Multiple-choice Questions in Otolaryngology with explanatory answers

Multiple-choice Questions in Otolaryngology with explanatory answers

Ramindar S. Dhillon, FRCS (Eng) James W. Fairley, FRCS (Eng)

Ferens Institute of Otolaryngology University College and Middlesex School of Medicine, London

M MACMILLAN

PRESS Scientific & Medical

© R.S. Dhillon & J.W. Fairley 1989

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First published 1989

Published by THE MACMILLAN PRESS LTD Houndmills, Basingstoke, Hampshire RG21 2XS and London Companies and representatives throughout the world

Typeset by Ponting-Green Publishing Services, London

ISBN 978-0-333-49109-6 ISBN 978-1-349-10805-3 (eBook) DOI 10.1007/978-1-349-10805-3

CONTENTS

Foreword Preface

Section 1: The Ear

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1 Foetal development 2 2 Development of the foetal ear 2 3 Development of the temporal bone 2 4 Development of the mastoid process 4 5 Anatomy of the external ear 4 6 In the adult 4 7 In the middle ear cleft 6 8 The anterior wall of the tympanic cavity 6 9 In the middle ear cleft 6

10 Mucosal folds, compartments and ligaments of the middle ear cleft 8

11 The middle ear cleft 8 12 Neurovascular supply of the middle ear cleft 8 13 In the labyrinth 1 0 14 In the inner ear 1 0 15 In the cochlear nerve 1 0 16 In the vestibular labyrinth 1 0 17 The vestibular nerve 12 18 Blood supply of the labyrinth 12 19 Anatomy of the internal auditory canal 12 20 Sensory nerve supply of the ear 14 21 The following lesions may cause referred otalgia 14 22 The following neoplasms may present with otalgia 14 23 In the physical examination of the ear 16 24 Radiological investigation of the petrous temporal bone 16 25 The following procedures are usually performed via a

permeatal incision 18 26 In temporal bone surgery 18 27 Principles of temporal bone surgery 18 28 The seventh cranial nerve 20 29 Physical properties of sound 20 30 Sound transmission in the middle ear 20 31 Middle ear acoustic impedance 20 32 Abnormalities of middle ear function 22 33 Middle ear muscles 22 34 Hearing by bone conduction 22

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35 In the cochlea 24 36 Theories of hearing 24 37 Localization of sound stimulus 24 38 In testing the hearing 24 39 In non-organic hearing loss 26 40 Audiological investigations 26 41 Impedance audiometry 28 42 Electric response audiometry 28 43 Assessment of hearing thresholds in young children 30 44 Electronic hearing aids 30 45 Vestibular labyrinthine physiology 32 46 Vestibular function tests 32 4 7 Bithermal caloric test 32 48 Electronystagmography 34 49 Congenital abnormalities of the external ear 34 50 Haematoma Auris 34 51 In otitis externa 36 52 In malignant otitis externa 36 53 Viral infections of the external ear 36 54 Neoplastic disease of the external ear 38 55 In the external auditory meatus 38 56 Congenital anomalies of the middle ear cleft 38 57 Surgery of congenital ear anomalies 40 58 Surgical correction of congenital atresia of the

external auditory meatus 40 59 Traumatic perforation of the tympanic membrane 40 60 In basal skull fractures involving the petrous temporal bone 40 61 Otitic barotrauma 42 62 Acute suppurative otitis media 42 63 Acute petrositis 44 64 Complications of acute inflammation of the middle ear

cleft include 44 65 Factors in the development and behaviour of chronic

otitis media include 44 66 Tubotympanic chronic suppurative otitis media (CSOM) 46 67 Pathogenesis of acquired cholesteatoma 46 68 In attica-antral CSOM 46 69 Management of chronic suppurative otitis media

with cholesteatoma 48 70 Management of cholesteatoma in children is difficult because 48 71 In an open mastoid cavity 48 72 Acute mastoiditis 48 73 Intracranial extension of suppurative otitis media 50 7 4 Complications of suppurative otitis media 50 75 Secretory otitis media (SOM) 50 76 Diagnosis and management of secretory otitis media 52 77 Late sequelae of otitis media 52 78 Tuberculous otitis media is 52 79 Malignant tumours of the middle ear cleft 54 80 Paragangliomas of the temporal bone 54 81 Osseous disorders of the temporal bone 54

Contents vii

82 Pathology of otosclerosis 56 83 Patients with otosclerosis 56 84 Diagnosis of otosclerosis 58 85 Treatment of otosclerosis 58 86 During stapedectomy 58 87 Complications of stapedectomy 60 88 Perilymph fistulae following stapedectomy 60 89 Van der Hoeve de Kleyn syndrome 62 90 In late syphilis in the temporal bone 62 91 Congenital deafness 62 92 Temporal bone fractures 64 93 In closed head injuries without fracture 64 94 Inner ear barotrauma 64 95 Excessive sound stimulation of the ear 66 96 lnfrasound 66 97 Hearing conservation programmes in industry 66 98 Otitic blast injury 68 99 Labyrinthine window rupture 68

168 Otitic labyrinthitis 68 1 01 In circumscribed labyrinthitis 70 1 02 In syphilitic labyrinthitis 70 103 Pathophysiology of Meniere's Disease 70 104 Clinical manifestations of Meniere's disease 72 105 Cogan's disease is characterized by 72 106 Investigation of Meniere's disease 72 107 Medical management of Meniere's disease 7 4 108 Surgical management of Meniere's disease 74 1 09 Pathology of presbyacusis 7 4 11 0 Management of presbyacusis 76 111 The ototoxic effects of 76 112 Objective tinnitus 76 113 Subjective tinnitus 78

Section 2: The Nose and Sinuses

114 Blood supply of the nose 82 115 Nasal anatomy 82 116 Examination of the nose and sinuses 82 117 Sinus X-rays 84 118 Operations on the nose and sinuses 84 119 Antral washouts 84 120 Sinus operations 86 121 Nasal respiration 86 122 The mucociliary 'conveyor belt' of the upper respiratory tract 86 123 Anosmia 86 124 Disorders of smell 88 125 Cleft lip and cleft palate 88 126 Congenital nasal malformations 88 127 Congenital choanal atresia 88 128 Management of maxillofacial injuries 88 129 Middle third facial fractures 90

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130 Blowout fracture of the orbit 90 131 Fractures involving the frontal or ethmoidal sinuses 90 132 Cerebrospinal fluid rhinorrhoea 90 133 Oro-antral fistula 92 134 Bullet wounds in the head and neck region 92 135 Sinus barotrauma 92 136 Nasal septal deformities 92 137 Septal haematoma 94 138 Septal abscess 94 139 Septal perforation 94 140 Foreign bodies in the nose 94 141 Rhinolith 96 142 Inflammation of the external nose 96 143 Acute infective rhinitis 96 144 Chronic non-specific rhinitis 96 145 Chronic hypertrophic rhinitis 98 146 Atrophic rhinitis 98 147 Wegener's granulomatosis 98 148 Syphilis and the nose 1 00 149 Nasal lupus vulgaris 1 00 150 Chronic specific rhinitis 1 00 151 Acute infective sinusitis 1 00 152 Acute infective sinusitis 1 02 153 Chronic non-specific sinusitis 1 02 154 Mixed infective and vasomotor chronic sinusitis 1 02 1 55 Acute maxillary sinusitis 1 04 156 Acute frontal sinusitis 1 04 157 Acute sphenoidal sinusitis 1 04 158 Treatment of chronic maxillary sinusitis 104 159 Treatment of chronic frontal sinusitis 106 160 Aetiology of sinusitis in children 1 06 161 Sinusitis in children 106 162 Spread of infection in suppurative sinusitis 1 08 163 Osteomyelitis of the frontal bone 1 08 164 Osteomyelitis of the frontal bone 1 08 165 Orbital complications of suppurative sinusitis 1 08 166 Orbital complications of suppurative sinusitis 11 0 167 Intracranial complications of suppurative sinusitis 11 0 168 Secondary effects of suppurative sinusitis 11 0 169 Transitional cell papilloma (Ringertz tumour) 112 170 Benign tumours of the paranasal sinuses 112 171 Malignant tumours of the nose and paranasal sinuses 112 172 Malignant tumours of the paranasal sinuses 114 173 Treatment of malignant tumours of the paranasal sinuses 114 17 4 Pituitary tumours 114 175 Maxillary cysts 116 176 Cysts of dental origin 116 177 Radiographic diagnosis of maxillary cysts 116 178 Odontogenic tumours 116 179 Causes of epistaxis 116 180 Sites of bleeding in epistaxis 118

Contents ix

181 Initial treatment of severe epistaxis 118 182 Surgical intervention in epistaxis 118 183 Epistaxis in hereditary haemorrhagic telangiectasia 120 184 Vasomotor rhinitis 120 185 Clinical features of vasomotor rhinitis include 120 186 Medical treatment of vasomotor rhinitis 120 187 Surgical treatment of vasomotor rhinitis 122 188 Aetiology of allergic rhinitis 122 189 Immunology of allergic rhinitis 122 190 Pathology of allergic rhinitis 124 1 91 Clinical features of allergic rhinitis 124 192 Treatment of allergic rhinitis 124 193 Surgical treatment of allergic rhinitis 124 1 94 Pathology of nasal polyps 126 1 95 Antrochoanal polyps 126 196 Treatment of simple nasal polyps 126 1 97 Epiphora 126

Section 3: The Larynx and Tracheobronchial Tree

1 98 Development of the larynx 130 1 99 The infantile larynx in comparison with the adult 130 200 Cartilaginous framework of the larynx 130 201 Laryngeal musculature 130 202 In the cavity of the larynx 132 203 Neurovascular supply and lymphatic drainage of the larynx 132 204 Physical examination of the larynx 132 205 Sphincteric functions of the larynx 134 206 During deglutition 134 207 In voice production 136 208 Symptoms and signs of laryngeal disease in the

newborn include 136 209 Congenital laryngeal stridor (laryngomalacia) 136 21 0 Congenital laryngeal web 138 211 In closed laryngeal injuries 138 212 Laryngeal trauma 140 213 Abnormal voice production 140 214 Acute non-specific laryngitis in children 140 215 Acute epiglottitis 142 216 Acute laryngotracheobronchitis 142 217 Keratosis of the larynx 142 218 Juvenile respiratory papillomatosis 144 219 Benign lesions of the larynx 144 220 In the 1 987 UICC classification of malignant tumours

of the larynx 146 221 Spread of malignant disease of the larynx 146 222 Total laryngectomy 148 223 Laryngocoeles 148 224 Oedema of the larynx 148 225 In episodes of stridor 150 226 Neural paralysis of the larynx 150

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227 Management of laryngeal paralysis 150 228 Voice disorders 150 229 Development of the trachea and bronchi 152 230 In the trachea 152 231 In the neck 152 232 In the tracheobronchial tree 152 233 In the upper air passages 154 234 In performing a tracheostomy 154 235 In the postoperative care of tracheostomy 154 236 In a child with a tracheostomy 156 237 Congenital abnormalities of the tracheobronchial tree 156 238 The following are indications necessitating tracheostomy 156 239 Tracheobronchial foreign bodies 158 240 In the management of an inhaled foreign body 158 241 Inflammatory processes in the tracheobronchial tree 158 242 In carcinoma of the bronchus 160 243 Management of benign tracheal stenosis 160

Section 4: The Mouth, Pharynx and Oesophagus

244 Development of the mouth 245 Development of the tongue 246 Development of the pharynx 247 The second pharyngeal pouch 248 Anatomy of the mouth 249 Dental anatomy 250 Anatomy of the nasopharynx 251 Anatomy of the oropharynx 252 The pharyngeal constrictor muscles 253 Anatomy of the palatine tonsil 254 The parapharyngeal space 255 The retropharyngeal space 256 The glossopharyngeal nerve 257 Lymphatic drainage of the pharynx 258 Immunology of the pharyngeal lymphoid tissue 259 Anatomy of the parotid gland 260 Anatomy of the submandibular gland 261 The infratemporal fossa 262 The temporomandibular joint 263 The soft palate 264 Derivatives of the pharyngeal pouches 265 White lesions of the oral cavity 266 Mouth ulcers 267 Tumours of the oral cavity 268 Salivary gland tumours 269 Benign salivary gland disease 270 During deglutition 271 Pathophysiology of swallowing 272 Stertor 273 Sleep apnoea in children

164 164 164 166 166 166 166 168 168 170 170 172 172 172 174 174 176 176 176 178 178 178 180 180 180 182 182 184 184 184

Contents xi

27 4 Diphtheria 186 275 Chronic non-specific pharyngitis 186 276 Chronic specific pharyngitis 186 277 Acute tonsillitis 188 278 Quinsy 188 279 Tonsillectomy 188 280 Benign tumours of the oropharynx 188 281 Malignant tumours of the oropharynx 190 282 Lymphoma of the oropharynx 1 90 283 Treatment of squamous carcinoma of the tonsil 190 284 Hypopharyngeal tumours 1 92 285 Carcinoma of the pyriform fossa 1 92 286 Total pharyngolaryngectomy 192 287 Total pharyngolaryngectomy and oesophagectomy 194 288 Recurrence of hypopharyngeal carcinoma 1 94 289 Malignant cervical lymph nodes 1 94 290 Radical neck dissection 196 291 Functional neck dissection 196 292 Pharyngeal pouch (Zenker's diverticulum) 196 293 Thyroglossal cysts and sinuses 1 98 294 Branchial sinuses and fistulae 198 295 Branchial cysts 198 296 In the oesophagus 200 297 The lower oesophageal sphincter 200 298 Congenital oesophageal atresia 200 299 Hiatus hernia 202 300 Perforation of the oesophagus 202 301 Clinical features of a foreign body in the oesophagus include 202 302 Benign neoplasms of the oesophagus 204 303 Carcinoma of the oesophagus 204 304 Management of oesophageal cancer 204 305 Oesophageal stricture 204 306 Achalasia of the cardia 206

Section 5: General and Related

307 Radiotherapy 210 308 Efficacy of radiotherapy 210 309 During a course of radical radiotherapy for head and

neck cancer 210 310 Cytotoxic agents in head and neck cancer 212 311 Adjuvant chemotherapy in head and neck cancer 212 312 Use of lasers in surgery 212 313 The carbon dioxide laser 214 314 For the safe use of lasers 214 315 Clinical application of a C02 laser 214 316 Photodynamic therapy 216 317 Local anaesthetic and vasoconstrictor agents used in ENT 216 318 Biomaterials in otolaryngology 216

FOREWORD

A great deal of work has gone into compiling these multiple-choice questions and answers. They are more interesting and entertaining than simply reading a text book, but are not, of course, an alternative.

At each stage in your study, take advantage of the questions section by section to see how much you have taken in. As the Americans say, 'frequent "mini exams" keep up the concentration'.

Not only students, but also all otolaryngologists will find this book worthwhile for occasional reading, to see how much they know or think they know. It will also be useful to those who have to set questions, whether multiple-choice or otherwise.

This book is something different and is certainly worthwhile. It does not take long to get used to the inevitable little tricks that multiple­choice questions present.

Richard A. Williams, MA, MB, BChir, FRCS, FRCS(E), DLO

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Director, Ferens Institute of Otolaryngology,

London August 1988

PREFACE

Like them or loathe them, multiple-choice questions are firmly established in undergraduate and postgraduate medical education. Their importance can only increase as computers are used more and more to automate the assessment of students.

This book is designed primarily as a revision aid. It is particularly suitable for DLO and FRCS candidates throughout the world, but it could be used with profit by undergraduates. It can be used to discover gaps in knowledge and to reinforce what has been learned from standard textbooks. We have included short notes with the answers. These provide further information and try to explain why we favour a given response in cases where there may be disagreement.

There are 1590 questions here, arranged as 318 stems, each with 5 independent true/false statements. All major areas of otolaryngology are covered. The questions are ordered by subject in 5 sections: Ear; Nose and Sinusus; Larynx and Tracheobronchial Tree; Mouth; Pharynx and Oesophagus; and General and Related Subjects.

The subject matter is covered in the standard British ENT textbooks. We have made extensive use of Scott-Brown, both fourth and fifth editions, the ear, nose and throat volumes of Rob and Smith's Operative Surgery, Groves and Gray's Synopsis of Otolaryngology, Stell and Maran's Head and Neck Surgery, and Mawson and Ludman's Diseases of the Ear.

When compiling MCQs it is tempting to stick to factual or uncontroversial issues. This artificial restriction takes a lot of the interest out of the subject. We have included controversial aspects of clinical practice, as well as basic anatomy, physiology and pathology. We recognize that the reduction of complex issues to a series of true/false statements can never be perfect. No doubt some experienced colleagues will disagree with our answers. Perhaps they will take consolation from the fact that in real life the unfortunate candidate not only has to know what is right, but also to know what the examiner knows is right!

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We are grateful to the Director and staff of the Ferens Institute of Otolaryngology, under whose auspices the book was produced. We also thank our colleagues and students at the Royal Ear Hospital, the Middlesex Hospital and Mount Vernon Hospital for their helpful suggestions. In particular we would like to thank Mr Richard Williams, Mr Graham Fraser, Mr Garry Glover and Mr Phillip Robinson for their careful reading of the questions. They have all pointed out ambiguities and inconsistencies which bedevil the MCQ compiler. Any faults which remain are the authors' responsibility. Finally, we would like to thank our wives, Georgina and Sylvia, for their continued support during the two-year gestation period of the book.

London, 1989 R.S.D. J.W.F.