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MyPasTest: MRCS A Online - Jan Exam 201532. Surgical specialties; Otorhinolaryngology and neck surgery (24Qs)
01. Theme: Stridor.
A Acute epiglottitis
B Acute laryngotracheobronchitis
C Anaphylactic reaction
D Angioneurotic oedema
E Bilateral recurrent laryngeal nerve paralysis
F Carcinoma of the larynx Page |
G Diphtheria
H Fracture of the larynx
1714
I Inhaled foreign body
J Inhalation or ingestion of irritants
K Laryngeal papilloma
L Ludwig’s angina
M Maxillofacial trauma
N Paralaryngeal haematoma
O Reduced consciousness level
P Thyroid carcinoma.
The following patients have all presented with stridor. Please select the most appropriate diagnosis
from the above list. The items may be used once, more than once, or not at all.
Scenario 1
A 1-year-old child presents on Boxing Day with a mild upper respiratory tract infection that has progressively
worsened. His mother now describes a cough like a seal’s bark and stridor. The child has a temperature of
38.5°C and is tachycardic. There is stridor and expiratory wheeze.
A - Acute epiglottitis« YOUR ANSWER
B - Acute laryngotracheobronchitis« CORRECT ANSWER.
This condition, also referred to as ‘croup’, is caused by viral infection (parainfluenza 1) and commonly
affects the 6-month to 3-year-old age group in the winter months. The stridor (and sometimes
respiratory obstruction) is caused by subglottic oedema. Treatment is with humidified air/oxygen in an
incubator (or croupette) to prevent crusting, and supportive nasogastric/intravenous fluids.
Intravenous antibiotics are used to cover for secondary bacterial infections or tracheiti in severe
cases.
Scrupulous observation is required for signs of impending respiratory obstruction that would require
nasotracheal intubation by a skilled anaesthetist or tracheostomy (if this fails). The condition is
distinguished from acute epiglottitis, where the child is usually older, and the presence of supraglottic
oedema (the epiglottis is red and swollen and protrudes above the tongue: the rising sun sign).
Diphtheria is a differential diagnosis in unimmunised populations.
Scenario 2
An 18-year-old girl presents with facial oedema, dyspnoea and stridor. She is apyrexial and has no past
medical history, drug history, or allergies.
B - Acute laryngotracheobronchitis« YOUR ANSWER
D - Angioneurotic oedema« CORRECT ANSWER.
This is a condition of unknown aetiology most commonly affecting young women. Management is by
close observation, antihistamines and intravenous steroids/epinephrine nebulisers. Should the
condition deteriorate, the patient may require orotracheal intubation. It is distinguished only from
anaphylactic shock by the absence of a precipitating allergen (antibiotics/bee stings etc).
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
32. Surgical specialties; Otorhinolaryngology and neck surgery (24Qs)
Scenario 3
A 25-year-old fireman is rescued by his colleagues after becoming trapped by falling debris in a burning
building. He is alert and orientated but has stridor, hoarseness and a cough productive of black sputum. He
has burns to the face and upper torso.
C - Anaphylactic reaction« YOUR ANSWER
J - Inhalation or ingestion of irritants« CORRECT ANSWER. Page |
In this case the patient has smoke inhalation with burns to the upper airway. The supraglottic airway 1715
is extremely susceptible to obstruction as a result of exposure to heat. When a patient is admitted to
hospital after burn injury you must always be alert to the possibility of airway involvement.
Clinical indications of inhalation injury include facial burns, singeing of the nasal hairs, carbon
deposits in the oropharynx, carbonaceous sputum, hoarseness and a carboxyhaemoglobin level >
10%. The symptom of stridor is an indication for immediate orotracheal intubation, although one
should hopefully have electively intubated the patient before this sign is present. A similar pattern of
airway obstruction can be causes by ingestion of corrosives such as strong acids and alkalis.
02. Theme: Epistaxis.
A Cocaine abuse
B Foreign body
C Haemophilia
D Hypertension
E Iatrogenic
F Idiopathic
G Malignant neoplasm
H Hereditary haemorrhagic telangectasia (Osler’s disease)
I Pyogenic granuloma
J Rhinitis
K Thrombocytopaenia
L Trauma
M Wegener’s granuloma.
The following patients have all presented with epistaxis. Please select the most appropriate diagnosis
from the above list. The items may be used once, more than once, or not at all.
Scenario 1
A 2-year-old child presents with bleeding from one side of the nose. His mother had noticed a foul-smelling
discharge from the nose on that side for some months. This had only temporarily responded to courses of
antibiotics. Examination of the nostrils shows an inflamed mucous membrane and a blood-stained
mucopurulent discharge.
A - Cocaine abuse« YOUR ANSWER
B - Foreign body« CORRECT ANSWER.
This may present with bleeding from the nose in the presence of longstanding inflammation. The
history of a foul-smelling nasal discharge and the age of the child (foreign bodies in the nose are
commonest in children aged 2–3) should alert one to the diagnosis.
Treatment is by removal under general anaesthesia once inflammation is established as in this case. If
the problem is identified early, various manoeuvres can be attempted in The Emergency Department
to blow out the offending foreign body.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
32. Surgical specialties; Otorhinolaryngology and neck surgery (24Qs)
Scenario 2
A 25-year-old man presents with a history of chronic sinusitis and epistaxis over the past 3 years. On
rhinoscopy he has nasal crusting with a small septal defect. On oral examination there is quite marked
gingivitis and tooth decay.
B - Foreign body« YOUR ANSWER
A - Cocaine abuse« CORRECT ANSWER. Page |
In this case, the patient is likely to be a regular user of cocaine (now one of the most common causes 1716
of recurrent epistaxis). The diagnosis is strongly suggested by the septal defect, dental problems and
sinus problems, especially in a young adult.
The commonest causes of epistaxis are: idiopathic (nose picking), external trauma and rhinitis
(allergic and infective). Other causes may also be local or secondary to systemic disease (especially
blood dyscrasias). Iatrogenic causes include anticoagulant therapy and nasogastric tubes.
03. Theme: Lumps in the neck.
A Cystic hygroma
B Carotid body tumour
C Tumour of the sternocleidomastoid muscle
D Branchial cyst
E Cervical lymphadenopathy
F Thyroid adenoma
G Carotid artery aneurysm.
For each of the clinical scenarios below choose the most likely diagnosis. Each option may be used
once, more than once, or not at all.
Scenario 1
A 3-year-old child presents with a slow-growing painless swelling on the right side of the base of the neck.
Examination revealed a fluctuant swelling that transilluminated.
A - Cystic hygroma« CORRECT ANSWER.
A cystic hygroma is a congenital cystic lymphatic malformation at the root of the neck, 50% of which
are present at birth. They are thin walled and transilluminable. CT and magnetic resonance imaging
(MRI) may be helpful for determination of their extent.
Scenario 2
A woman in her 30s complained of a swelling between the anterior and posterior triangle on the anterior
surface of the mid-third of the sternomastoid muscle for the past week, which was painless on examination.
She gave a history of a similar swelling a few months ago which regressed spontaneously.
B - Carotid body tumour« YOUR ANSWER.
Branchial cysts are found at the anterior border of the sternocleidomastoid. They usually present in
the third decade. Patients complain of an enlarging lump, usually presenting from behind the junction
of the upper and middle thirds of the sternocleidomastoid, although it may occur behind or just in
front of the muscle.
Scenario 3
A 35-year-old woman, who works as an animal handler, with painless swelling in the posterior triangle of her
neck for 2 months.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
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