Diploma in Otolaryngology – Head and Neck Surgery (DO-HNS) (RCSI, Ireland)

A 4-year-old child presents with a 24-hour history of severe right ear pain, high fever of 39.5°C, and irritable behavior. Otoscopy reveals a bulging, intensely erythematous right tympanic membrane with loss of landmarks and visible purulent effusion behind it. What is the single best initial management step for this child, assuming no signs of systemic complications?

• AReassurance and watchful waiting for 48 hours
• BOral amoxicillin at 80-90 mg/kg/day split into two doses
• CImmediate referral for urgent myringotomy and grommet insertion
• DTopical ciprofloxacin-dexamethasone ear drops

A 22-year-old university student presents with right ear pruritus, mild discomfort, and a sensation of fullness after returning from a summer beach holiday. Otoscopy shows a narrowed external auditory canal containing white, fuzzy debris with black spores that resembles wet blotting paper. What is the most appropriate first-line treatment for this patient?

• ASystemic oral fluconazole for 7 days
• BAural toilet followed by topical clotrimazole or acetic acid drops
• CTopical ciprofloxacin ear drops for 7 days
• DOral amoxicillin-clavulanate for 10 days

A 68-year-old male with poorly controlled type 2 diabetes presents with deep, unrelenting right-sided otalgia that is worse at night, and persistent purulent otorrhea. Otoscopy reveals granulation tissue at the junction of the cartilaginous and bony parts of the external auditory canal. What is the most likely pathogen responsible for this condition?

• AStreptococcus pneumoniae
• BPseudomonas aeruginosa
• CStaphylococcus aureus
• DAspergillus fumigatus

A 32-year-old female presents with slowly progressive, bilateral hearing loss, which she notes is easier to tolerate in noisy environments (paracusis Willisii). Otoscopy shows normal, mobile tympanic membranes, though a faint pinkish blush is visible behind the left tympanic membrane. Audiometry confirms bilateral conductive hearing loss with a notch at 2000 Hz. Which surgical procedure is the treatment of choice for this patient?

• ACortical mastoidectomy
• BStapedotomy or stapedectomy
• CMyringotomy and grommet insertion
• DEndolymphatic sac decompression

A 45-year-old man presents with recurrent episodes of rotational vertigo lasting between 1 and 3 hours, accompanied by a roaring sound in his left ear and a sensation of pressure. Audiometric testing during an symptomatic phase demonstrates a low-to-medium-frequency sensorineural hearing loss in the left ear. What is the primary pathophysiological mechanism underlying this disease?

• AEctopic bone formation around the stapes footplate
• BEndolymphatic hydrops leading to distension of the membranous labyrinth
• CMigration of calcium carbonate crystals into the posterior semicircular canal
• DMicrovascular compression of the vestibulocochlear nerve in the cerebellopontine angle

A 58-year-old woman describes brief episodes of room-spinning vertigo lasting 20-30 seconds, triggered whenever she rolls over to the right side in bed or looks up to reach a high shelf. What is the gold standard diagnostic test to confirm the most likely diagnosis?

• AFrenzel goggles examination during head shake
• BDix-Hallpike maneuver
• CCaloric reflex test
• DVideo head impulse test (vHIT)

A 48-year-old man presents with progressive left-sided hearing loss and mild unsteadiness over the last 18 months. Audiometry shows a unilateral high-frequency sensorineural hearing loss in the left ear with poor word recognition scores. What is the diagnostic imaging modality of choice to evaluate this patient?

• AHigh-resolution non-contrast CT scan of the temporal bones
• BMagnetic resonance imaging (MRI) of the brain and internal auditory meatus (IAM) with gad…
• CPositron emission tomography (PET-CT) of the skull base
• DDuplex ultrasound of the carotid arteries

A 35-year-old male presents with sudden onset of complete right-sided facial weakness. On examination, he is unable to wrinkle his forehead, close his right eye fully, or smile on the right side. There is no otalgia, otorrhea, vesicles, or hearing loss. What is the most appropriate first-line medical therapy according to clinical consensus guidelines?

• AImmediate referral for surgical decompression of the facial nerve
• BHigh-dose oral corticosteroids (e.g., prednisolone 1 mg/kg/day) started within 72 hours o…
• CIntravenous acyclovir therapy alone
• DPhysical therapy and electrical nerve stimulation only

A 52-year-old female presents with severe pain in her right ear, vertigo, and a right-sided lower motor neuron facial nerve palsy. On physical examination, painful vesicular eruptions are observed on the right concha and within the external auditory canal. What is the causative organism of this clinical syndrome?

• AHerpes simplex virus type 1 (HSV-1)
• BVaricella-zoster virus (VZV)
• CEpstein-Barr virus (EBV)
• DCoxsackievirus A16

A 40-year-old woman presents to the emergency department complaining of sudden hearing loss in her left ear that occurred upon waking yesterday morning. She has associated mild vertigo and tinnitus. Audiometry confirms a 45 dB sensorineural hearing loss across three contiguous frequencies in her left ear. What is the initial treatment of choice?

• AReassurance and repeat audiometry in 4 weeks
• BImmediate initiation of oral corticosteroids (prednisolone) at 1 mg/kg/day
• CVasodilator therapy and hyperbaric oxygen therapy
• DMyringotomy and insertion of a grommet

A 28-year-old male with a history of recurrent ear infections presents with a foul-smelling, purulent discharge from his left ear and progressive hearing loss. Otoscopy reveals an attic retraction pocket filled with squamous debris and erosion of the posterosuperior canal wall. What is the primary concern that mandates surgical intervention?

• AProgression to malignant otitis externa
• BDestruction of middle ear structures and risk of intracranial complications
• CTransformation into a middle ear cholangiocarcinoma
• DPermanent occlusion of the Eustachian tube

A 74-year-old man presents with progressive, symmetric hearing loss. He reports difficulty understanding speech, particularly in crowded social situations with background noise, and complains of a high-pitched constant tinnitus. Audiometry reveals bilateral, symmetrical down-sloping sensorineural hearing loss at high frequencies. What is the most likely diagnosis?

• ABilateral vestibular schwannomas
• BPresbycusis
• COtosclerosis
• DAutoimmune inner ear disease

A 45-year-old factory worker who has worked without hearing protection for 15 years presents for a routine health check. An audiogram is performed and demonstrates a bilateral, symmetrical sensorineural hearing loss with a characteristic dip (notch) at 4000 Hz. What is the most likely etiology of this hearing pattern?

• AChronic ototoxicity from industrial solvents
• BNoise-induced hearing loss (NIHL)
• CCongenital connexin 26 mutation
• DCongenital rubella syndrome

A 24-year-old man is struck in the left ear by a flying squash ball. He immediately experiences sharp pain, transient dizziness, and a subjective drop in hearing. Otoscopy reveals a dry, linear 20% central perforation of the left tympanic membrane. What is the most appropriate first-line management?

• AImmediate referral for tympanoplasty under general anesthesia
• BPrescription of antibiotic ear drops and dry ear precautions, with review in 4-6 weeks
• CWater precautions alone, avoiding ear drops unless infection develops, and review in 4-6…
• DAural toilet and application of a paper patch in the outpatient clinic

A 29-year-old male scuba diver experiences sudden, severe right ear pain and vertigo during a rapid ascent from a depth of 20 meters. On examination in the clinic, he is noted to have a bulging, erythematous right tympanic membrane with dark fluid and air bubbles behind it. What is the most likely diagnosis?

• ADecompression sickness of the inner ear
• BMiddle ear barotrauma
• CAcute suppurative labyrinthitis
• DPerilymph fistula

A 54-year-old woman presents with persistent, right-sided pulsatile tinnitus synchronous with her heartbeat. Otoscopy reveals a reddish, pulsatile mass behind the anteroinferior quadrant of the intact tympanic membrane. Pneumatic otoscopy causes the mass to blanch (Brown sign). What is the most likely diagnosis?

• AOtosclerosis
• BGlomus tympanicum tumor
• CHigh jugular bulb anomaly
• DVestibular schwannoma

A 38-year-old woman describes episodes of vertigo and oscillopsia triggered by loud noises, such as a telephone ringing or a dog barking, and when she strains or coughs. She also reports autophony (hearing her own voice and eye movements abnormally loudly). High-resolution CT of the temporal bone is requested. What specific pathology is suspected?

• ASemicircular canal fistula due to cholesteatoma
• BSuperior semicircular canal dehiscence (SSCD)
• COtosclerosis affecting the oval window
• DVestibular neuritis

A 5-year-old child with bilateral profound sensorineural hearing loss since birth is evaluated for cochlear implantation. The child has achieved minimal benefit from appropriate hearing aids worn for 6 months. Which of the following is an absolute anatomical contraindication to cochlear implantation?

• APartial ossification of the basal turn of the cochlea
• BComplete aplasia of the cochlea (Michel deformity)
• CEnlarged vestibular aqueduct
• DBilateral chronic serous otitis media

A 42-year-old man is brought to the emergency department following a high-speed motor vehicle collision. He has a hematoma over his left mastoid (Battle's sign) and bleeding from his left ear canal. CT of the head reveals a temporal bone fracture. On exam, he has a conductive hearing loss on the left side, but his facial nerve function is completely intact. What type of temporal bone fracture is most likely present?

• ATransverse temporal bone fracture
• BLongitudinal temporal bone fracture
• COblique temporal bone fracture
• DOccipital-mastoid diastasis

A 45-year-old man presents with severe, constant left-sided ear pain of 3 weeks' duration. He has no otorrhea, vertigo, or hearing loss. Otoscopy, tympanometry, and cranial nerve examination are entirely normal. However, on examination of the oral cavity, a 1 cm ulcerated lesion is noted on the left lateral border of the tongue. What is the anatomical explanation for this patient's ear pain?

• AReferred pain via the auriculotemporal branch of the trigeminal nerve (CN V)
• BReferred pain via the tympanic branch of the glossopharyngeal nerve (CN IX)
• CReferred pain via the auricular branch of the vagus nerve (CN X)
• DReferred pain via the greater auricular nerve (C2/C3)

A 32-year-old female presents with severe left-sided ear pain and swelling. Examination reveals tenderness when pressure is applied to the tragus and when the auricle is gently pulled. The external auditory canal is diffusely edematous and erythematous, with scanty watery discharge. The tympanic membrane is partially visible and appears normal. What is the most appropriate first-line therapy?

• AOral ciprofloxacin for 7 days
• BTopical ciprofloxacin-dexamethasone drops for 7 days
• CAmoxicillin ear drops and oral paracetamol
• DSystemic oral prednisolone taper

During an Auditory Brainstem Response (ABR) test, click stimuli are delivered to a patient's ear, and surface electrodes record electrical activity. Which wave of the ABR waveform represents the electrical activity originating specifically from the lateral lemniscus?

• AWave I
• BWave III
• CWave V
• DWave IV

A 6-year-old child is referred to the clinic due to concerns about hearing. Otoscopy reveals a dull, retracted tympanic membrane with no signs of acute inflammation. A tympanogram is performed and demonstrates a flat curve with a normal ear canal volume (Type B). What does this tympanometry result indicate?

• ANormal middle ear pressure and compliance
• BMiddle ear effusion or fluid
• CEustachian tube dysfunction with negative middle ear pressure
• DOssicular chain disruption

A 35-year-old male surfer presents with recurrent episodes of otitis externa and mild conductive hearing loss. Otoscopy reveals multiple, bilateral, smooth, bony growths covered by normal skin, narrowing the lumen of the external auditory canal. What is the most likely diagnosis?

• AOsteosarcoma of the temporal bone
• BExternal auditory canal exostoses
• COsteoma of the external auditory canal
• DSquamous cell carcinoma of the ear canal

A 5-year-old child presents with a 3-day history of right ear pain and fever, which has worsened today. On examination, the child's right pinna is displaced anterolaterally, and there is marked tenderness, fluctuance, and erythema over the postauricular mastoid area. Otoscopy shows a bulging, purulent tympanic membrane. What is the most appropriate next step in management?

• APrescribe oral amoxicillin and review in 48 hours
• BAdmit the patient for intravenous antibiotics, urgent CT scan of the temporal bones, and…
• CPerform an incision and drainage of the postauricular swelling in the outpatient clinic
• DApply a warm compress and insert a wick into the external auditory canal

A 34-year-old woman presents with a 12-day history of nasal congestion, facial pressure, and purulent nasal discharge. She reports that her symptoms seemed to improve around day 5, but then worsened significantly on day 8, with a new fever of 38.3°C and severe unilateral maxillary pain. What is the most likely diagnosis?

• AAcute viral rhinosinusitis (common cold)
• BAcute bacterial rhinosinusitis (ABRS)
• CChronic rhinosinusitis with nasal polyps (CRSwNP)
• DAllergic rhinitis flare-up

A 40-year-old man presents with progressive nasal obstruction, anosmia, and a constant post-nasal drip. On anterior rhinoscopy, bilateral, mobile, translucent, grape-like masses are visualized in the middle meatuses. He has a history of severe asthma and reports experiencing severe bronchospasm after taking ibuprofen. What is the name of this clinical triad?

• AKartagener's triad
• BGradenigo's syndrome
• CAspirin-Exacerbated Respiratory Disease (AERD) / Samter's triad
• DWegener's granulomatosis triad

A 19-year-old male presents with acute bleeding from his right nostril. This is his third episode this week. On anterior rhinoscopy, a prominent, actively oozing vessel is visualized on the anteroinferior part of the nasal septum. Which vascular network is the source of this bleeding?

• AWoodruff's plexus
• BKiesselbach's plexus / Little's area
• CThe sphenopalatine artery system
• DThe ethmoidal arterial system

A 75-year-old hypertensive male presents with severe, unremitting epistaxis. Bleeding is noted from both nostrils and down the posterior pharynx. Despite bilateral anterior nasal packing, the patient continues to expectorate bright red blood. What is the most appropriate next step in the surgical management of this patient?

• AUrgent ligation of the internal carotid artery
• BEndoscopic sphenopalatine artery (SPA) ligation
• CChemical cauterization of Kiesselbach's plexus
• DLong-term systemic administration of antifibrinolytics

A 16-year-old boy presents to the emergency department 4 hours after being struck in the nose during a football match. He has mild nasal pain and complete bilateral nasal obstruction. On examination, there is no active epistaxis, but a bilateral, red, fluctuant swelling of the nasal septum is noted, completely occluding both nasal cavities. What is the most critical immediate intervention required?

• APrescribe oral antibiotics and arrange outpatient review in 7 days
• BPerform urgent incision and drainage of the septal swelling followed by anterior nasal pa…
• CRequest an urgent CT scan of the facial bones to rule out nasal fractures
• DReassure the patient and advise ice packs to reduce swelling

A 26-year-old male describes a 3-year history of paroxysmal sneezing, nasal itching, clear rhinorrhea, and bilateral nasal congestion occurring primarily in the spring. Examination shows pale, boggy nasal mucosa with swollen inferior turbinates. What is the recommended first-line long-term pharmacological therapy?

• AOral antihistamines as needed
• BIntranasal corticosteroid sprays
• CTopical decongestant sprays (e.g., oxymetazoline)
• DSystemic oral prednisolone course

A 42-year-old female presents with constant, clear, watery discharge from her right nostril for 2 months, which she notes drops rapidly when she bends forward. She has a history of a minor head injury 3 months ago. What diagnostic test on the nasal fluid is the most specific to confirm the suspected diagnosis?

• AGlucose concentration measurement of the fluid
• BBeta-2 transferrin assay
• CTotal protein electrophoresis of the fluid
• DCulture and sensitivity of the fluid

A 55-year-old man presents with progressive left-sided nasal obstruction and occasional minor nosebleeds over the past 6 months. Rigid endoscopy reveals a unilateral, irregular polypoid mass arising from the lateral nasal wall around the middle turbinate. A biopsy is performed. What is the most likely diagnosis?

• AAntrochoanal polyp
• BInverted papilloma
• CEsthesioneuroblastoma
• DNasal lobular capillary hemangioma

A 14-year-old boy presents with progressive, severe nasal obstruction on the left side and recurrent, profuse epistaxis requiring emergency packing. On examination, a lobulated, reddish-purple mass is visualized in the posterior nasal cavity. What is the most critical diagnostic or therapeutic contraindication in this patient prior to definitive surgery?

• ARigid nasal endoscopy in the clinic
• BPre-operative arterial embolization
• CIncisional biopsy of the nasal mass
• DContrast-enhanced MRI of the brain and paranasal sinuses

A 35-year-old woman presents complaining of a constant high-pitched whistling sound during nasal breathing, along with persistent nasal crusting. She has a history of a septoplasty 2 years ago. What is the most likely diagnosis?

• AAtrophic rhinitis
• BNasal septal perforation
• CVestibular stenosis
• DChronic rhinosinusitis

A 28-year-old male with chronic sinusitis refractory to standard medical management undergoes a CT scan of the paranasal sinuses. The scan reveals unilateral expansion of the ethmoid sinus with areas of high attenuation (double density sign) and nasal polyposis. Endoscopic sinus surgery is performed, yielding thick, 'peanut-butter' mucin. Histopathology of the mucin reveals Charcot-Leyden crystals and non-invasive fungal hyphae. What is the diagnosis?

• AInvasive fungal sinusitis
• BAllergic Fungal Rhinosinusitis (AFRS)
• CMycetoma (fungal ball) of the sinus
• DRhinosporidiosis

A 65-year-old poorly controlled diabetic patient presents to the emergency department with a 24-hour history of acute left orbital pain, swelling, and fever. On examination, there is proptosis and restricted extraocular movements on the left side. Rigid nasal endoscopy reveals a black, necrotic eschar on the left middle turbinate. What is the most critical next step in managing this patient?

• AInitiate high-dose intravenous corticosteroids
• BUrgent surgical debridement and initiation of intravenous liposomal amphotericin B
• COrder a routine MRI orbit and wait for results
• DPrescribe oral broad-spectrum antibacterials and review in 24 hours

A 18-year-old male sustains a blow to the nose during a rugby match. On examination, he has moderate swelling and tenderness over the nasal bridge, with mild epistaxis that has resolved. There is no septal hematoma. Rigid endoscopy reveals a patent airway. A plain radiograph of the nasal bones is normal. What is the most appropriate management plan?

• APerform immediate closed reduction of the nasal bones under local anesthesia
• BReassure the patient and review in 5-7 days after the soft tissue swelling has subsided
• CArrange urgent open reduction and internal fixation within 24 hours
• DOrder a CT scan of the skull and brain to evaluate for subclinical fractures

During a functional endoscopic sinus surgery (FESS), the surgeon identifies the natural ostium of the maxillary sinus. Through which anatomical space does the maxillary sinus naturally drain into the nasal cavity?

• ASuperior meatus
• BInfundibulum / middle meatus
• CInferior meatus
• DSphenoethmoidal recess

A 45-year-old male with acute sphenoid sinusitis presents with severe headache, high fever, bilateral periorbital edema, proptosis, and ophthalmoplegia. On cranial nerve examination, he is found to have deficits in CN III, IV, V1, and VI on the left side. What life-threatening complication is most likely occurring?

• AFrontal lobe abscess
• BCavernous sinus thrombosis (CST)
• CEpidural empyema
• DLateral sinus thrombosis

A 48-year-old woman presents with a 6-month history of progressive nasal crusting, frequent minor epistaxis, and a newly developed 'saddle nose' deformity. Urinalysis shows hematuria and proteinuria. A biopsy of the nasal mucosa reveals necrotizing granulomatous inflammation and vasculitis. What is the most specific serological marker to support the diagnosis of this disease?

• AAnti-nuclear antibody (ANA)
• BCytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) / PR3-ANCA
• CPerinuclear antineutrophil cytoplasmic antibody (p-ANCA) / MPO-ANCA
• DRheumatoid factor (RF)

A 30-year-old male presents with loss of smell (anosmia) following a severe upper respiratory tract infection 4 weeks ago. On examination, the nasal passages are entirely patent, with no polyps, mucosal edema, or abnormal discharge. What is the most likely mechanism of this patient's olfactory loss?

• AConductive loss due to mucosal swelling in the olfactory cleft
• BSensorineural loss due to direct viral damage to the olfactory neuroepithelium
• CCentral nervous system damage to the temporal lobe
• DMalingering or psychosomatic anosmia

A 3-year-old girl is brought to the clinic by her mother due to a unilateral, thick, foul-smelling, purulent nasal discharge from the left nostril of 4 days' duration. There is no history of fever or trauma. What is the most likely diagnosis?

• AAcute ethmoid sinusitis
• BUnilateral nasal foreign body
• CUnilateral choanal atresia
• DNasal septal abscess

A newborn infant is observed in the neonatal intensive care unit to have cyclic episodes of cyanosis and respiratory distress. The distress is immediately relieved whenever the infant cries, at which point the skin color returns to normal. What is the most likely diagnosis?

• ALaryngomalacia
• BBilateral choanal atresia
• CTracheoesophageal fistula
• DCongenital subglottic stenosis

A 28-year-old male presents with severe, constant nasal congestion. He reports that he has been using a topical decongestant spray (oxymetazoline) 5-6 times daily for the past 6 months to help him breathe. Every time he tries to stop the spray, his nose blocks completely. What is the diagnosis?

• AAllergic rhinitis
• BRhinitis medicamentosa
• CAtrophic rhinitis
• DVasomotor rhinitis

A 35-year-old woman is referred due to recurrent, severe epistaxis since childhood. On examination of her oral cavity, multiple pinpoint red lesions that blanch on pressure are noted on her tongue and mucosal surfaces of her lips. Her father also suffered from recurrent nosebleeds. What is the most likely diagnosis?

• AHereditary Hemorrhagic Telangiectasia (HHT) / Osler-Weber-Rendu disease
• BSystemic lupus erythematosus (SLE)
• CSjögren's syndrome
• DThrombocytopenic purpura

A 52-year-old man presents with progressive swelling in his left forehead and displacement of his left eye downwards and outwards. He has a history of chronic frontal sinusitis. CT scan of the sinuses demonstrates a homogeneous, non-enhancing, fluid-filled cystic lesion in the left frontal sinus causing bone resorption of the orbital roof. What is the diagnosis?

• AOsteoma of the frontal sinus
• BFrontal sinus mucocele
• CInverted papilloma
• DFrontal lobe glioma