’s bar is a vertical bony septum in the upper part of internal auditory canal . It
divides this compartment into two – one for facial nerve in anterosuperior
compartment and other for superior vestibular nerve in posterosuperior
compartment. The lower compartment has cochlear and inferior vestibular
nerve.
15.A patient of head injury suffered hearing loss. He has normal tympanic
membrane Ossicular disclocation.

How much conductive hearing loss is expected in this patient?

a. 30 dB b. 38dB c. 54 dB d. 10 dB

Hearing loss in different situations

 Ossicular Dislocation with Intact TM- 54 dB

 Ossicular Dislocation with perforated TM- 38 dB
 Glue Ear – 10-40 dB
 Wax—30 dB

16.Which is not found on the medial wall of middle ear?

a. Promontry
b. Pyramid
c. Secondary tympanic membrane
d. Oval window

Pyrmaid lies on posterior wall of middle ear

Promontory lies on medial wall of middle ear

Promontory is projection of basal turn of cochlea on medial wall of

middle ear

Donaldson’s line is l surgiclandmark for endolymphatic sac

Mcevan’s triangle ( suprameatal triangle) is landmark for mastoid

antrum

Korner septum is a variation and a remnant of petro squamous

suture. If present, it leads to difficulty in finding the mastoid antrum
during mastoid surgery

Round window membrane is secondary tympanic membrane. It lies

 on medial wall of middle ear

Canal for tendon of tensor tympani lies on anterior wall of Middle

ear.

17.Mohan, 22 year old, male gives history of right sided ear discharge,
foul smelling and occasionally blood stained for last 6 years. He also
complains of hearing loss for last 2 years. For last 3 days patient has
developed fever with chills, headache and pallor and oedema over
mastoid region. The most probable diagnosis is
a.Atticoantral CSOM with Meningitis
b. Atticoantral CSOM with Brain abscess
c. Atticoantral CSOM with Lateral sinus thrombosis
d. Atticoantral CSOM with subdural empyema

This is a case of lateral sinus thrombosis which is also called as sigmoid sinus
thrombosis. It is an intracranial complication of CSOM.

Lateral sinus Thrombosis

1. Pt develops spiky fever – PICKET FENCE FEVER
2. There is Headache and Pallor
3. GRIESSENGER SIGN - pitting oedema over mastoid due to blockage of
mastoid emissary vein
4. Absence of Rise of CSF pressure on pressing internal jugular vein. If this
phenomenon is seen on lumbar puncture , it is called TOBEY AYER TEST
and if seen on fundus – CROWE BECK TEST
5. CECT- Delta sign

18.Which of the following is not a feature of Otosclerosis?

a. Paracusis willisii
b. Carhart’s Notch
c. Schwatz sign
d. Rising Sun sign

Rising sun sign is a feature of Glomus Jugulare.

Paracusis Willisi means patient can hear better in noisy surroundings. This is a
feature of otospongiosis=otosclerosis.

Otosclerosis (Otospongiosis) –
A disease of bony labyrinth
* Irregularly laid spongy bone replace dense enchondral layer of bony otic
capsule
* Most commonly involves Stapes region - Stapes fixation & conductive
deafness
* Age of onset - 20 -30 yrs.
* The hearing loss increases during pregnancy

VAN DER HOEVE SYNDROME - Triad of blue sclera ,deafness ( Otosclerosis),

osteogenesis imperfacta

Symptoms :
1. Conductive hearing loss - Usually Bilateral and, progressive
2. ParacusisWillisii - Patient hears better in noisy than quiet surroundings

Signs : Tympanic membrane is normal in 90 percent cases. Rest 10 % show

Schwartz sign. Schwartz sign is flamingo pink appearance behind TM.
Schwartz sign is seen in early stage of the disease. Surgery is contraindicated
in Schwartz sign positive patients
 Pure tone audiometry shows a dip at 2000 Hz in BC which is called the
Carhart’s notch
 Carhart’s notch disappear after successful stapedectpmy.

Surgical - Stapedectomy is the t/t of choice. In Schwartz sign positive patients,

sodium fluoride is the treatment of choice.

Q.19.All are true about embryology of ear development except

a. cochlea development completes by 20th week
b. pinna development completes by 20th week
c. Mastoid tip is developed at the time of birth
d. Malleus Incus develop from First arch
Mastoid tip is absent at birth. It develops by 2 years of age. Hence, facial nerve
lies unprotected at the level of stylomastoid foramen in younger children.

Malleus and incus develops from first branchial arch. Stapes develops from
second arch.

Pinna develops from first and second arch. Tragus develops from first arch, rest
of pinna develops from second arch.

EAC develops from first branchial cleft and eustachian tube from first branchial
pouch.

Cochlea develops from neuroectoderm (otic capsule). Pinna and cochlea develop
by 20th week.

Middle ear ossicles and cochlea are fully grown at the time of birth

20.All are clinically applicable statements to glomus Jugulare except

a. Rising Sun Sign

b. Brown Sign
c. Biopsy from middle ear mass is diagnostic
d. Pulsatile tinnitus is present

Glomus jugulare originates from glomus cells lying around the jugular bulb.

It’s a benign non capsulated locally invasive highly vascular tumour. It erodes the
floor of middle ear and start appearing in the middle ear as red vascular mass
(Rising sun sign).

It is more common in females. It spreads on skull base which leads to erosion of

septum between carotid canal and jugular foramen (Phelp sign).

Biopsy is contraindicated. Preoperative embolisation helps to reduce blood loss

during surgery.
21. A 5 year old patient presents with the history of hearing loss. On examination
he is found to have a pearly white mass behind the intact tympanic membrane.
What is the most possible diagnosis?
a. Congenital cholesteatoma
b. Otomycosis
c. Otosclerosis
d. Exosteosis

Cholesteatoma is the ectopic presence of skin in the middle ear cleft. It can be due
to retraction pockets( primary acquired) or due to marginal perforation
( secondary acquired). Rarely it can be congenital. Pearly while mass in this
question denotes the appearance of cholesteatoma. Intact tympanic membrane
denotes that it is congenital.

22. A patient of left atticoantral CSOM presents with the history of

headache, vomiting and convulsions. His CT scan of brain has revealed left
temporal lobe abscess. What is the best surgical treatment of this patient?

a. Urgent modified radical mastoidectomy

b. Urgent radical mastoidectomy
c. Neurosurgical treatment
d. Urgent petrosectomy

Condition Treatment of choice

1. Atticoantral CSOM ( unsafe - MRM

CSOM)
-
2. Unsafe CSOM with Hearing loss
- MRM
3. Unsafe CSOM with Vertigo
- MRM
4. Unsafe CSOM with Facial Nerve
- MRM
 Paralysis -

5. Unsafe CSOM with Labyrinthine - MRM

fistula
- MRM
6. unsafe CSOM with Acute
Mastoiditis

7. Unsafe CSOM with Brain Abscess - Referred to Neuro surgeon

-
8. Unsafe CSOM with Subdural
Empyema - Referred to Neurosurgeon

9. Unsafe CSOM with Extradural

abscess - MRM + open the dural plate &
10. Unsafe CSOM with Sigmoid drain the Abscess
sinus Thrombosis - MRM + open the sinus plate &
clear the thrombus

23.The most common complication of Chronic Suppurative otitis media (CSOM)

is

a. Meningitis
b. Mastoiditis
c. Facial Palsy
d. Labyrinthitis

Mastoiditis is the most common complication of CSOM. Meningitis is the most

common intracranial complication of CSOM.
Unsafe CSOM= atticoantral CSOM is associated with complications due to bone
eroding properties of cholestatoma. Cholesteatoma causes bone erosion due to
inflammatory osteitis and by secreting bone destroying enzymes.

24.A 75 year-old diabetic patient presents with severe pain in the ear and facial
palsy. Examination reveals granulation tissue in external auditory canal. What is
the probable diagnosis?

a. Malignant otitis externa

b. Keratosis obturans

c. Squamous cell carcinoma ear canal

d. Exosteosis of External auditory canal

.Malignant otitis externa= Skull base osteomyelitis

It is infection of bony EAC which is part of skull base, therefore this disease
is actually skull base osteomyelitis

It is caused by pseudomonas and it is seen in elderly diabetics.

There are granulations is the external auditory canal which leads to blood
stained ear discharge. Patient has severe ear ache.

Cranial nerve palsies (7, 9-12) can be there – facial nerve is the most commonly
involved nerve

Treatment:

o antibiotics (3rd Generation cephalosporins)

25.All of the following are ototoxic drugs except

a. Chloroquine

b. Amikacin
c. Cisplatin

d. Cinnarazine

Ototoxic drugs--

1. Aminoglycosides :

A. Vestibulotoxic drugs: damage hair cells of crista

Streptomycin , gentamicin, tobramycin

B. Cochleotoxic drugs: damage outer hair cells of cochlea

Neomycin, kanamycin, amikacin

2. Loop diuretics: cause oedema of stria vascularis

furosemide, ethacrynic acid

3. Analgesics: salicylates ( aspirin)- indomethacin Ibuprofen

4. Antimalarials --quinine-chloroquine

5. Anticancer drugs : cisplatin carboplatin

6.Chelating agent: desferroxamine

7. Antibiotics:Vancomycin, erythromycin

Ototoxicity involves high frequencies more than the low frequencies. Therefore
high frequency audiometry is useful in its diagnosis
26.Infection of CNS spreads to inner ear through:

a. Cochlear aqueduct

b. Endolymphatic sac

c. Vestibular aqudeuct

d. Ductus reuniens

1.Perilymph ( inner ear)

aqeduct of cochlea

subarachnoid space (csf)

2.Stria vascularis of cochlea

endolymph

endolymphatic duct and sac

 High Na ions and low K in perilymph

 High K and low Na ions in endolymph

3.Ductus reuniens connect cochlea to saccule.

27. Total ossicular replacement prosthesis

is used for improvement of hearing when

a) Malleus is absent

b) Malleus and incus are absent

c) Malleus incus and stapes head are absent

d) All ossicles are present

PORP ( Partial ossicular replacement prosthesis) is used in ossicular situation

when malleus and incus are absent

TORP ( Total ossicular replacement prosthesis) is used in ossicular situation

when malleus , incus and stapes head are absent and only footplate is there.

28.Facial palsy features appearing one week after head trauma and fracture of
mastoid, intervention to be done is:

a) Facial Nerve Decompression

b) Electrophysiological nerve testing
c) Electrical stimulation of facial muscles
d) Oral Steroid for 3 weeks

In temporal bone fractures, the facial palsy is either of immediate or delayed

onset
Immediate onset need immediate surgery which is facial nerve
decompression and if need be end to end anastomosis or nerve grafting
 Delayed onset should be managed with 3 weeks of steroid therapy as the
cause is oedema in this case.

If there is no recovery after 3 weeks of steroid therapy, electrophysiological

nerve testing should be done. If test shows that there is significant facial
nerve degeneration, patient should be taken for surgery ( facial nerve
decompression)

29. A case of Bell’s palsy: no improvement after 3 weeks: What to do next?

a) Facial nerve decompression b) continue with same dose of steroids
c) Increase dose of steroids d) Electrophysiological nerve study

Bell’s palsy is idiopathic sudden onset lower motor neuron facial palsy.
In lower motor neuron facial palsy, forehead muscles are also involved .
(Supranuclear spares the forehead). Herpes simplex is being postulated
as an aetiology for Bell’s palsy.

Steroids are the main stay of management. A patient who reports

within first three days should be given acyclovir as well. Care of the eye
is a very important part of management to prevent exposure
keratopathy.

Chances of recovery in Bell’s palsy are 85% and above.

If there is no recovery after 3 weeks of steroid therapy, electrophysiological

nerve testing should be done. If test shows that there is significant facial nerve
degeneration, patient should be taken for surgery ( facial nerve decompression)

30.Treatment of choice in a c/o Otosclerosis with positive Schwartze's sign :

a) Stapedectomy b) Fenestration
c) Hearing Aid d) Sodium Flouride

In Otosclerosis, Tympanic membrane is normal in 90 percent cases. Rest 10 %

show Schwartz sign. Schwartz sign is flamingo pink appearance behind TM.
Schwartz sign is seen in early stage of the disease. Surgery is contraindicated in
Schwartz sign positive patients. Sodium Flouide is the treatment of choice in
Schwartz sign positive patients.

Sodium flouide increases osteoblastic and decreases osteoclastic activity. It has

inhibitory effect on proteolytic enzymes. Thus it helps in stablisation of
otosclerotic focus

31.Gradigego’s syndrome includes all except

a) Conductive hearing loss

b) Unilateral discharging ear
c) Diplopia
d) Retroorbital pain

Gradinego syndrome= petrositis is a complication of CSOM. There is an abscess at

petrous Apex which leads to involvement of V and VI cranial nerves.
There is a triad of
1. Ear discharge.
2. Retroorbital pain due to V nerve involvement
3. Diplopia due to VI nerve involvement.

HRCT of temporal bone will show abscess at petrous apex.

32.Hennebert's sign is a false positive fistula test when there is no evidence of

middle ear disease causing fistula of horizontal semicircular canal, it is seen
in
a. Congenital syphillis
b. Stapedectomy
c. Meniere's disease
d. Cholesteatoma

Fistula test is positive in labyrinthine fistula of lateral semicircular canal.

It is best seen using Seigel speculum or putting tragal pressure.

It is false negative in fistula covered by cholesteatoma & fistula in a dead

labyrinth
It is false positive in Congenital syphilis ( Heinnebert sign)
It is truly negative in a normal ear.

33.Epley’s manouvre is therapeutic of:

a) Meniere’s disease b) Acoustic neuroma
c) Benign Paroxysmal Positional Vertigo d) Sigmoid sinus thrombosis

Otoliths or otoconia are calcium carbonate crystals lying embedded in the

gelatinous layer of macula. Macula is the sensory end organ of utricle and saccule
whose function is linear balance.

BPPV ( Benign Paroxysmal Positional Vertigo)

 Displaced otoconia from macula is the aetiology
 Most commonly otoliths come to lie in posterior semicircular canal
 Dix hallpike’s test is diagnostic test.
 Epley’s maneuver is therapeutic which is particle repositioning maneuver

The vertigo is mostly transient in BPPV ( for few seconds) and there is no hearing
loss.

34.Rinne test is positive in

a. Wax occlusion of canal
b. Chronic suppurative otitis media
c. Otosclerosis
d. Presbyacusis

It is a tuning fork test .

Rinnie Test : In this AC. of the ear is compared with its BC.

It is +ve when AC > BC ( in normal and in sensorineural hearing loss SNHL ).

Presbyacusis is SNHL so Rinne will be + in this case

Rinne is negative in conductive hearing loss ( BC> AC). Rine is positive in

Sensorienural hearing loss ( AC>BC)

Choices a, b and c are causes of CHL where as Presbyacusis is age related SNHL.
35.False regarding Cochlear implant
(a) used for bilateral profound hearing loss
(b) The implant electrode is placed in Scala Media
(c) Speech therapy is required after implantation
(d) It delivers direct electrical stimulation to cochlear nerve endimgs

Cochlear Implant is a device that converts sound to electrical energy and directly
stimulates cochlear nerve fibres electrically ( normal 8th nerve is a must
criterion)

Patient selection
Bilateral profound hearing loss with no benefit seen with hearing aid

Parts of cochlear implant:

A.External parts
Microphone
Speech processor
Transmitter
Battery

B. Internal parts: Reciever stimulator =electrode

Better results are seen in post lingual deaf ( the one who turns deaf after
developing normal speech)

Insertion of electrode through round window membrane inro scala tympani of

cochlea.

Speech therapy is must after cochlear implantation

36.Which of the following would be the most appropriate treatment for

rehabilitation of a patient with bilateral profound sensorineural loss
following surgery for bilateral acoustic schwannoma?
(a) Bilateral high powered digital hearing aid
(b) Bilateral cochlear implants
(c) Unilateral cochlear implant
(d) Brain-stem implant
Cochlear Implant is a device that converts sound to electrical energy and directly
stimulates cochlear nerve fibres electrically ( normal 8th nerve is a must
criterion).

In this case both side 8th nerve has been damaged, therefore the treatment of
choice will be brain stem implant.

Brain stem implant is placed on lateral recess of 4th ventricle .

The given patient is a case of Neurofibroma type 2 which has bilateral vestibular
schwannoma.

37. The posterosuperior retraction pocket, if allowed to progress, will lead to:
(a) Primary aquired cholesteatoma (b) Sceondaryaquired cholesteatoma
(c) Tympanosclerosis (d) Congenital Cholestatoma

Cholesteatoma is the ectopic presence of skin in the middle ear cleft. It can be due
to retraction pockets( primary acquired) or due to marginal perforation
( secondary acquired). Rarely it can be congenital.
Retraction pockets are the most common cause of cholesteatoma formation
( primary aquired). Retraction pockets of tympanic membrane are more
common in pars flaccida

38. Aim of mastoid surgery in unsafe CSOM which should receive First priority is:
(a) Making the ear dry (b) Improvement in hearing
(c) Preservation of hearing (d) Rendering the ear safe

Main aim of mastoid surgery in unsafe CSOM is to make the ear safe which means
that there should be no cholesteatoma in the middle ear cleft.

Mastoid surgry are of two types:

Canal wall down (CWD) procedures

modified radical mastoidectomy, radical mastoidectomy, atticotomy

Canal wall up (CWU) procedures

 cortical mastoidectomy ( schwartz operation), combined approach
tympanoplasty

39. A congenitally deaf child with bilateral profound sensorineural hearing loss
on radiological evaluation of cochlea and brain with MRI/CT scan has been found
to have normal eighth nerve on both sides. What is the best method of hearing
rehabilitation in this case.

a. cochlear implant
b. Digital Hearing aid
c. Auditory brain stem implant
d. Bone anchored hearing aid

Cochlear Implant is a device that converts sound to electrical energy and directly
stimulates cochlear nerve fibres electrically ( normal 8th nerve is a must
criterion)

Patient selection
Bilateral profound sensorineural hearing loss with no benefit seen with hearing
aid
Auditory brain stem implant is indicated in neurofibroma type 2 which has
bilateral vestibular schwannoma ( 8th nerve tumours)
40. All are true about serous otitis media except
a. 10-40dB conductive hearing loss
b. Very painful condition
c. Grommet insertion is helpful in its management
d. Flat tympanogram

Glue ear= (serous otitis media= secretory otitis media)

Is accumulation of non purulent serous fluid in the middle ear.

Its Incidence highest in School going children due to ET blockage due to

adenoid hypertrophy
symptoms
 - conductive Hearing loss
- Delayed speech development
- heaviness in the ear ( not painful)

Otoscopy :-Tympanic membrane

- dull Retracted TM with
- Air fluid level behind / bubbles

INVESTIGATIONS
• Pure tone audiometry : Conductive Hearing loss (10-40 dB)
• Impedance audiometry : Type B curve.

TREATMENT . Myringotomy and grommet insertion in the anteroinferior

quadrant of tympanic membrane. Also, adenoidectomy is an important
part of Treatment

41. Which tuning fork test is specifically used to diagnose otosclerosis?

a. Stenger test
b. Schwbach test
c. Gelle’s test
d. Rinne test

Gelle’s test is a special tuning fork test used to diagnose otosclerosis. This test
sees the effect of seigelisation on the bone conduction of sound signal.

Bing test is also another tuning fork test used to diagnose otosclerosis.

Schbach test is nearly similar to absolute bone conduction test

42. Which of the following isapplicable to Carhart’s notch seen in Otosclerosis?

a. Dip at 2000 Hz in Bone conduction
b. Dip at 200HZ in Air conduction
c Dip at 4000Hz in Air conduction
d. Dip at 40000 Hz in Bone Conduction

 Dip at 2000 Hz in BC curve is seen in Otosclerosis ( Carhart’s Notch)

 Dip at 4000 Hz in AC and BC curve in audiogram is suggestive of noise

induced hearing loss. This is called acoustic dip.

 Meniere’s disease has rising audiogram as it causes low frequency SNHL in

early stages. It is mostly unilateral.

 Presbyacusis has sloping audiogram as age causes high frequency hearing

loss in early stages in both ears.

43. Which type of audiogram is seen in early stage of Meniere’s disease

a. Sloping Audiogram
b. Rising audiogram
c. Dip at 4000Hz in AC BC
d. Dip at 2000 Hz in BC

 Dip at 2000 Hz in BC curve is seen in Otosclerosis ( Carhart’s Notch)

 Dip at 4000 Hz in AC and BC curve in audiogram is suggestive of noise

induced hearing loss. This is called acoustic dip.

 Meniere’s disease has rising audiogram as it causes low frequency SNHL in

early stages. It is mostly unilateral.

 Presbyacusis has sloping audiogram as age causes high frequency hearing

loss in early stages in both ears.
44. The surgical landmark for Mastoid antrum during mastoid surgery is
a. Donaldson’s line
b. MacEwen’s triangle
c. Trautmann’s triangle
d. Korner septum

Boundaries of Macewen's triangle = suprameatal triangle

 Superiorly: Suprameatal crest
 Anterior-inferiorly: Posterosuperior wall of external auditory canal
 Posteriorly: A tangential line to posterior canal wall

It is a surgical landmark for mastoid antrum.

45. Otoliths are concerned with which function of inner ear?

a. Sound Conduction
b. Angular Balance
c. Linear balance
d. Sound Amplification

Otoliths or otoconia are calcium carbonate crystals lying embedded in the

gelatinous layer of macula. Macula is the sensory end organ of utricle and
saccule whose function is linear balance.

BPPV ( Benign Paroxysmal Positional Vertigo)

 Displaced otoconia from macula is the aetiology
 Most commonly otoliths come to lie in posterior semicircular canal
 Dix hallpike’s test is diagnostic test.
 Epley’s maneuver is therapeutic which is particle repositioning maneuver

The vertigo is mostly transient in BPPV ( for few seconds) and there is no hearing
loss.

46. A 43 year old male patient is suffering from recurrent epiosdes of vertigo ,
hearing loss and Tinnitus for last 3 years. The episode has nausea vomiting
 along with vertigo. The episode settles in few hours only. What is the
possible diagnosis?
a. benign Paroxysmal positional vertigo
b. Meniere’s disease
c. Acoustic neuroma
d. viral Labyrinthitis

Meniere’s disease is an episodic disease with three features

1. Tinnitus
2. vertigo with nausea vomiting
3. hearing loss.

The episode ends within 24 hours. It is also called endolymphatic hydrops.There

is high endolmph volume due to poor absorbtion by endolymphatic sac.

47. Which ossicle has least blood supply?

a. Handle of Malleus
b. Foot plate of Stapes
c. Long process of Incus
d. Head of Malleus

Incus has no muscle attached to it, hence it has least blood supply. Therefore, it is
more vulnerable to be eroded in CSOM.

Tensor tympani muscle attaches to malleus and is supplied by mandibular

division of trigeminal nerve.

Stapedius is attached to stapes and is supplied by facial nerve.

48. Putsatile Tinnitus with bleeding polypoidal red mass in external auditory
canal of a female patient is typically seen in :
a) Glomus Jugulare
b) Acoustic Neuroma
c) Meniere’s disease
 d) Tympanosclerosis

Glomus jugulare is a highly vascular tumour which originates from glomus cells
lying around the jugular bulb. It is more common in females

It’s a benign non capsulated locally invasive highly vascular tumour. It erodes the
floor of middle ear and start appearing in the middle ear as red vascular mass
(Rising sun sign). Later, it spreads to external auditory canal.

Chief complaint:

1. pulstaile tinnitus
2. bleeding ear mass

Biopsy is contraindicated

49. A 30 year old lady has bilateral hearing loss since 4 years which worsened
during pregnancy. Type of impedence audiometry curve will be :
a) Ad
b) As
c) B
d) C

This is a case of otosclerosis as hearing loss worsening during pregnancy is

typical of this disease

Tympanometry = Impedance audiometry curves

Type A--- Normal
Type B-- Glue Ear ( it is a flat curve)
Type C--- Negative middle ear pressure/ retracted TM
Type Ad---- ossicular dislocation
Type As----- otosclerosis
50. While syringing for the ear wax, the cold water should not be used . What is
the appropriate reason for this ?
a. it may lead to perforation of tympanic membrane
b. it may lead to vertigo
c. it may lead to infection of external auditory canal.
d. it may make the wax hard and difficult to remove.

Syringing for was removal

Water should be directed in posterosuperior direction . We must use lukewarm

water. Cold water stimulation may lead to vertigo.
LARYNX
1.Which of the following is main tensor of the vocal cord:
a) Cricothyroid b) Posterior crioarytenoid
c) Interarytenoid d) Lateral criocoarytenoid

Intrinsic muscles of larynx

 Abductor posterior cricoarytenoid

 Adductors
1. Lateral cricoarytenoid
2. Inter-arytenoid
3. Cricothyroid
4. Thyro-arytenoid
 Tensor
1. . Cricothyroid ( main tensor)
2. Vocalis

2.Ideal treatment for Reinke’s Oedema

(a) antibiotics and steroids (b) steroids only
(c) speech therapy (d) decortication of cords

(Reinke's oedema)

* Due to oedema of subepithelial space of the VC (Reinke's space)

Causes – Smoking ( most common), vocal abuse

Hoarseness is the common symptom,

T/t : Decortication of the VC

Also advice cessation of smoking

3. Most common laser used in laryngeal surgery is?

A. Argon laser
B. Nd YAG laser
C. CO2 laser
D. KTP laser

Carbon dioxide laser is the best laser used for laryngeal procedures. This is the
invisible laser and an aiming beam is used to target this laser on to the
tissues . its wavelength is 10,600nm.

4. A 45 year old female was operated for emergency appendicectomy under

general anesthesia. After surgery she is complaining of hoarseness of voice. What
can be the most probable aetiology?

a) Injury to Vagus nerve

b) Injury to Diaphragm
c) Intubation Granuloma
d) Functional aphonia

 This patient was given general anaesthesia. Therefore intubation granuloma is

the most probable cause of this situation. It is an iatrogenic entity.

They are bilateral and form at the junction of anterior 2/3 rd and posterior1/3rd of
vocal cords. They are surgically removed 9 Microlaryngeal surgery)

5. A young child comes to emergency with stridor and respiratory distress for
last 6 hours. On Direct laryngoscopy, the vocal cords are found to be lying in
median position and are immobile. Which of the following would not be part
of the management strategy of this patient—

a. Type I thyroplasty
 b. Laser cordectomy
c. Emergency Tracheostomy
d. Suture lateralization of vocal cord

This is a case of bilateral abductor palsy. The immediate treatment will be

emergency tracheostomy. Then we wait for 6 months, if patient shows no
recovery, then the treatment of choice is vocal cord lateralization (type 2
thyroplasty). Other treatment for this entity is CO2 laser cordectomy.

Type 1 thyroplasty is done in the case of bilateral adductor palsy

TYPE I MEDIALISATION OF CORD done

in adductor palsy
TYPE II LATERALISATION OF CORD done
in abductor palsy
TYPE III SHORTENING/LOOSENING done
is puberphonia
TYPE IV LENGTHENING/TIGHTENING
done in androphonia

6. In a child with suspected diagnosis of epiglottitis Indicate your first line

treatment
(a) Order an X-ray of soft tissue lateral view neck to establish the diagnosis
(b) Take throat swab and blood culture and start intravenous fluids
(c) Perform a laryngoscopy
(d) Secure an airway by intubation

Acute Epiglottitis is an airway emergency.

In any airway problem, the first treatment is to establish the airway first

Aute Epiglottitis (syn. Acute supraglottitis/ supraglottic laryngitis)

Acute inflammatory condition of the supraglottic structures:

Organism; Sreptococci> H. Influenza - type B

Features:
a. Age group : 2-7 yrs
b. Onset: abrupt
c. Rapid progression : over a few, hours
d. Starts with URI
e. Fever (sometimes> 40 degree)
f. Sore throat and dysphagia
g. Drooling of saliva
h. Voice not affected or may be plummy
i. Child prefers sitting position with outstretched hands (tripod sign)
j. thumb sign on X-ray of soft tissues of neck

Treatment:
 Intubation/ tracheostomy ( airway)
 I/v antibiotics (ampicllin/chloramphenicol/cefotaxime)
 I/v steroids

7. Treatment of choice of vocal nodule is :

a) Microlaryngeal surgery (MLS) b) Oral Steroids
c) Cryotherapy d) speech therapy

VOCAL NODULE =singer’s nodules= scremaer’s nodules= teacher’s nodules

Bilaterally symmetrical
Seen in: teachers, singers/ actors,

Site: junction of anterior 1/3 with posterior 2/3rd

Etiology: Overuse and improper use of voice

Treatment: Speech therapy or voice rest

8. Phonation in dysphonia plica ventricularis is produced by:

(a) True vocal cords
(b) False vocal cords
(c) Ventricle
(d) Palatopharyngeal fold

Dysphonia plica ventricularis

Voice production is by false cords . it is a voice disorder.

False vocal cords= ventricular bands are rudimentary structures in supraglottis.

9. A patient of T3NoMo carcinoma larynx has undergone total

laryngectomy. He has permanent tracheostomy following this surgery. HE
is using the device given in picture for vocal rehabilitation.

What is the name of this device?

a. Electrolarynx device
b. Blom Singer prosthesis
c. Esophageal speech device
d. Panje Device

Electrolarynx or artificial larynx is a hand held battery operated device with a

vibrating disc. It is used for voice production after total laryngectomy

Blom singer prosthesis is a tracheoesophageal puncture device. It is a one way

valve surgically placed between trachea and esophagus.

It is used for vocal rehabilitation after laryngectomy. It sends air from trachea to
esophagus which is used to produce voice. But it does not let the food particles to
go from esophagus to trachea so aspiration is not significant

10. A 52 year old female patient underwent total thyroidectomy. While

surgery, both side superior laryngeal nerves got damaged. What are the
expected post operative symptoms of patient?
a. poor quality of voice
b. respiratory distress & Aspiration
c. respiratory distress with poor quality of voice
d. respiratory distress with normal voice
External branch of SLN supplies cricothyroid muscle . Cricotyroid muscle is the
main tensor of vocal cord which gives us quality of voice. In this case we see
bowed down vocal cords due to loss of tension.

11. 6 year old child presented to ENT OPD with the chief complaint of
hoarseness of voice for last 6 months which is progressively increasing in
severity. There is no history of vocal abuse. What is the most probable
diagnosis?

a. Vocal nodules
b. Juvenile papilloma of larynx
c. Reinke’s edema
d. Vocal Polyp

Juvenile papillomas of larynx is caused by HPV-6,11. The infection is transmitted

from mother at the time of birth.They can spread downwards to trachea bronchi
lungs.

Typically seen in young children with chronic hoarseness and +- respiratory

distress.

CO2 laser is the treatment of choice. Recurrences are common after surgery.
They are premalignant

12. One month old Child presents with difficulty in breathing since day
seven of birth, which on making the patient prone, improves. The
probable diagnosis is Larygomalacia. What would be the ideal
management
a) Intubation b) tracheostomy
c) Reassurance to parents d) epiglottopexy

Laryngomalacia

 Most common congenital anamoly of larynx

 Excessive flaccidity of supraglottic larynx , AE folds are weak

  Inspiratory stridor increases on crying relieved in prone position

 Cry is normal

 Fibreoptic laryngoscopy -- Omega shaped epiglottis

 No treatment required. It usually disappears by 2 yrs of age. Reassure the

parents.

13. Which is the appropriate match is—

a. Type I Thyroplasty- Bilateral Adductor palsy

b. TypeIIThyroplasty- Puberphonia

c. Type III Thyroplasty- Androphonia

d. Type IV- Thyroplasty— Bilateral abductor palsy

TYPE I MEDIALISATION OF CORD done

in adductor palsy

TYPE II LATERALISATION OF CORD done

in abductor palsy

TYPE III SHORTENING/LOOSENING done

is puberphonia

TYPE IV LENGTHENING/TIGHTENING

done in androphonia

.
14.The immediate treatment of T3 NO M0 carcinoma larynx presenting with
respiratory distress and stridor is:
a) tracheostomy
b) Total laryngectomy with post op radiotherapy
c) Total laryngectomy
d) High dose steroids

this is a trap question--- and such questions are many where the problem is
highlighted in first part of the statement but the real thing is in the last part
of the statement of question. Kindly read the whole statement carefully when
questions sound simple and kind of expected..

This patient has respiratory distress and stridor. So, The answer here is
tracheostomy as airway is always the immediate concern .And do the high
tracheostomy in Ca larynx.

15.The ideal treatment for T1N0M0 glottic cancer larynx is

a. Radiotherapy
b. Laser cordectomy
c. Total laryngectomy
d. Decortication of vocal cord

Laryngeal carcinoma T1 and T2 – Radiotherapy is treatment of choice.

In recent literature, For T1 lesions, co2 laser has replaced radiotherapy as the
treatment of choice.

For T3 and T4 .. treatment of choice is total laryngectomy followed by

radiotherapy.

16. A case of carcinoma larynx with the involvement of Left vocal cord, left
aryepiglottic fold, left ventricular band and left vocal cord is immobile. Which of
the following statements is true for the managements of this case?

a) Horizontal partial laryngectomy and radiotherapy

b) Vertical partial laryngectomy and radiotherapy
c) Total Laryngectomy and radiotherapy
d) Radiotherapy alone
This is the stage T3 of cancer larynx as vocal cord is fixed. Therefore total
laryngectomy and radiotherapy is required in this case.

17. A chronic smoker presents with history of hoarseness. On examination he

was found to have keratosis of the larynx. All of the following are possible
treatment modalities except:
a) Laser
b) Partial laryngectomy
c) Elimination of chronic laryngeal irritants
d) Stripping of the vocal cord

It is a premalignant condition. It is due to smoking. it presents with

hoarseness of voice. On examination, there is plaquy/warty lesion over vocal
cord. The treatment is stripping of the vocal cords ( type1 cordectomy)
which can be done with laser as well. Laryngectomy is indicated in laryngeal
carcinoma.

18. Voice problems in public appearances is :

(a) Puberphonia (b) Mogiophonia
(c) Phonasthenia (d) Androphonia

 Mogiophonia is the voice problems in public appearances only ( for

example on mike)

 Dysphonia Plica Ventricularis is the production of sound from false vocal

cords.
 Rhinolalia clausa is hyponasality. This is due to nasal obstruction, nasal
polyp, sinusitis, adenoid hypertrophy, angiofibroma.
 Rhinolalia aperta is hypernasality. This is due to cleft
palate,palatalperforation,palatal palsy

 Puberphonia is high pitch voice in males

 Androphonia is low pitch voice in females

19.Laryngocele arises as a herniation of laryngeal Mucosa through the

following membrane
(a) Thyrohyoid (b) Cricothyroid
(c) Cricotracheal (d) Cricosternal

Saccule is a mucosal outpouching from ventricle which is the space between

true vocal cords and false vocal cords.

Laryngocele is a dilated saccule. It can appear in the neck as external

laryngocele by piercing thyrohyoid membrane.
20.Blom singer prosthesis is used for
(a) Ossicular reconstruction in tympanoplasty
(b) Stapeotomy surgery in otosclerosis
(c) Vocal Rehabilitation of laryngectomised patient
(d) Augmentation rhinoplasty in saddle nose

Blom singer prosthesis is Tracheoesophageal puncture device. It is used for

vocal rehabilitation of laryngectomised patient, it is a valve which is
surgically placed between trachea and esophagus.
For stapes surgery , an artificial Teflon or titanium stapes piston prosthesis is
used.
For ossiculoplaty, TORP, PORP ( total and partial ossicular replacement
prosthesis) is used

21.Turban epiglottis is seen in:

a) Syphilis b) Tuberculosis
c) Laryngomalacia d) Epiglottitis

TB larynx is a painful condition .It involves posterior part of larynx in early

stages.

Turban epiglottis and mouse bitten appearance of vocal cords are features of
tuberculosis of larynx. It presents with weakness of voice( 1st symptom) and
painful phonation.

22.The statement not true about Laryngeal Web is

a. Congenital anamoly
b. Cry is normal in the patient
c. CO2 Laser is helpful in its management
d. Most common site is Glottis

Laryngeal webs are congenital with the glottis being the most common site. The
cry is hoarse as the vocal cords are affected. The treatment is excision with Co2
laser.

23.Which of the following is not true about anatomy of larynx-

 a. Posterior cricoarytenoid muscle is the abductor of vocal cord
b. Epiglottis is an elastic cartilage
c. Cricoid is a complete ring like cartilage
d. Cricothyroid muscle is supplied by recurrent laryngeal nerve.

Cricothyroid muscle is supplied by external branch of superior laryngeal nerve.

Rest all laryngeal muscles are supplied by recurrent laryngeal nerve.

Epiglottis is elastic cartilage and it does not ossify with age.

Cricoid is ring like cartilage.

24.All are true about functional aphonia except

a) Cough sound is normal

b) More common in young females
c) Speech therapy is treatment of choice
d) Vocal cords are mobile

Functional aphonia (hysterical aphonia)

This is a psychological disease seen in young females. The presentation involves

the patient pretending the symptom of sudden loss of voice. Cough sound is
normal. Vocal cord movements are normal as well.

Treatment : Psychotherapy

25. Type of voice in nasopharyngeal angiofibroma is:

a) Rhinolalia aperta
b) Rhinolalia clausa
c) Hot-potato voice
d) Dysphonia Plica ventricularis
Rhinolalia clausa is hyponasality. This is due to nasal obstruction, nasal polyp,
si- nusitis, adenoid hypertrophy, angiofibro- ma.

Rhinolalia aperta is hypernasality. This is due to cleft palate,palatal

perforation,pal- atal palsy, palatal weakness ( velopharyn- geal insufficiency),
submucos cleft palate, bifid uvula.

Dysphonia Plica Ventricularis is the pro- duction of sound from false vocal
cords. Mogiophonia is speech defect in public ap- pearance only

Hot Potato voice = Plummy Voice Seen in Quinsy, paraphrayngeal abscess,

retropharyngeal abscess, prevertebral abscess, supraglottic and base tongue
cancer

26. A young man while having dinner suddenly becomes aphonic and develops
respiratory difficulty. What should be the appropriate management?

a) Intubation
b) Emergency tracheostomy
c) Humidified oxygen
d) Heimlich maneuver

Heimlich manoeuvre

Heimlich manoeuvre is sudden thrust directed upward and backwards below the
epigastrium. It squeezes the air from lungs, which dislodges the foreign body.
This manoeuvre should not be done if there is partial obstruction.

Cricothyroidotmy or emergency tracheosotomy is done if Heimlich maneuver

fails.

27. Which of the following airway obstruction level causes inspiratory stridor?

a. subglottic obstruction

b. supraglottic obstruction

c. glottic obstruction
d. tracheal obstruction

The stridor means noisy breathing. It is due to airway obstruction. Depending

on the level of obstruction, it is of three types.

28. Which of the following is abductor of the vocal cord:

a) Cricothyroid b) Posterior crioarytenoid

c) Interarytenoid d) Lateral criocoarytenoid

Intrinsic muscles of larynx

 Abductor posterior cricoarytenoid

 Adductors

5. Lateral cricoarytenoid

6. Inter-arytenoid
 7. Cricothyroid

8. Thyro-arytenoid

 Tensor

1. . Cricothyroid ( main tensor)

2. Vocalis

29. which of the following is the initial symptom of glottic malignancy?

a. Odynophagia

b. Dysphagia

c. Hoarse voice

d. Hot potato voice

The first symptom of any glottis ( =vocal cord) disorder will be hoarse voice.

The supraglottic cancer presents with dysphagia, throat pain referred to ear, hot
potato voice.

30. A 3month old baby presents with inspiratory stridor almost since birth. The
cry of baby is normal. The stridor decreases in prone position. What is the
possible diagnosis?

1. Vocal cord palsy

2. Acute epiglottitis

3. Acute laryngotracheobronchitis
 4. Laryngomalacia

Laryngomalacia

 Most common congenital anamoly of larynx

 Excessive flaccidity of supraglottic larynx , AE folds are weak

 Inspiratory stridor increases on crying relieved in prone position

 Cry is normal

 Fibreoptic laryngoscopy -- Omega shaped epiglottis

 No treatment required. It usually disappears by 2 yrs of age. Reassure the

parents.

31. Which of the following can not be seen on indirect laryngoscopy

a. Anterior commissure

b. posterior commissure

c. Lingual surface of epiglottis

d. arytenoids

Indirect Laryngoscopy is done using a pre warmed indirect laryngoscopy mirror.

It does not show

1. anterior commissure

2. laryngeal surface of epiglottis

3. ventricle and saccule

4. undersurface of vocal cords and adjoining area of subglottis

5. apeax of pyriform sinus

6. post cricoids area

32. In carcinoma laynx patient with stridor and respiratory difficulty,

tracheostomy is done at which level ?
a. 1st and 2nd cervical vertebra level
b. 3rd and 4th tracheal rings
c. 1st and 2nd tracheal rings
d. 3rd and 4th tracheal rings

The usual level of tracheostomy is 2nd and 3rd rings. If we involve first ring,
it can cause subglottic stenosis later on.

High trachestomy means when it starts from first ring. It is only done in a case
of cancer larynx.

33. Which is the narrowest part of Infant larynx

a. Supraglottis
b. Subglottis
c. Glottis
d. Ventricle

In infants, larynx is high ( C2 C3 level) subglottis is narrowest part of larynx in

children.

In adults, Larynx is low in neck ( C3 to C6 level) and glottis is narrowest part

34. A 20 year old male patient has high pitch voice. His fiberoptic
laryngoscopy is normal. The clinician has advised him for speech therapy
What is the name of this manoeuvre for speech therapy?
a. Heimlich manoeuvre
b. Gutzmann’s manoeuvre
c. Muller’s manoeuvre
d. Valsalva manoeuvre

It is a case of Puberphonia. The patient needs speech therapy for few months.
The name of maneovure for speech therapy is Gutzmann’s maneovure. In this
maneovure, patient is asked to speak with pulling thyroid cartilage
downwards and pressing it backwards.

35. Which structure is not removed in Radical Neck dissection?

a. Internal Jugular vein
b. Sternocleidomastoid muscle
c. Accessory Spinal Nerve
d. Digastric muscle

Radical neck dissection is done to clear the secondary neck nodes in a case of
metastatic head and neck cancer.
NOSE AND PARANASAL
SINUSES
1. 16.Which of the following is best description of Pott’s puffy tumour?

a. tuberculosis of nose
b. Mucocele of frontal sinus
c. subperiosteal abscess of frontal bone
d. osteoma of frontal sinus

Pott’s puffy tumour is osteomyelitis of frontal bone which leads to

subperiosteal frontal abscess. It is a complication of frontal sinusitis, more
common in adults. Maxillary osteomyelitis is more common in children.

2. Target sign on filter paper is a feature of

a. CSF rhinorrhoea
b. Meningoencephalocele
c. Fracture mastoid
d. Traumatic CSF leak

Traumatic CSF leak is blood mixed CSF , so on filter paper it gives target
sign=halo sign.

Most common site of traumatic csf leak from nose is Fovea ethmoidalis. It is
seen in skull base fractures e.g. Nasoethmoid Fracture, Le Fort II, III fractures.
( not a feature of zygomatic and Le Fort I fractures)

A memory aid is:

 Le Fort I is a floating palate (horizontal)
 Le Fort II is a floating maxilla (pyramidal)
 Le Fort III is a floating face (transverse)

3. All of the following are true about CSF rhinorrhoea except

a. Cribriform plate is the commonest site of leak
b. Immediate transnasal endoscopic surgical closure of leak site should
be done
c. HRCT skull base is the radiological investigation of choice to detect
site of leak
d. Beta 2 transferrin is helpful in confirmation of diagnosis

Overall most common site of CSF rhinorrhea is cribriform plate. Most

common cause now a days is iatrogenic ( e.g. FESS). Second common cause is
traumatic CSF leak.

Beta-2 transferrin is the best confirmatory test.

 HRCT skull base helps to find out the site of leak. MRI T2 images area also
useful. Rarely invasive test like CT cisternography are required to find the site
of leak

It should be managed initially conservatively with bed rest and antibiotics. If

it does not resolve, surgical repair is planned.

4. The radiological presence of which paranasal sinus appears at 6 years of age

a. Maxillary sinus
b. Ethmoid sinus
c. Sphenoid sinus
d. Frontal sinus

5.A wide roomy nasal cavity with thick crust formation and bad odour from
nose is seen in
a) Atrophic Rhinitis b) Rhinosporidiosis
c) Rhinoscleroma d) Rhinitis sicca

Atrophic rhinitis.
Atrophic Rhinitis (=Ozeana)

It is progressive atrophy of mucosa, submucosa and underlying bones of nasal

cavity

Klebsiella ozaenae is possible aetiology

There are wide roomy nasal cavities, filled with crusts which emit bad smell.

Merciful anosmia is a symptom

Treatment

 Alkaline nasal douching ( Soda bicarbonate Sodium biborate , Sodium

chrolide.)
.
Surgical treatment of atrophic rhinitis
1. Lautenslager's operation:-
- Surgical procedures aimed at medializing the lateral nasal wall

2. Modified Young's operation:-

- partial closure of both nostrils leaving behind a 3m hole

Extra points to memorise

 Mulberry like nasal polyp is a feature of Rhinosporidiosis

 Mulberry like appearance of nasal mucosa is seen in Inferior

turbinate hypertrophy

 Strawberry appearance of nasal mucosa is seen in Sarcoidosis

 Strawberry gingiva means granular appearance of gums and it

6. A patient of suspected sinusitis has undergone CT scan of sinuses. The
radiologist reports an anatomical variation of posterior ethmoid air cell
lying in close proximity to optic nerve. Identify the cell.

a) Onodi cell
b) Haller cell
c) Conchal Bullosa
d) Agger Nasi

These are variations of ethmoidal air cells.

Haller cell is a variation of anterior ethmoid air cells and they lie in relation to
orbital floor.
Onodi cell is a variation of posterior ethmoid and lie in relation to optic nerve.
When present they can increase the chance of complications during FESS.

Another variation of ethmoid air cells is Concha bullosa which means

pneumatised middle turbinate.

7. All statements are true about Ringertztumour of Nose except

a. Arises from nasal septum
b. Locally invasive tumour
c. More common in males
d. Inverted Papilloma

Ringertz tumour is other name of inverted papilloma of nose. It is a benign but

locally invasive tumour and can show malignant conversion. It arises from lateral
wall of nose . Its more common in males in 40-70 years of age. Medial
maxillectomy will be ideal treatment for this locally invasive tumour as this will
remove its site of origin.

8. Which is not a true statement

a. Osteomas are most commonly seen in frontal sinus
b. Malignancy is most common in Maxillary sinus
c. Fungal balls are most common in Ethmoid sinus
d. Mucoceles are most common in Frontal sinus

 Fungal balls or aspergilloma are most commonly seen in maxillary sinus.

 Mucocecles are most common in frontal sinus.
 Osteomas are most common in frontal sinus.
 Malignancy is most common in maxillary sinus.
 Ethmoid bone is a single bone which lies between two orbits. Therefore,
ethmoid sinusitis is most likely to cause orbital infection.

9. Which statement is true about Ethmoidal polyp

a. better seen on posterior rhinoscopy
b. Endoscopic removal is the preferred treatment
c. More common in children
d. Recurrences are common after surgery

Recurrences are more common in Ethmoidal polypi after removal as they are
allergic in origin.

Antrochoanal polyp is more common in children and its better seen on posterior
rhinoscopy.

FESS/Endoscopic polypectomy is the treatment of choice for AC polyp. For

recurrent AC polyp

10.Which structure cannot be approached through transnasal endoscopic

surgery

a. Lacrimal Sac
b. Cribriform plate
c. Lacrimal gland
d. Optic nerve

Think about anatomy… lacrimal glands lie in lateral part of orbit. Lacrimal sac
can be approached through transnasal route and hence we do endoscopic DCR
( Dacryocystorhinostomy) these days for epiphora .

Also, the most common surgical approach for pituitary adenomas these days is
transnasal transspehnoid approach

11. A 62 year old man comes to emergency at 4.00 am with severe epistaxis
and high blood pressure (180/110mm Hg). Management of hypertension
started. But the epistaxis could not be controlled on anterior nasal packing
and posterior nasal packing. What is the next best management of this
patient--
a)Ligation of External carotid artery
a) Endoscopic ligation of Sphenopalatine artery
b) Foley’s catheter placement in the nose and inflate the bulb
c) Electocauterisation of Liitle’s area

The blood supply of nose. 80 % is from external carotid artery(ECA) and 20 % is

from Internal carotid artery (ICA) via anterior and posterior ethmoidal arteries.

Sphenopalatine artery is the most common source of epistaxis in hypertensive

patients. In case of intractable epistaxis, the next management should be
endoscopic spheopalatine artery ligation

12. A 7 year old child while playing fell down. He has developed nasal
blockage on both sides and there is swelling around the nose.
What is the further treatment of this child?
a. Aspiration of septal swelling
b. Anterior Nasal packing
c. Start Intravenous steroids
d. Start Topical Corticosteroid nasal spray

This is a cae of traumatic septal haematoma.

Septal hematoma is collection of blood between the perichondrium of nasal

septum and the septal cartilage. Nose is the most prominent part of the face and
hence is more prone for injuries resulting in a hematoma formation in the nasal
septum. It is generally bilateral. The dominant symptom is nasal obstruction.
The treatment of choice is immediate aspiration or drainage

13.All of the following lead to perforation of Cartilaginous part of nasal

septum except
a. Tuberculosis
b. Leprosy
c. Lupus
d. Syphilis

There are many causes of septal perforation.

1. most common cause is trauma
2. septal surgery
3. cocaine snorting
4. tuberculosis, leprosy ,Lupus cause perforation of cartilaginous part of septum
5. syphilis cause perforation of bony part of septum
6. wegner’s granulomatosis cause perforation of both parts of septm

Treatment—closure of perforation using septal buttons

14. A 27-year-old man presents with complaints of chronic nasal

congestion. For About 2 months , he is using oxymetazoline nasal
drops twice daily.
He has persistent nasal blockage .What is the most appropriate
treatment?
a. Discontinue oxymetazoline
b. Antibiotics
c. Oral antihistamine
d. Discontinue oxymetazoline and start steroid nasal spray

This is a case of Rhinitis medicamentosa. This is due to prolonged use of topical

decongestants which leads to rebound congestion

Treatment—stop using these nasal drops and start steroid nasal spray

15. A 29 year old HIV positive individual presents to emergency in a critical

state with deranged vitals. The examination shows a blackish necrotic
debris in the nasal cavity with necrosed skin of external nose. What is
the best treatment of this patient?
 a) Amphotericin B b) Nystatin
c) Itraconazole d) Clotrimazole

Mucormycosis (rhinocerebral phycomycosis):

Is an aggressive opportunistic fungal infection by Mucor/Rhizopus oryzae
Predisposing factors: immunosuppressed patients, uncontrolled young diabetics

Features:
1. Remarkable affinity for blood vessels- arteries
2. Leads to extensive endothelial damage & thrombosis

Findings:
The disease begins in the nose, invade  P.N.S  orbit  cribiform plate
meninges brain

Typical Finding
1. Black necrotic mass seen filling the entire nasal cavity
2. Erosion of the nasal septrum and the hard palate may be appreciable
There is anesthesia over face, nose with reduced mucosal bleeding

Treatment:
  Systemic amphotericin ( Liposomal)

16..Fracture of nasal bone; the ideal treatment is:

a) Immediate reduction
b) Reduction after 48 hours
c) Put POP cast only

d) Reduction after 7 days

The nasal bone fracture should be reduced immediately before edema starts.
This is done using Walsham forceps.

If patient comes late and edema has already started, then wait for 7 days for
edema to subside and then do reduction of fracture

17. A roomy nasal cavity filled with foul smelling crusts with disfigured hard
external nose is seen in

a) Atrophic Rhinitis

b) Rhinosporidiosis

c) Rhinoscleroma

d) Rhinophyma

The first stage of rhinoscleroma resembles atrophic rhinitis

Rhinoscleroma= Woody nose

Definition: Chronic, progressive granulomatous infection of external nose, nasal

cavity and upper lip area.

Organism: Klebsiella rhinoscleromatis (Gram negative: Frisch Bacillus).

It is more common in northern part of India

Clinical Picture:

1.Atrophic Stage

Atrophic changes occur in the floor of the nose, septum and turbinates. This stage
resembles atrophic rhinitis.

2. Granulomatous Stage:

Subdermal infiltration of the lower part of the external nose and the upper lip
(woody Nose)

3. Fibrosis Stage: in this stage due to fibrosis, patient develops cosmetic

deformity

Biopsy findings:

Mikulicz Cells:

Large foam cells with a central nucleus & vacuolated cytoplasm (contain the
bacilli)

Russell Bodies:

Eccentric nucleus and a pink- staining cytoplasm- Look like plasma cells.

Treatment:

1. Streptomycin

2. Tetracyline

18. The most common long term complication of Functional endoscopic sinus
surgery

a. Atrophic rhinitis

b. Anosmia

c. Intranasal synechiae formation

d. Intermittent nasal bleeds

The most common long term complication of any nasal surgery is synechaie
formation in nose (adhesions) .

Topical application of Mitomycin C is helpful to reduce synechiae formation since

this drug has antifibroblastic properties.

19. . What is the significance of given line in the image?

a. Total Maxillectomy in carcinoma of maxillary sinus

b. Partial Maxillectomy in carcinoma of maxillary sinus

c. Prognostic evaluation of carcinoma of maxillary sinus

d. Total laryngectomy in carcinoma of larynx

Ohngren’s line is from medial canthus of the eye to the angle of mandible. It is
used to assess the prognosis of carcinoma of maxillary sinus

This line divides maxilla into superstructure and infrastructure. The malignancy
of superstructure has poor prognosis due to proximity to orbit.
Weber fergusson incision is used for total maxillectomy in a patient of
carcinoma of maxillary sinus

20. A patient in ENT examination was found to be non responsive to smell of

coffee, tea and Asfoetida. He is able to respond to which agent/

a. clove oil

b. pipperment

c. Ammonia

d. Garlic

This is a case of anosmia. A patient of anosmia can sense ammonia which is

sensed through trigeminal nerve. Ammonia is not a smell , it is an irritant.

21. Onodi cells and Haller cells of ethmoid are related respectively to:

a) Orbital floor ,Optic nerve

b) Orbital floor, Internal carotid Artery

c) Nasolacrimal duct
d) Optic nerve, orbital floor

These are variations of ethmoidal air cells.

Haller cell is a variation of anterior ethmoid air cells and they lie in relation to
orbital floor.

Onodi cell is a variation of posterior ethmoid and lie in relation to optic nerve.

Another variation of ethmoid air cells is Concha bullosa which means

pneumatised middle turbinate.

Few points about normal ethmoid air cells

 Anterior ethmoid air cells are from 2-8.Posterior ethmoid air cells are 1-8

 Agger nasi is the anterior most anterior ethmoidal air cell.

 Bulla ethmoidalis is the most constant and largest anterior ethmoid air cell

22. Which of the following is not correct statement

a. Sphenoid sinus drains into sphenoethmoidal recess

b. In DCR surgery, lacrimal sac opening is made in inferior meatus

c. Anterior ethmoid cells drain into middle meatus

d. Posterior ethmoid air cells drain into superior meatus

The natural opening of nasolacrimal duct is in inferior meatus. The surgical
opening of lacrimal sac in Dacryocystorhiostomy ( DCR) surgery is made in
middle meatus. This surgery is done for chronic dacryocystititis.

 Maxillary, frontal sinuses and anterior ethmoid sinuses drain into

middle meatus

 Posterior ethmoid air cells drain into superior meatus

 Sphenoid sinus drains into sphenoethmoidal recess.

23. Identify the Finding shown in NCCT of Nose and Paranasal Sinuses
( marked with arrow)

a. Bulla Ethmoidalis

b. Haller cell

c. Concha Bullosa

d. Onodi cell

29. B Haller cell

Three variations of ethmoidal air cells.

a. Haller cell is a variation of anterior ethmoid air cells and they lie in
relation to orbital floor.
 b. Onodi cell is a variation of posterior ethmoid and lie in relation to
optic nerve.

c. Another variation of ethmoid air cells is Concha bullosa which

means pneumatised middle turbinate.

24. A 39 year old male patient presenting with mulberry like nasal l mass ( see
the image) and epistaxis. What is the possible diagnosis?

a. Angiofibroma

b. Rhinoscleroma

c. Rhinosposridiosis

d. Rhinophyma

Rhinosporidiosis

Organism : Rhinosporidium seeberi—

Rhinosporidium seeberi is an aquatic protozoa

Distribution: India (Southern parts), Sri lanka

Sites

1. Most commonly: Nose

2. Others: oral cavity, conjunctiva, genital mucosa

The disease is transmitted through contaminated water of ponds

Lesions:

Mulberry like polypoidal mass in the nose with epistaxis is typical presentation

Diagnosis: Biopsy

Treatment:

Complete excision of the mass with a cutting diathermy and cauterization of its
base.

Medical management: Dapsone is a useful drug to prevent recurrence

25. Keisselbach’s plexus in Little’s area of septum gets contribution from all
these arteries except-

a. Anterior Ethmoidal artery

b. Posterior Ethmoidal artery

c. Sphenopalatine artery

d. Greater Palatine artery

Keisselbach’s plexus is made by superior labial, greater palatine, sphenopalatine

and anterior ethmoidal arteries.

It lies in Little’s area on septum which is the most common site of epistaxis

26. The anterior most anterior ethmoidal air cell is called as

a. Bulla Ethmoidalis b. Agger Nasi

c. Concha Bullosa d. Onodi cell

 Anterior ethmoid air cells are from 2-8.Posterior ethmoid air cells are 1-8

 Agger nasi is the anterior most anterior ethmoidal air cell.

 Bulla ethmoidalis is the most constant and largest anterior ethmoid air cell.

Variations of ethmoid air cells

a. Haller cell is a variation of anterior ethmoid air cells and they lie in
relation to orbital floor.

b. Onodi cell is a variation of posterior ethmoid and lie in relation to

optic nerve.

c. Another variation of ethmoid air cells is Concha bullosa which

means pneumatised middle turbinate.

27. In a patient of resistant epistaxis from left nasal cavity, even the bleeding
could not be controlled with external carotid artery ligation.

What is the possible source of bleeding in this patient?

a. Maxillary artery

b. Sphenopalatine artery

c. Ethmoidal artery

d. Facial artery

Think about the blood supply of nose. 80 % is from external carotid artery(ECA)
and 20 % is from Internal carotid artery (ICA) via anterior and posterior
ethmoidal arteries.

Since ECA has been tied, only remaining circulation is from ethmoidal arteries
Sphenopalatine artery is the most common source of epistaxis in hypertensive
patients.

Rendu Osler Weber disease, also called as hereditary hemorrhagic telengectesia

presents with recurrent epistaxis. Septodermoplasty means removal of nasal
mucosa and grafting with skin to treat recurrent epistaxis in this condition

28. Deviated Nasal Septum can lead to all of the following except

a. Headache b. Sinusitis

c. Nasal polyp d. Hyposmia

Deviated nasal septum can lead to nasal obstruction, crust formation in nose,
epistaxis, hyposmia, sinusitis, headache, external nasal deformity

But it can nit lead to atrophic changes in nose, nasal polyp formation

Nasal polypi form due to allergy or infection as a result of chronic inflammation.

DNS can not lead to polyp formation.

29. All of the following are true about Rhinosporidiosis except

a. Dapsone is the drug of choice in this condition

b. Can involve oral cavity, conjunctiva along with nose

c. Russell bodies and Mikulicz cells are characteristic histopathological

features

d. Rhinosporidium seeberi , its causative organism ,is being recently

described as an aquatic protozoa
Russell bodies and Mikulicz cells are histopathological features of Rhinoscleroma
and NOT rhinosporidiosis

Rhinosporidiosis

Organism : Rhinosporidium seeberi—

Rhinosporidium seeberi is an aquatic protozoa

Distribution: India (Southern parts), Sri lanka

Sites

1. Most commonly: Nose

2. Others: oral cavity, conjunctiva, genital mucosa

The disease is transmitted through contaminated water of ponds

Lesions:

Mulberry like polypoidal mass in the nose with epistaxis is typical presentation

Diagnosis: Biopsy

Treatment:

Complete excision of the mass with a cutting diathermy and cauterization of its
base.

Medical management: Dapsone is a useful drug to prevent recurrence

30. Which of the following does not contribute to formation of nasal septum

a. Crest of palatine bone

b. Spine of maxilla

c. Spine of sphenoid

d. Spine of frontal bone

Septum is made of 7 components

A.3 Major

1. septal cartilage

2. perpendicular plate of ethmoid

3. Vomer

B. 4 minor

1. spine of maxilla

2. spine of frontal bone

3. rostrum of sphenoid

4. crests of palatine and maxillary bones

31. Mulberry like appearance of nasal mucosa is seen in

a. Rhinosporidiosis

b. Rhinoscleroma
 c. Inferior turbinate hypertrophy

d. Atrophic rhinitis

Mulberry like nasal polyp is a feature of Rhinosporidiosis

Mulberry like appearance of nasal mucosa is seen in Inferior turbinate

hypertrophy

Strawberry appearance of nasal mucosa is seen in Sarcoidosis

Strawberry gingiva means granular appearance of gums and it is seen in

wegner’s granulomatosis

32.Modified Young’s operation is indicated for

(a) Vasomotor thinitis (b) Atrophic rhinitis

(c) Rhinitis sicca (d) Rhinitis caseosa

Atrophic Rhinitis (=Ozeana)

It is progressive atrophy of mucosa, submucosa and underlying bones of nasal

cavity

Klebsiella ozaenae is possible aetiology

There are wide roomy nasal cavities, filled with crusts which emit bad smell.

Merciful anosmia is a symptom

Treatment
  Alkaline nasal douching ( Soda bicarbonate Sodium biborate , Sodium
chrolide.)

Surgical treatment of atrophic rhinitis

1. Lautenslager's operation:-

- Surgical procedures aimed at medializing the lateral nasal wall

2. Modified Young's operation:-

- partial closure of both nostrils leaving behind a 3m hole

33. In fracture maxilla most common nerve involved is

a. Infra orbital nerve

b. Supraorbital nerve

c. Trochlear nerve

d. Mandibular nerve

In Fracture Maxilla, zygomatic fracture andcarcinoma of maxillary sinus, there is

involvement of infraorbital nerve which leads to cheek anaesthesia
34. All of the following open into middle meatus except:
a) Maxillary sinus b) Sphenoid sinus

c) Frontal recess d) Anterior ethmoidal air cells

 Maxillary, frontal sinuses and anterior ethmoid sinuses drain into

middle meatus

 Posterior ethmoid air cells drain into superior meatus

 Sphenoid sinus drains into sphenoethmoidal recess.


 The natural opening of nasolacrimal duct is in inferior meatus. The
surgical opening of lacrimal sac in Dacryocystorhiostomy ( DCR)
surgery is made in middle meatus. This surgery is done for chronic
dacryocystititis.
 35. Specific indicator to identify CSF:

a) Sugar content b) Protein content

c) Globulins d) 2 transferrin

Overall most common site of CSF rhinorrhea is cribriform plate.

Most common cause now a days is iatrogenic ( e.g. FESS).

Second common cause is traumatic CSF leak.

Beta-2 transferrin is the best confirmatory test for CSF rhinorrhoea.

HRCT skull base helps to find out the site of leak.

MRI T2 images area also useful.

It should be managed initially conservatively with bed rest and antibiotics. If it

does not resolve, surgical repair is planned.
PHARYNX
1.All of the following are part of Laryngopharynx (=Hypopharynx) except

a. Post Cricoid area

b. Pyriform sinus

c. Vallecula

d. Posterior Pharyngeal wall

Hypopharynx= laryngopharynx

It has 3 parts

1. Pyriform sinus right and left

2. post cricoids area

3 . posterior pharyngeal wall.

Anterior pillar , posterior pillar, palatine tonsil, posterior one third tongue,
Vallecula lingual tonsil, soft palate, uvula are parts of oropharynx.

So, Vallecula is a part of oropharynx

2. A 17 years old male patient underwent tonsillectomy on Monday. His post

operative period was uneventful. He was discharged on next day. On Sunday
morning, he has presented in the Emergency Department of hospital with the
complaint of mild bleeding from oral cavity.

What is the best further management?

a. It is normal to have mild bleeding in post operative period, so
patient can be reassured and sent home .
b. Admission and antibiotics
c. Admission and Immediate Re-exploration in operation theatre
d. Start Oral Hematinics

This is a case of secondary haemorrhage.

(i) Reactionary hemorrhage is seen after 24 hours of tonsillectomy. It is due to

slippage of ligature and it should be immediately re-explored under GA.

(ii) Secondary hemorrhage is seen after 5th day of tonsillectomy. It is due to

infection of tonsillar fossa and is managed with I/V antibiotics.

(iii) Primary Haemorrhage is during surgery

3. All of the following are true about Trotter’s triad in Nasopharyngeal

Carcinoma except

a. Palatal palsy

b. Temporo-parietal Neuralgia

c. Conductive Hearing loss

d. Sensorineural Hearing loss

Trotter’s triad is a feature of Nasopharyngeal carcinoma.

It has temporoparietal pain ( due to 5th nerve involvement), palatal palsy ( due to
10th nerve involvement) and unilateral conductive hearing loss ( due to
serous otitis media).

4. The investigation of choice for a 12- year- old male child presenting with
polypoidal mass in the nose, which bleeds on touch is:

a) CECT scan

b) CT scan

c) Biopsy

d) CECT scan + Angiography

Angiofibroma is the most common benign tumour of nasopharynx seen in

adolescent males. ‘

It originates from sphenopalatine foramen.

It’s a highly vascular tumour.

CECT scan shows Hollman Miller ( =Antral) sign.

Angiography is also done .

Surgery is treatment of choice.

Debulking or biopsy of this tumour is never done as it is a highly vascular

tumour.

5. All are true about Ludwig’s angina except

a. Trismus is a feature

b. Tracheostomy may be required

c. Submandibular space infection

d. Staphylococcus aureus is the causative organism

Ludwig’s angina is infection of floor of mouth= submandibular space caused due

to dental infections. ‘

The bacteriology is mixed- streptococci and anaerobes.

Patient has chin swelling, trismus and occasionally respiratory distress. The
treatment is by incision and drainage externally deeper to mylohyoid muscle.
Occasionaly, tracheostomy may be needed .

6. A young Child operated for Adeno-tonsillectomy has developed atlantoaxial

subluxation. What is the possible diagnosis in this case?

a. Kallman’s syndrome

b. Grisel Syndrome

c. Ortner syndrome

d. Eagle syndrome

Grisel’s syndrome, defined as subluxation of the atlanto-axial joint, not

associated with trauma or bone disease, is found primarily in children. This
syndrome has been observed after otolaryngologic procedures such as
adenoidectomy. It presents with torticollis, neck.

Kallmann’s syndrome

Anomia with hypogonadism

Eagle syndrome = styalgia

Long styloid process pressing glossopharyngeal nerve presenting with throat

pain radiating to ear.

Ortner syndrome

Left atriomegaly casing left recurrent laryngeal nerve palsy

7. What is the commonest presentation of nasopharyngeal carcinoma?

a. Unilateral Conductive hearing loss

b. Cervical lymphadenopathy

c. Nasal obstruction

d. Epistaxis

Nasopharngeal cancer is occult hidden primary. This patient most commonly

presenting with metastatic neck node. = secondary neck node= neck mass.

This cancer is caused by EB virus

Chenoradiation is the treatment of choice

8. Oropharyngeal picture of a patient with Trismus, plummy voice and dysphagia

is shown in the given image. What is the possible diagnosis?
 a. Quiencke’s disease
b. Quinsy
c. Parapharyngeal abscess
d. Retropharyngeal abscess

34. B Quinsy
This is a case of quinsy=peritonsillar abscess.Tonsil is pushed medillay and uvula
is deviated to other side. This is classical feature of quinsy. There is NO outer
neck swelling in Quinsy. Patient has Trismus ( due to spasm of medial
pterygoid muscle), odynophagia, hot potato voice.

If similar history and examination findings are there along with neck swelling
close to angle of mandible, then the diagnosis is parapharyngeal abscess.

Acute retropharyngeal abscess - Commonly seen in children < 3yrs

* Results of suppuration of retropharyngeal LN
C/F : * Dysphagia & difficulty in breathing (prominent symp)
* Stridor

* Bulge in post. Pharyngeal wall (usually seen on one side of midline)

Xray STN lat. view - widening of prevertebral shadow
T/t – airway management,
I & D without GA, antibiotics

Quiencke’s disease is sudden idiopathic isolated angioedema

9. . In a patient of Quinsy, Trismus develops due to spasm of which muscle

a) Medial pterygoid

b) Lateral pterygoid

c) Masseter
 d) Temporalis

Quinsy=peritonsillar abscess.

In Quinsy, Tonsil is pushed medillay and uvula is deviated to other side.

There is NO outer neck swelling in Quinsy.

Patient has Trismus ( due to spasm of medial pterygoid muscle), odynophagia,

hot potato= plummy voice.

10. A patient, 23 year old has developed chin swelling with trismus following
right lower last molar infection. What is the most probable diagnosis?

a. Quiencke’s disease

b. Quinsy

c. Parapharyngeal abscess

d. Ludwig’s angina

Ludwig’s angina is infection of floor of mouth= submandibular space caused due

to dental infections. ‘
The bacteriology is mixed- streptococci and anaerobes.

Patient has chin swelling, trismus and occasionally respiratory distress. The
treatment is by incision and drainage externally deeper to mylohyoid muscle.
Occasionaly, tracheostomy may be needed .

11. What is the best treatment of reactionary hemorrhage after tonsillectomy?

a. wait and watch

b. immediate re-exploration

c. intravenous antibiotic

d. cold saline gargles

(i) Reactionary hemorrhage is seen within 24 hours of tonsillectomy. It is due to

slippage of ligature and it should be immediately re-explored under GA.

(ii) Secondary hemorrhage is seen after 5th day of tonsillectomy. It is due to

infection of tonsillar fossa and is managed with I/V antibiotics.

12. A patient with features of sore throat, fever, cervical lymphadenopathy and
oropharyngeal picture given in the image. What is the possible diagnosis?

a. Acute Streptococcal Tonsillitis

b. Diphtheric Tonsillitis
c. Oral Candidiasis

d. Ludwig’s angina

The whitish membrane extending beyond the tonsil, enlarges lymph nodes go in
favour of Diphtheria

CAUSES OF WHITISH MEMBRANE ON TONSIL

Acute membranous tonsillititis

Infectious mononucleosis

Diphtheria

Candidiasis

Vincent angina

Malinanacy of tonsil

Leukaemia

13. A 14 year old boy has presenting with recurrent episodes of profuse epistaxis
and reddish nasal mass is seen filling nasal cavity. What is the possible diagnosis

a. Nasopharyngeal cancer

b. Inverted papilloma

c. Thornwaldt disease

d. Angiofibroma

This is a case of Angiofibroma. Angiofibroma is the most common benign tumour

of nasopharynx seen in adolescent males. It originates from sphenopalatine
foramen. It’s a highly vascular tumour.

CECT scan shows Hollman Miller ( =Antral) sign. Surgery is treatment of choice.
Biopsy of this tumour is never done as it is a highly vascular tumour.

14. A 52 year adult patient presenting with right side hearing loss has been
subjected to audiological investigations and diagnosed to be a case of right sided
serous otitis media. What will be the priority in further management of this
patient?

a. Nasopharyngoscopy and biopsy

b. Myringotomy

c. Myringotomy and grommet insertion

d. Antibiotic and decongestant therapy

This is a suspected case of Nasopharyngeal carcinoma. The unilateral serous

otitis media in an adult patient should always arise the suspicion of
nasopharyngeal carcinoma. Hence, Nasopharyngoscopy should be done and
biopsy of any suspicious area should be taken.

Myringotomy and grommet insertion will be done at a later date when NPC is
ruled out.

15. Which virus has been implicated as an aetiological agent in nasopharyngeal

carcinoma?

A. EB Virus

b. Human papilloma virus

c. Herpes Simplex virus

d. Hepatitis C virus
Nasopharyngeal carcinoma is more common in China and this cancer is caused
by EB virus. It arises from Fossa of Rosenmuller

Nasopharngeal cancer is occult hidden primary. This patient most commonly

presenting with metastatic neck node. = secondary neck node= neck mass.

Chenoradiation is the treatment of choice

16. Type of voice in adenoid hypertrophy is:

e) Rhinolalia aperta
f) Rhinolalia clausa
g) Hot-potato voice
h) Dysphonia Plica ventricularis

 Rhinolalia clausa is hyponasality. This is due to nasal obstruction, nasal

polyp, sinusitis, adenoid hypertrophy, angiofibroma.

 Rhinolalia aperta is hypernasality. This is due to cleft

palate,palatalperforation,palatal palsy

17. A 6 year old child with the history of mouth breathing, mal-occlusion of teeth
and conductive hearing loss due to glue ear . Which of the following will be best
management plan for this patient?

a. Adenoidectomy

b. Myringotomy

c. Adenoidectomy with Myringotomy

d. Adenoidectomy with Myringotomy with grommet insertion

This is a typical case of glue ear arising due to adenoid hypertrophy which mostly
causes bilateral ET blockage.

This child would need adenoidectomy , Myringotomy with Grommet insertion.

18. In Nasopharyngeal carcinoma, which of the following is true about the
hearing loss in the patient?

a. Unilateral Sensorineural hearing loss due to 8th nerve involvement

b. Bilateral Sensorineural hearing loss due to 8th nerve involvement

c. Unlateral Conductive hearing loss due to serous otitis media

d. Bilateral conductive hearing loss due to secretory otitis media

Nasopharyngeal carcinoma will cause unilateral ET blockage and hence it will

lead to unilateral serous otitis media= glue ear. This causes unilateral conductive
hearing loss.

Trotter’s triad is a feature of Nasopharyngeal carcinoma.

It has temporoparietal pain ( due to 5th nerve involvement), palatal palsy ( due to
10th nerve involvement) and unilateral conductive hearing loss ( due to
serous otitis media).

19. All are applicable to Juvenile Nasopharyngeal Angiofibroma except

a. Hollman Miller Sign on CECT

b. Frog Face Deformity

c. Biopsy is diagnostic

d. Sphenopalatine foramen is the site of origin

Angiofibroma is the most common benign tumour of nasopharynx seen in

adolescent males. It originates from sphenopalatine foramen. It’s a highly
vascular tumour. There is proptosis in this child due to orbital extension which is
called Frog Face Deformity

Biopsy of this tumour is never done as it is a highly vascular tumour.

CECT scan shows Hollman Miller ( =Antral) sign. Surgery is treatment of choice.

20.. Killian’s dehiscence is an area of pharynx devoid of muscular support. It lies

amongst the fibres of which muscle ?

a. Superior constrictor

b. Palatopharyngeus

c. Inferior constrictor

d. Palatoglossus

Killian’s dehiscence is a weak area unsupported by muscles lying in between the

2 type of fibres of Inferior constrictor muscles. ( Thyropharyngeus and
cricopharyngeus)

Killian’s dehiscence is site of formation of Zenker’s Diverticulum= pharyngeal

pouch.

Also, it is a possible site of perforation during rigid endoscopy.