DFT-EMREE-ENT-15-10-2025-STUDYWITHMAXEMO

A 68 Y/O M with a Hx of T2DM presents with a 3-day history of severe, deep pain in his L ear & acute-onset L-sided facial drooping. O/E, he is unable to close his L eye or raise his L eyebrow. There are several small vesicles on an erythematous base noted on his L auricle & within the external auditory canal. Weber test lateralizes to the R ear. Neurological exam is otherwise unremarkable.What is the most likely diagnosis?

• Bell's Palsy

• Trigeminal Neuralgia

• Ramsay Hunt Syndrome

• Necrotizing Otitis Externa

• Acute Otitis Media with facial nerve involvement

Answer explanation

The classic triad of ipsilateral facial paralysis, severe otalgia, and a vesicular rash in the ear canal or on the auricle is pathognomonic for Ramsay Hunt Syndrome (Herpes Zoster Oticus). This condition results from the reactivation of the varicella-zoster virus in the geniculate ganglion of the facial nerve (CN VII).The patient's unilateral lower motor neuron facial palsy (inability to raise eyebrow) and vesicles are key features.

A 35 Y/O F c/o persistent, foul-smelling L ear discharge & progressive hearing loss. O/E: Otoscopy reveals a perforation in the attic region (posterosuperior quadrant) of the tympanic membrane, with white, cheesy debris visible within the middle ear.What is the most likely Dx?

• Chronic suppurative otitis media

• Malignant otitis externa

• Tympanosclerosis

• Glomus tympanicum

• Cholesteatoma

Answer explanation

This presentation is pathognomonic for a cholesteatoma. The key diagnostic clues are the location of the perforation in the attic (pars flaccida) and the visualization of "white, cheesy debris," which is accumulated keratin. A cholesteatoma is a destructive skin cyst that causes bony erosion, leading to chronic, foul-smelling otorrhea and progressive conductive hearing loss.

A 55 Y/O M c/o sudden hearing loss in his R ear x3D, associated with tinnitus and unsteadiness. He also notes progressive R-sided facial numbness over the last month. O/E: Otoscopy is clear. Weber test lateralizes to the L ear. Cranial nerve exam reveals ↓ sensation on the R side of his face and a subtle R-sided facial droop.What is the most appropriate next investigation to establish the underlying diagnosis?

• Pure tone audiogram

• Start high-dose oral corticosteroids

• CT scan of the temporal bones

• MRI of the brain and internal auditory canals with gadolinium

• Auditory brainstem response (ABR)

Answer explanation

The presence of unilateral sensorineural hearing loss accompanied by other focal neurological signs (trigeminal numbness - CN V, and facial weakness - CN VII) is a major red flag for retrocochlear pathology, specifically a lesion in the cerebellopontine angle like a vestibular schwannoma. A gadolinium-enhanced MRI is the gold standard for visualizing soft tissue structures in this region and is the critical next step to rule out a tumor.

A 52 Y/O F with a Hx of hypertension, for which she is poorly compliant with medication, is brought to the ER for a 2-hour, profuse nosebleed. She c/o gagging on blood. O/E, BP is 165/95 mmHg, HR 105 bpm. Active bleeding is noted from both nares and in the posterior oropharynx. Initial attempts to control the bleeding with anterior nasal packing have failed. Coagulation studies are pending but initial Hb is 11.2 g/dL.What is the most appropriate next step in management?

• Cauterize Kiesselbach's plexus with silver nitrate

• Administer IV tranexamic acid and observe for 30 minutes

• Perform posterior nasal packing with a balloon catheter

• Immediately consult for endoscopic sphenopalatine artery ligation

• Discharge with instructions for nasal saline and follow-up

Answer explanation

The clinical picture strongly suggests posterior epistaxis (bleeding in the pharynx, failure of anterior packing). The immediate, necessary step to control the hemorrhage is to place a posterior pack, for which a balloon catheter (e.g., Foley or specialized epistaxis balloon) is a standard and effective method. This provides direct tamponade to the likely source.

A 24 Y/O university student c/o sore throat, nasal congestion, & rhinorrhea x3D. She denies fever, myalgia, or significant fatigue. O/E, T=37.4°C, HR=78/min, RR=16/min. Nasal mucosa is edematous & erythematous with clear discharge. Pharynx is mildly injected without exudates. Lungs are clear to auscultation.Which of the following is the most likely causative organism?

• Influenza A virus

• Rhinovirus

• Streptococcus pyogenes

• Respiratory Syncytial Virus (RSV)

• Adenovirus

Answer explanation

Rhinovirus is the most common cause of the common cold (acute viral rhinitis). The patient's presentation of afebrile upper respiratory symptoms (sore throat, congestion, rhinorrhea) without systemic features like myalgia or high fever is classic for a rhinovirus infection.

A 48 Y/O F presents with a 4-month Hx of unilateral otitis media with effusion and a growing mass in her neck. A biopsy of a suspicious lesion in the nasopharynx is performed. The pathologist reports sheets of undifferentiated large epithelial cells with indistinct cell borders, vesicular nuclei, and prominent eosinophilic nucleoli, admixed with a heavy, non-neoplastic infiltrate of lymphocytes and plasma cells.This characteristic histopathological pattern is best described as which of the following?

• Keratinizing squamous cell carcinoma

• Lymphoepithelioma

• Adenoid cystic carcinoma

• Olfactory neuroblastoma

• Hodgkin lymphoma

Answer explanation

The description of large, undifferentiated malignant epithelial cells syncytially arranged within a dense lymphoplasmacytic stroma is the classic definition of lymphoepithelioma. This is the histological appearance of WHO Type III (undifferentiated) nasopharyngeal carcinoma, the subtype most strongly and consistently associated with EBV infection.

28 Y/O F c/o recurrent, episodic vertigo & nausea lasting 30 mins to a few hours, occurring several times a year. She is asymptomatic between episodes. She also reports a sensation of fullness & progressive hearing loss in her L ear. O/E: Nystagmus is absent between attacks. Audiometry shows L-sided sensorineural hearing loss.What is the most likely Dx?

• Benign Paroxysmal Positional Vertigo (BPPV)

• Vestibular neuritis

• Meniere's disease

• Acoustic neuroma (Vestibular schwannoma)

• Labyrinthitis

Answer explanation

Meniere's disease is the classic diagnosis for the triad of episodic vertigo (lasting minutes to hours), unilateral sensorineural hearing loss, and tinnitus or aural fullness. The patient's age, recurrent nature of attacks, and associated auditory symptoms are hallmark features.

A 6 Y/O M presents with fever and sore throat. O/E: T 38.3°C. Tonsils are erythematous without exudates. No tender anterior cervical lymphadenopathy is noted. The patient also has a cough. Based on the Modified Centor criteria, his score is calculated to be 2.What is the most appropriate next step in management?

• Prescribe a 10-day course of oral amoxicillin

• Advise symptomatic treatment only with paracetamol and fluids

• Perform a rapid antigen detection test (RADT)

• Administer a single dose of intramuscular benzathine penicillin G

• Obtain a Monospot test

Answer explanation

A Modified Centor Score of 2 indicates an intermediate risk (15-20%) of Group A Streptococcus (GAS) infection. In this situation, clinical judgment alone is insufficient. The recommended guideline-based approach is to perform a confirmatory test like an RADT to guide the decision on antibiotic use, thus avoiding unnecessary prescriptions while not missing a true bacterial infection.

A 6-month-old boy is brought to the paediatric clinic by his mother with concerns about his development. She notes that while his motor skills seem appropriate for his age and he babbles normally, he consistently fails to startle or respond to loud noises. Pregnancy Hx was unremarkable, and he was born full-term with no complications. O/E: The infant is alert, interactive, and has normal motor tone. Vitals are stable. In the absence of other risk factors or syndromic features, what is the most common underlying etiology for this patient’s suspected condition?

• Congenital cytomegalovirus (CMV) infection.

• Chronic otitis media with effusion.

• Perinatal asphyxia.

• Non-syndromic genetic hearing loss.

• Maternal rubella infection.

Answer explanation

Genetic factors are the most common cause of congenital sensorineural hearing loss, accounting for over 50% of cases. In a child with an unremarkable prenatal/perinatal history and no other physical findings (non-syndromic), an underlying genetic cause (e.g., mutations in the GJB2 gene for connexin 26) is the most probable etiology.

A 15 Y/O M presents to the ED after a direct blow to his R ear during a rugby match. He c/o significant pain and a feeling of fullness. O/E, the superior aspect of the R auricle is diffusely swollen, tender, and boggy, with loss of the normal cartilaginous landmarks. The overlying skin has a violaceous hue. The tympanic membrane is normal on otoscopy.What is the most appropriate initial management for this patient?

• Prescribe oral antibiotics and analgesia.

• Apply warm compresses and observe for 24 hours.

• Incise and drain the hematoma, followed by a pressure dressing.

• Provide reassurance and discharge with follow-up if symptoms worsen.

• Obtain a CT scan of the temporal bone to R/O fracture.

Answer explanation

Immediate drainage (via incision or needle aspiration) is crucial to relieve pressure and allow the perichondrium to re-adhere, restoring blood flow to the cartilage. A pressure dressing (e.g., a dental roll bolster) is essential to prevent re-accumulation.