5 - Ballengers-MCQs
5 - Ballengers-MCQs
BALLENGER,S - MCQs
BY DR. MOHAMMED ATIAA KAREEM
ALNASHY
[1]
Otorhinolaryngology Examination Items and Teaching Commentaries
[2]
Otorhinolaryngology Examination Items and Teaching Commentaries
[3]
Otorhinolaryngology Examination Items and Teaching Commentaries
CHAPTER ONE
DIAGNOSTIC AUDIOLOGY, HEARING AIDS, AND HABILITATION
OPTIONS
Answer
The reference for the intensity level used in plotting pure-tone and speech
thresholds on the audiogram is the expected hearing level (HL) for young
normally hearing persons. Thus, 0 dB HL is not the absence of sound but, rather,
the intensity level just heard by a typically normal ear. Other intensity levels used
in physical or audiologic measurements include dB sound pressure level (SPL)
and dB sensation level (SL). The unit dBA is used in measurements of
environmental noise levels. Hz refers to stimulus frequency, not intensity.
(Best response: D)
Answer
The masking dilemma occurs when enough masking to eliminate a response
owing to stimulation of the nontest ear exceeds interaural attenuation and “crosses
[4]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
All of the choices except the masking level difference (MLD) are well-established
components of the immittance (impedance) test battery. The MLD is a measure
of hearing threshold for pure-tone or speech signals in the presence of noise that
is either in or out of phase with the signal. Masking is less effective when it is out
of phase with the signal. This is referred to as release from masking. The MLD is
mediated primarily at the brainstem level where interactions of input from each
ear first occur. (Best response: B)
Answer
The work of Aage Møller in the early 1980s delineated our understanding of the
generators of the auditory brainstem response (ABR). The wave V component
arises from the lateral lemniscus fibers just caudal to their arrival at the inferior
colliculus. The inferior colliculus is anatomically complex, consisting of
numerous regions and neuron types, and is therefore not capable of generating an
ABR component. The ABR wave III receives contributions from the superior
olivary complex. The cochlea is distal to, and the thalamus proximal to, the ABR
anatomy. (Best response: A)
[5]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
It is now clear that energy related to outer hair cell movement following the
presentation of sound to the ear is propagated outward from the basilar membrane
through the ossicular chain and the tympanic membrane to the ear canal, where it
is measured as otoacoustic emissions (OAEs). Activation of the efferent system
typically suppresses outer hair cell motility and thus OAEs. Traveling waves
along the basilar membrane play an important role in activating outer hair cells.
The eighth cranial nerve does not influence OAE production. (Best response: D)
Answer
All of the choices except for “decreased word identification scores over time” are
well-documented benefits of binaural amplification. In fact, a patient who has
been fit monaurally may experience auditory deprivation in the unaided ear,
resulting in a decline in word identification scores over time relative to the aided
ear. (Best response: D)
[6]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
According to federal law, a customer may return a hearing aid for refund during
the 30-day trial period. However, some hearing aid companies extend the trial
period without penalty. (Best response: B)
Answer
The most popular hearing aid style for children is a behind the- ear (BTE) hearing
aid. This style offers the most flexibility in terms of hearing aid technology,
frequency response characteristics, and use with assistive listening devices.
Additionally, when a new earmold is being made, the child is not left without a
hearing aid to use as he/she would be with the other hearing aid styles. The other
hearing aid styles, ITE, ITC, and CIC, are more limiting. A digital hearing aid is
not a type of hearing aid style but rather a type of hearing aid technology.
(Best response: C)
[7]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Language but also includes grammatical features and follows English syntax.
Total communication is a communication modality that involves one or more
modes of communication at any given time in the child’s educational program,
whether it is manual, oral, auditory only, or written. American Sign Language
(ASL) is the common language of the Deaf community. Cued speech employs
eight hand shapes placed at four different locations near the mouth. Auditory oral
emphasizes the use of amplified residual hearing and spoken language, using
speech reading cues as a supplement. Signed Exact English uses much of the
same vocabulary as ASL but includes English grammatical features and syntax.
(Best response: A)
[8]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Only the functional studies show the ability to predict disability and functionality.
The extent and site-of-lesion studies characterize just that. As the central
compensation process proceeds, the lesion extent typically does not alter, but its
functional impact on the patient lessens. Therefore, it will take evaluation tools
that accurately characterize the status of the compensation process to lessen the
dichotomy indicated above. (Best response: B)
Answer
History is the primary tool to determine management, with the direct clinical
examination suggesting a site of lesion. Electronystagmography and the
rotational chair are primarily confirmatory for the suspected site of lesion. It is
when unexpected results are obtained that management is driven by the laboratory
studies. (Best response: D)
[9]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Two-dimensional eye movement recordings cannot be used after the fact to
determine a positive result for benign paroxysmal positional vertigo. The disorder
and the particular canal involved are characterized by specific eye movements
that, other than the horizontal canal, involve a torsional eye movement
component. Torsional eye movements cannot be accurately represented by two-
dimensional recordings. (Best response: D)
4. Determination that a patient has absence of warm, cool, and ice water
caloric responses for right ear irrigations implies that
A. The right peripheral system is completely nonresponsive throughout the
frequency range (dead system).
B. There is severe low-frequency loss of sensitivity for the right peripheral
part of the vestibular system.
C. The right medial vestibular nucleus is severely reduced in its low-
frequency responsiveness.
D. This finding can only occur secondary to technical error(s) and is not
reliable.
E. None of the above.
Answer
Caloric irrigation is the equivalent of a low-frequency rotational stimulus of low
amplitude. Therefore, when a peripheral system is not responsive to the external
stimulus, it cannot be assumed that it is completely gone. The mid- and higher-
frequency portions of the system have not been tested. Also, the caloric irrigation
is primarily a test of horizontal canal function; therefore, no knowledge about the
vertical canal systems and the otolith organs has been obtained with this test.
Because of this situation and the fact that the rotational chair affects both
peripheral organs simultaneously, there is no way to determine whether there is
any residual function in a single end-organ. (Best response: B)
[10]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
It is rare that the rotational chair, like electronystagmography (ENG), will
actually drive the management process. It can identify peripheral involvement
when ENG is normal and provide for an avenue of counseling for the patient in
that regard. (Best response: B)
Answer
The rotational chair is the only study to determine the extent of bilateral
involvement. In doing so, aspects of the vestibular and balance rehabilitation
program for treatment of these patients can be altered based on realistic goals for
what can be accomplished in light of the severity of bilateral involvement. (Best
response: B)
[11]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Since the total-body low-frequency (at or below 1 Hz) rotational chair test uses
natural stimuli of rotational acceleration, it is always affecting both peripheral
systems at the same time. Although this sets certain limitations in the form of
localization of right versus left, this method allows for a more natural
characterization of the function of the vestibulo-ocular reflex controlling system.
(Best response: E)
Answer
Although patients with other symptoms may be appropriate for different aspects
of vestibular and balance rehabilitation therapy activities, globally, the ones that
are the most appropriate are those with head or visual motion-provoked
symptoms and those with functional deficits related to balance and ambulation.
(Best response: C)
[12]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Spontaneous nystagmus, most often noted with fixation removed when it is of a
peripheral origin, is very common within the first 1 to 2 weeks following a
unilateral labyrinthine injury. In electronystagmography, it is recorded with the
patient sitting, fixation removed, and head straight. (Best response: E)
Answer
Sensory organization testing is strictly a functional evaluation giving relative
information as to the use of sensory cues for the maintaining of stance. It is not a
site-of-lesion study, although other protocols of computerized dynamic
posturography can be used for that purpose. Because of its functional emphasis,
it is useful as an outcome measure for vestibular rehabilitation programs and can
detect patients who are exaggerating their results for whatever reason. (Best
response: E)
[13]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Thrombolytic agents like streptokinase have not been demonstrated to be
effective in auricular hematoma. Simple aspiration is inadequate treatment for
auricular hematoma. Organized hematoma is so solid that it cannot be aspirated.
Incision and drainage alone are not enough because the fluid will promptly
reaccumulate. The most effective treatment for auricular hematoma is adequate
incision and drainage with suture-secured bolsters to ensure coaptation of the
perichondrium and the cartilage. (Best response: E)
2. Cerumen
A. Is more acidic in the diabetic patient.
B. Should be removed periodically.
C. Is hydrophilic.
D. Forms an acidic coat that aids in the prevention of external auditory canal
infection.
E. Lacks a bactericidal enzyme.
Answer
Cerumen is a combination of the secretions produced by sebaceous and apocrine
glands admixed with desquamated epithelial cells. This combination forms an
acidic coat that aids in the prevention of external auditory canal infection. The
pH of the cerumen is high in diabetic patients. This predisposes diabetic patients
to otitis externa. Cerumen is not hydrophilic, but it does contain lysozyme, an
enzyme capable of destroying bacterial cell membranes. Owing to the self-
cleaning mechanism of the external auditory canal, cerumen does not require
periodic removal. (Best response: D)
[14]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The two most common microorganisms isolated from the external auditory canal
of normal individuals are Staphylococcus epidermidis and Corynebacterium
species, whereas Pseudomonas aeruginosa and Staphylococcus aureus are the
most common pathogens cultured in acute diffuse external otitis.
(Best response: A)
4. Otic preparations
A. Are more neutral than ophthalmic preparations.
B. Are more viscous than ophthalmic preparations.
C. Have less adverse reaction than ophthalmic preparations.
D. Can more easily penetrate narrow lumens than ophthalmic preparations.
E. Are more allergenic than ophthalmic preparations.
Answer
Otic preparations are more acidic than ophthalmic preparations. Patients unable
to tolerate acidic otic drops may tolerate more neutral ophthalmic drops. An
additional advantage of ophthalmic drops is a low viscosity, allowing improved
penetration in the narrow lumens encountered in external otitis. They are not less
allergenic than otic drops. (Best response: B)
5. Keratosis obturans
A. Is associated with bronchiectasis or sinusitis.
B. Is characterized by bone erosion of the external auditory canal.
C. Usually requires surgical treatment.
D. Is usually unilateral.
E. Is not associated with inflammation in the external auditory canal.
Answer
Keratosis obturans is characterized by the accumulation of large plugs of
desquamated keratin in the bony portion of the external auditory canal. This
condition is usually asymptomatic and bilateral and is discovered incidental to
[15]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Magnetic resonance imaging is of no use in detecting bony changes, but it may
be better for evaluation and follow-up of meningeal involvement and changes
within the osseous medullary cavity. A CT scan is important in initial assessment
of the extent of the infection. With a technetium scan, early bony involvement
can be detected. A gallium scan is a sensitive indicator of infection and is the best
for monitoring resolution of the infection. Culture of the external auditory canal
is essential. (Best response: D)
Answer
A gallium scan is best for monitoring resolution of disease and is useful in
determining the duration of antimicrobial therapy. The erythrocyte sedimentation
rate is a nonspecific test but is useful in following the response to antibiotics.
Although relief of pain is the first indication of a favorable response to therapy,
it is not useful in determining how long therapy should be continued. Likewise,
serum glucose levels, although important, and electroneuronography do not
predict how long therapy should be continued. (Best response: C)
[16]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Exostoses are not traditionally considered neoplastic. Exostoses are common in
patients who swim or bathe frequently in cold water. They are usually bilateral
and appear as two or three smooth sessile protrusions on opposing surfaces of the
bony canal medial to the isthmus. (Best response: E)
Answer
Malignant tumors can arise from the external auditory canal, middle ear, and
temporal bone. When patients present with advanced neoplasms, it may not be
possible to determine the sites of origin. The majority of cancers of the middle
ear and mastoid originate in the external auditory canal from ectodermal tissue.
(Best response: A)
Answer
In discussing neoplasms of the ear, temporal bone, and skull base, it is helpful to
divide the discussion into anatomic regions because the tumor type, clinical
presentation, prognosis, and treatment are determined by the anatomic location
of the tumor. (Best response: C)
[17]
Otorhinolaryngology Examination Items and Teaching Commentaries
1. Factors that may predispose children to otitis media (OM) include all of
the following except
A. Day care.
B. Family history.
C. Native American ethnicity.
D. Second-hand smoke.
E. Craniofacial anomalies.
Answer
Although second-hand smoke has been thought to be linked to OM, no studies
have demonstrated direct causation. Epidemiologic studies of OM have
demonstrated a higher incidence of disease in children attending day care, those
with a strong family history, those of Native American ethnicity, and those with
significant anatomic abnormalities of the head and neck. (Best response: D)
Answer
Studies have not been able to demonstrate increases in serum IgE levels in
children with OME. Studies have found immune complexes in the serum and
middle ear effusion of children with OME. In addition, other indicators, including
increased IgG levels, mast cell degranulation, and eustachian tube edema
secondary to inflammatory mediators, have all been identified.
(Best response: B)
[18]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Otitis media associated with confirmed or potential suppurative complications is
an absolute indicator for tympanocentesis. In addition, the procedure may be used
to relieve severe otalgia and to confirm the microorganisms present in the middle
ear to determine appropriate antibiotic coverage. Otitis media in the newborn or
immunocompromised child also presents the potential for unusual
microorganisms, thus indicating the need for appropriate identification of middle
ear contents. (Best response: C)
4. The most common pathogens in otitis media (OM) include the following
except
A. Group B Streptococcus.
B. Streptococcus pneumoniae.
C. Haemophilus influenzae.
D. Branhamella catarrhalis.
E. Staphylococcus aureus.
Answer
Group A Streptococcus is more likely to cause OM than group B. Streptococcus
pneumoniae, H. influenzae, B. catarrhalis, and S. aureus have all been implicated
as common pathogens in OM. (Best response: A)
5. Therapy that has been proven to help in otitis media (OM) includes all
of the following except
A. Antibiotics.
B. Antihistamines.
C. Corticosteroids.
D. Tympanostomy tube placement.
E. Analgesics.
Answer
Controlled studies have failed to demonstrate the efficacy of antihistamines in the
treatment of OM. Similar studies have shown efficacy in the treatment with
[19]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Studies have shown that chronic middle ear fluid may spontaneously resolve up
to 12 weeks after onset. Tympanostomy tubes have been found useful in patients
who are unresponsive to antibiotic therapy, have a significant conductive hearing
loss, and demonstrate severe enough middle ear negative pressure to risk
cholesteatoma formation. They are also efficacious in patients who have
antibiotic allergies for which options for treatment are significantly diminished.
(Best response: E)
[20]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
All children will ultimately benefit from this vaccine. Pneumococcus is the most
common bacterial cause of OM in children. (Best response: A)
10.Currently, the most effective medical therapy for chronic otitis media
with effusion is
A. A 7-day course of antibiotics.
B. Daily dose of antibiotic prophylaxis.
C. Decongestants.
D. Antihistamines.
E. A 30-day course of full-dose antibiotics.
Answer
Numerous clinical trials have concluded that some patients may respond to a 21-
to 30-day course of full-dose antibiotic therapy. No data exist for shorter courses
of antibiotics. The use of antihistamines has not proven efficacious in any trial to
date. Decongestants have been shown to be effective in reducing nasal
congestion, but efficacy in middle ear disease is uncertain. (Best response: E)
[21]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Otorrhea in itself is not a serious concern in chronic otitis media. Computed
tomography is inappropriate unless other symptoms such as fever or pain are
present to suggest an intracranial complication. Cholesteatoma is not necessarily
required to produce otorrhea, and intensive medical or surgical treatments are not
required. Cleansing of the ear and topical drops are appropriate.
(Best response: C)
Answer
Granulation tissue often forms during the healing phase after open cavity
mastoidectomy. It should not be allowed to persist and cause otorrhea or to mature
into neomembranes that might obscure portions of the cavity. Computed
tomography is not helpful, and a revision operation is not performed unless
conservative measures fail. Thus, the surgeon should carefully débride the
granulation tissue and cauterize the base, while keeping in mind the critical
landmarks of the cavity to avoid injury to the facial nerve or the stapes.
(Best response: A)
[22]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Urgent surgical treatment may be required for intratemporal suppurative
complications or a facial palsy. Hearing results vary, but sometimes excellent
hearing results are obtained. The incus need not be removed if the ossicular chain
is intact, and the disease can be resected or exteriorized without removing the
incus. Open cavity surgery may be indicated under several circumstances such as
cholesteatoma in the only hearing ear, large labyrinthine fistula, etc. Thus, the
surgeon should individualize the approach to cholesteatoma depending on the
clinical setting and operative findings. (Best response: E)
4. The most critical factor in avoiding injury to the facial nerve during
mastoid operations is
A. Use of a facial nerve monitor.
B. A preoperative CT scan.
C. Drilling parallel to the nerve.
D. Using a diamond bur.
E. Exposing the sheath of the nerve by removing the overlying bone.
Answer
Facial nerve monitoring, although sometimes helpful to the surgeon in complex
mastoid surgery, is not sufficient to prevent injury if other critical technical
factors are not observed. A CT scan may demonstrate erosion of the fallopian
canal, which is important for alerting the surgeon to potentially higher risk to the
nerve, but cannot itself prevent surgical injury. Use of a diamond bur may be
appropriate for final polishing of the facial ridge but may produce injury to the
nerve if the proper technique is not observed. Intimate knowledge of the
intratemporal course of the facial nerve and proper surgical technique are the
critical factors in preventing injury. The surgeon must always drill parallel to the
course of the facial nerve, using copious irrigation and inspecting for the sheath
becoming evident through the intact bone. Exposing the sheath is not advised in
routine cases, and attempts to do so may actually jeopardize the nerve’s integrity.
(Best response: C)
[23]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The medial technique suffers from poorer exposure, which results in difficulty in
repairing anterior perforations. Although graft healing rates may be satisfactory
with either technique, the lateral approach provides slightly more reliable results,
especially for large and/or anterior perforations. The graft is placed medial to the
malleus with both techniques. Thus, the primary advantages of the medial
technique are its technical simplicity and the quicker healing resulting from
minimal dissection of ear canal skin. (Best response: A)
Answer
The first four choices are correct statements, making E the best response.
(Best response: E)
Answer
Although facial nerve paralysis is a feared complication in any ear operation, it is
not likely to occur with either tympanoplasty technique and would not be more
[24]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Ossicular reconstructive procedures may, on occasion, produce normal hearing,
but this is not expected routinely. Reconstruction procedures are often performed
in conjunction with mastoidectomy, sometimes at the same stage. Generally, the
use of the incus is preferred to synthetic prostheses owing to cost and
biocompatibility issues. Extrusion continues to be a problem even with the most
modern materials used in the middle ear. Success depends on proper placement
of the prosthesis, good eustachian tube function, and ongoing health of the middle
ear cleft. (Best response: D)
9. Options for reconstructing the ossicular chain when the long process of
the incus is eroded include all except
A. Performing an autograft incus interposition.
B. Using bone cement to restore ossicular continuity.
C. Placing a total ossicular replacement prosthesis between the malleus and
the head of the stapes.
D. Placing a partial ossicular replacement prosthesis between the tympanic
membrane and the head of the stapes.
E. Using a synthetic incudostapedial joint prosthesis.
Answer
A total ossicular replacement prosthesis is used only when the stapes
superstructure is absent and thus is inappropriate for the setting described. Any
of the other techniques listed are suitable for reconstruction of the middle ear
when the incudostapedial joint is eroded or disarticulated. (Best response: C)
[25]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
To minimize the size of the mastoid cavity, the mastoid tip should be removed
and the cavity should be widely saucerized. The facial ridge should be lowered
to a satisfactory level, and the proper technique involves drilling parallel to the
nerve and using copious irrigation to keep the field cool and clear of bone dust.
A proper meatoplasty is essential to the long-term outcome. Although many
authors may advise soft tissue obliteration, it is not essential to success and thus
is optional. (Best response: B)
[26]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The initial favorable clinical response suggests effective antibiotics for the
meningitis, and useful information from a tympanocentesis now is unlikely.
Repeat lumbar puncture without another imaging study is contraindicated. The
significant risk here is the development of another central nervous system
complication. Enhanced MRI to look specifically for cerebritis or brain abscess,
lateral sinus thrombosis, epidural abscess, and subdural empyema is essential, so
appropriate changes in management can be made. (Best response: C)
Answer
Meningitis in a 15-month-old child is likely to be a hematogenous complication
of acute otitis media, which will respond to medical management, whereas the
[27]
Otorhinolaryngology Examination Items and Teaching Commentaries
3. A 39-year-old man is seen with a chronically draining left ear and has a
positive fistula test in that ear. A computed tomography scan suggests
possible erosion of the lateral semicircular canal. Against which of the
following pairs of microorganisms should antibiotic therapy be directed?
A. Streptococcus pneumoniae and Mycoplasma pneumoniae
B. Pseudomonas aeruginosa and Mycoplasma pneumoniae
C. Haemophilus influenzae and Bacteroides fragilis
D. Haemophilus influenzae and Streptococcus pneumoniae
E. Pseudomonas aeruginosa and Bacteroides fragilis
Answer
Nearly all fistulae from chronic suppurative ear disease are caused by
cholesteatomas. The most common bacterial pattern in cholesteatoma is the
presence of multiple bacteria including both aerobic and anaerobic
microorganisms. Pseudomonas is the dominant aerobe, and Bacteroides species
are the most common of the anaerobic bacteria isolated. (Best response: E)
Answer
Large, clinically silent cholesteatomas are most likely to erode much of the
tympanic segment of the fallopian canal and be in direct contact with the facial
[28]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Although most of these techniques can detect lateral sinus thrombosis, the risk of
complications with arteriography and venography precludes their use. Enhanced
MRI is the choice because it is more sensitive than CT scanning and has low
morbidity. (Best response: D)
Answer
Computed tomography can demonstrate the bony destruction and coalescence
that are the hallmarks of coalescent mastoiditis. Magnetic resonance imaging
gives little or no information about bone disease but can more sensitively detect
evidence of all of the other conditions mentioned above. (Best response: B)
[29]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Although meningitis, epidural abscess, and subdural empyema are all associated
with fever, often high and sometimes spiking, diurnal spikes are uncommon. The
diurnal spikes, which on a graph resemble a picket fence, are classic for lateral
sinus thrombosis, even though they may only be present in 50% of cases today.
(Best response: B)
Answer
Except for the child with coalescent mastoiditis, all of the others could have an
encephalocele and a CSF leak. The girl with recurrent meningitis could have any
of several sources for CSF leakage or even a complement cascade deficiency
underlying her recurrent meningitis. Unoperated cholesteatoma has an extremely
low likelihood of causing this complication, even though it does rarely occur. The
43-year-old man with apparent serous otitis could have a spontaneous CSF leak
but more likely will have serous otitis from some other cause. The three previous
operations for cholesteatoma can easily have removed tegmen and abraded dura
and set the stage for this complication. (Best response: C)
[30]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Lumbar puncture is never performed until a computed tomography scan has
documented the absence of intracranial hypertension for fear of causing
cerebellar tonsil herniation and its catastrophic consequences. The principal
reason for lumbar puncture is to rule out or establish the diagnosis of meningitis
so that prompt treatment can be started. If the enhanced magnetic resonance
imaging is negative for other intracranial complications, a positive lumbar
puncture will establish the diagnosis of meningitis and rule out emergency
surgery, which is necessary for brain abscess and subdural empyema. If the
underlying otologic cause of meningitis is acute otitis media, only medical
treatment is necessary, as long as a post-treatment CT scan and tympanometry
document that the otitis media is completely resolved. If the underlying cause is
chronic otitis media, mastoidectomy is undertaken during the same
hospitalization as soon as the meningitis has been stabilized. (Best response: E)
10. A 14-year-old girl is febrile and toxic and has a 2 cm diffuse, tender mass
at the angle of the mandible. The ear on that side has been draining for
3 weeks; granulation tissue is seen coming through a perforation of the
tympanic membrane, but examination is difficult. Before you obtain a
computed tomography (CT) scan, your clinical impression is
A. Masked mastoiditis.
B. Bezold’s abscess.
C. Coalescent mastoiditis.
D. Cervical adenopathy.
E. Cholesteatoma.
Answer
A tender mass in the upper neck in the presence of suppurative otitis is a Bezold’s
abscess until proven otherwise. It can occur without any perforation or otorrhea,
so it is necessary to obtain a CT scan to verify the presence of mastoiditis.
(Best response: B)
[31]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Otosclerosis is an ongoing process of resorption and deposition of bone in bone
that developed from cartilage that surrounds the inner ear during development.
Otosclerosis is limited to the otic capsule. (Best response: B)
Answer
The highest prevalence of otosclerosis occurs in ethnic groups whose original
homelands surround the Mediterranean Sea. The incidence is low in Asiatic
peoples, including the Chinese, Indians, and Japanese. Likewise, there is a low
incidence in Native Americans. The lowest incidence occurs in Africans.
(Best response: A)
[32]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Schwartze’s sign is often seen during pregnancy. (Best response: C)
Answer
Otosclerosis often causes a mixed conductive and sensorineural hearing loss but
rarely causes a sensorineural hearing loss without a conductive component.
Otosclerosis progresses more rapidly during hormonal changes, as occur in
pregnancy. In stapes fixation, a type AS (depressed) tympanogram is found,
whereas the type AD (no point of maximum compliance) tympanogram is
characteristic of ossicular discontinuity. Otosclerosis is the most likely diagnosis
with a progressive conductive hearing loss in an adult with a normal otoscopic
examination. (Best response: E)
[33]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The main objective of stapes surgery is to restore sound pressure transmission to
the inner ear. This pressure is transmitted to the perilymph, but the objective is
not to increase inner ear fluid movement or movement of the round window
membrane. Preservation of the stapedius muscle may aid in protecting the inner
ear from intense sound. Although ossicular continuity is temporarily disrupted
during the procedure, the objective is to restore ossicular mobility rather than
continuity. (Best response: D)
Answer
Many otologists advise patients who wish to continue scuba diving or flying
nonpressurized aircraft not to have a stapes operation. Vocalists may experience
a change in the perception of their voice but with the plasticity of the central
nervous system quickly adjust. Rare persisting disequilibrium following a stapes
operation could be a problem for a professional dancer. (Best response: B)
[34]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Using a smaller opening in the footplate reduces the mechanical trauma to the
inner ear. All of the other choices represent false concepts. (Best response: B)
10. The most reliable means of improving hearing in the patient with
otosclerosis is a
A. Hearing aid.
B. Fenestration operation of Lempert.
C. Stapedectomy.
D. Stapedotomy
E. Partial stapedectomy.
Answer
Nearly all patients with a moderate or worse conductive hearing loss can be
helped with a hearing aid. In view of the risks of stapes surgery, the operation
should be discussed with the patient in the context of this fact.
(Best response: A)
[35]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Although it is difficult to obtain exact data for the percentage of congenital
hearing loss that is inherited, it is estimated to be 50% or greater. The incidence
of deafness attributable to infectious and iatrogenic causes is decreasing, and as
our ability to diagnose genetic abnormalities improves, the relative importance of
hereditary factors as causes of deafness increases. The severity of congenital
hearing loss varies from mild to profound. Congenital hearing loss, by definition,
is prelingual. It may be sensorineural, conductive, or mixed. (Best response: B)
Answer
Syndromic hearing loss accounts for nearly one-third of cases of hereditary
hearing loss. Twenty to 30% of hereditary hearing loss is inherited in an
autosomal dominant fashion. There is typically marked phenotypic variation in
syndromic hearing loss. Hereditary hearing loss may be associated with
mitochondrial mutations in a small percentage of cases and may be both
congenital and late onset. (Best response: B)
[36]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Branchio-oto-renal syndrome is inherited in an autosomal dominant fashion. It
may be associated with a dilated vestibular aqueduct, although this is more
characteristic of Pendred’s syndrome. Branchio-oto-renal syndrome is associated
with mutations in EYA1, although in 70% of cases, mutations have not been
found. Renal anomalies occur in up to 75% of cases. Branchio-oto-renal
syndrome exhibits marked phenotypic variability, which suggests that it may be
a heterogeneous disease. This was recently confirmed with the identification of a
second locus. (Best response: B)
Answer
Hearing loss is typically sensorineural, prelingual, and non- progressive. It varies
from mild to profound, with profound bilateral loss being most common. Shah-
Waardenburg syndrome combines the features of WS2 with Hirschsprung’s
disease. Dystopia canthorum occurs in WS1 and WS3 but not in WS2 and WS4.
Heterochromia iridis is a typical feature of Waardenburg’s syndrome. (Best
response: C)
[37]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Although goiter may be apparent at birth in Pendred’s syndrome, it typically
presents in mid childhood. Despite a defect in the thyroid gland, affected
individuals usually remain euthyroid. The administration of a perchlorate in the
form of a challenge releases unbound iodide from thyroid follicular cells. The
disease is caused by mutations in PDS. (Best response: C)
Answer
Usher’s syndrome is the most common autosomal recessive syndromic hearing
loss. Type 2 Usher’s syndrome is not associated with vestibular loss. Usher’s
syndrome demonstrates considerable genetic heterogeneity as demonstrated by
the identification of 11 loci to date. Electroretinography may uncover early
retinitis pigmentosa. Mutations in EYA1 have not been demonstrated in Usher’s
syndrome. (Best response: A)
[38]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Mitochondrial hearing loss may be associated with diabetes mellitus. The number
of mitochondrial mutations increases with age. A point mutation at base pair 1555
(adenine to guanine) in the 12S rRNA causes both maternally inherited
nonsyndromic hearing loss and maternally inherited susceptibility to
aminoglycoside ototoxicity. In the United States, over 15% of persons with
aminoglycoside-induced hearing loss carry this mutation. (Best response: E)
[39]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Numerous different deafness-causing Cx26 mutations have been identified.
Mutations in Cx26 are responsible for over one half of moderate-to-profound
hearing impairment in many world populations. In the United States and much of
northern Europe, the most prevalent mutation is the 35delG mutation. In the
midwestern United States, the carrier rate for all deafness Cx26 mutations is 3%.
Connexin 26 is involved in gap junction formation. (Best response: B)
[40]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
In managing this problem, the ear canal should be cleaned thoroughly and
antibiotic drops prescribed. If bleeding persists, the site should be cauterized or
packed with Gelfoam coated with topical thrombin. (Best response: C)
Answer
Slap injuries are, by far, the most common cause of tympanic membrane
perforation, accounting for more than 80% in some series. Slag injuries tend to
cause a permanent perforation because the slag cauterizes the drumhead as it
passes through. Lightning causes vertigo and tinnitus in addition to a perforation
of the tympanic membrane. Penetrating objects are also likely to disrupt the
ossicles. (Best response: E)
[41]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The forces that lead to the development of a longitudinal fracture of the temporal
bone also tend to separate the incudostapedial joint. In many cases, fibrous
adhesions form between the drumhead and the incus and the stapes so that only a
minimal air–bone gap remains. (Best response: B)
Answer
The correction of a dislocated incus is largely dependent on the surgeon’s
preference. All of these methods give very similar results. (Best response: E)
[42]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Benign paroxysmal positional vertigo occurs in 25% of all head injuries whether
there is a fracture or not. It is treated with mild vestibular suppressants and
particle repositioning maneuvers. (Best response: A)
Answer
Schuknecht proposed that the high-frequency hearing loss seen after most head
injuries is attributable to concussive forces transmitted to the cochlea either
through the bone or through the stapes footplate. (Best response: D)
[43]
Otorhinolaryngology Examination Items and Teaching Commentaries
10. Which is the most common site for traumatic facial nerve injury
associated with gunshot wounds?
A. Mastoid segment
B. Geniculate-ganglion region
C. Stylomastoid foramen
D. Tympanic segment
E. Labyrinthine segment
Answer
This site seems to have the greatest predilection, perhaps because the nerve is
relatively fixed there. (Best response: C)
[44]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Temporary threshold shift (TTS) of less than 40 dB usually recovers within a
matter of a few hours; a TTS of greater than 40 dB may take several days to clear.
The former usually recovers completely, but the latter indicates greater damage
and is usually followed by some permanent threshold shift (PTS). The mechanism
of TTS appears to be that an excess secretion of glutamate, a neurotransmitter
released by stimulation of the hair cells, produces damage to the hair cells and the
receptor endings of the afferent nerve fibers in the synapses. Both recover.
Fractures of the cilial rootlets take place with more intense sound exposure and
are usually followed by outer hair cell death and PTS. (Best response: C)
Answer
The outer hair cells are not primarily transducers of sound. They do respond to
exposure to sound in a frequency-specific manner by contracting, thereby pulling
the tectorial membrane and the basilar membrane closer together, thus amplifying
the displacement of the cilia of the inner hair cells. The inner hair cells depolarize
as a result of the cilial displacement and trigger a nerve impulse. The outer hair
cells contain myosin. The contractions of the outer hair cells produce otoacoustic
emissions. The outer hair cells have an efferent nerve supply that represents the
effector arm of a feedback loop from the central nervous system.
(Best response: A)
[45]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The number of individuals exposed to potentially harmful levels of workplace
sound in the United States is about 30 million. If only industrial workers are taken
into account, the number would be between 8 and 11 million; but this excludes
such noisy occupations as mining, forestry, construction, road building, and the
armed forces. Thus, over 10% of the population of the United States is at risk
from excessive occupational noise exposure (according to the US National
Occupational Safety and Health Administration). Hearing loss produced by noise
exposure was the most common single cause of pensions following the war in
Vietnam. It is inadequately recognized that agricultural noise is a major source of
hearing loss. Farm workers are exposed for many hours to a variety of sound,
including heavy diesel motors in tractors and harvesting equipment, grain dryers,
ventilating fans, and chain saws. (Best response: E)
Answer
Permanent threshold shift usually begins with a 4 kHz dip but may also begin
with a hearing loss centered at 3 or 6 kHz. Lower-frequency hearing loss from
noise exposure is rare and late. The hearing loss progresses quite rapidly to begin
with, the rate dependent on the level of noise and individual susceptibility, and
then slows down. The notch, if it is going to occur, is usually already present
within a few months of beginning noise exposure and certainly by 2 years. It
peaks in the “notch” by 10 years, following which increased loss is much less at
that frequency, but it begins to spread into other areas. In later years, it becomes
more difficult to distinguish between presbycusis and noise-induced hearing loss.
(Best response: D)
[46]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
A worker who travels to and from work on a motorcycle may well be at further
risk from noise exposure; someone who fires pistols, shotguns, or rifles will also
develop hearing loss unless appropriate protection is worn. This loss, in the case
of rifles and shotguns, is usually asymmetric, with the ear nearer the muzzle being
more damaged, and is additive to any loss caused by occupational noise exposure.
Certain chemical solvents used in industry and leisure potentiate the effect of loud
sound, including toluene and petroleum products. What evidence there is suggests
that portable personal radio cassette players do not produce hearing loss. This is
not true of larger “boom boxes,” which may add to the problems. Neither snoring
nor snorkeling produces noise-induced hearing loss. (Best response: E)
Answer
Of the list, cab driving is probably the only non-noise hazardous occupation.
Farm workers are exposed to high levels of sound. Forestry workers, who use
heavy diesel equipment and chain saws, are very much at risk for hearing loss.
Many truck drivers are at risk, depending on whether they drive with the windows
open and on the position of the engine and soundproofing of the cab. Commercial
fishermen are close to the sound of the diesel motor of their vessels and, together
with seamen working on commercial tugs, are at risk from noise because they
may be exposed for 24 hours a day for several days at a time. (Best response: A)
[47]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Cerebellopontine angle lesions occur in industrial workers, as in the rest of the
population, and are a rare cause of asymmetric hearing loss in legal claims, but
they must be ruled out. Asymmetric hearing loss is an infrequent way of
malingering in industrial hearing loss claims; however, it is much more common
after head injury. It may be caused by leisure activities involving noise exposure
such as small arms fire. (Best response: D)
Answer
Hearing conservation programs include all of the items in the list. It must be
emphasized that hearing conservation is a system of health care, not just the
provision of hearing protectors. It is necessary to identify whether workers are at
risk, to label the area as hazardous, and to involve the workers in protecting
themselves from sound. Every measure must be taken to isolate them from
excessive sound, either by silencing machinery or insulating the workplace.
Hearing protectors should be provided if sound elimination is not possible.
Appropriate instruction in their use and monitoring that they are worn regularly
are necessary. The system should be monitored by regular hearing testing, which
identifies individual workers at risk and groups of workers for whom the hearing
conservation program is ineffective. It should be emphasized that the workers’
agreement to such a program is essential if it is to be effective. Management
participation is mandatory. (Best response: E)
[48]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Whether there is a genetic susceptibility to the harmful effect of noise in humans is
not clear, although it has certainly been identified in mice, some strains of which
develop hearing loss from noise exposure much more than other strains. Mice that
have early age-related hearing losses are also more susceptible to noise-induced
hearing loss. By implication, the same is suggested for humans. There is no evidence
that smoking predisposes to noise-induced hearing loss. Although it has been
suggested that blue-eyed people are more at risk, this has not withstood critical
evaluation. Men develop worse hearing loss than women, but this is usually
attributed to men having more noise exposure, particularly leisure or military noise
exposure. It is also suggested that happy sounds produce less hearing loss than
equivalent obnoxious sounds. The mechanism of this central feedback is unclear.
(Best response: A)
Answer
There is now considerable literature about the interaction between various
chemicals and noise exposure in the cochlea. These include aminoglycoside
antibiotics and certain organic solvents. Toluene, widely used in the printing
industry, is particularly well studied. It is synergistic with noise. Thus, lower safe
levels of noise are required in an atmosphere that contains otherwise safe levels
of toluene. Similarly, unexpectedly severe hearing losses have been found in
refinery operators, although most workers are isolated from the noise. Lead
exposure and certain other heavy metals such as mercury produce hearing loss
and interact with noise, as does carbon disulfide, which is used in certain chemical
processes. Fortunately, although aspirin in high doses is ototoxic, there is no
evidence that it is synergistic with noise exposure. (Best response: C)
[49]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Salicylates do not appear to affect the metabolism or excretion of aminoglycoside
antibiotics, nor do they appear to alter the distribution of aminoglycosides to the
cochlear tissues. They appear to act by chelating iron, making it less available for
combining with aminoglycosides to form free radicals, which can damage both
the cochlea and kidney. (Best response: C)
Answer
The outer hair cells of the basal turn of the cochlea are damaged first following
exposure to ototoxic doses of aminoglycoside antibiotics. The other cells listed
are less frequently damaged. The damage generally proceeds from base to apex
in the outer hair cells and then from apex to base in the inner hair cells. The latter
seems to occur only after most of the outer cells of the entire cochlea have been
destroyed. The basal turn outer hair cells seem to be most vulnerable because they
have the lowest concentration of glutathione, a powerful protective antioxidant.
This property would make them more vulnerable to free radical damage.
(Best response: D)
[50]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Cisplatin damages the outer hair cells most frequently, whereas carboplatin
damages the inner hair cells in animal experiments. Cisplatin is extremely
nephrotoxic, but carboplatin has much less nephrotoxicity. Both drugs suppress
the bone marrow. Vestibular symptoms occur infrequently after administration of
either drug. (Best response: C)
Answer
Recent studies have shown that hypersensitivity to aminoglycoside- induced
hearing loss can be transmitted by mothers to their offspring by a mutation of the
DNA in their mitochondria. Aminoglycoside antibiotics are poorly absorbed
through the gastrointestinal tract or through intact skin. Because of the former,
they are generally administered by injection. Aminoglycosides are excreted by
glomerular filtration through the kidneys; therefore, in the presence of renal
failure, the amount of drug in the body remains longer than in patients with
normal renal function. (Best response: A)
[51]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Cisplatin is much more likely to cause hearing loss in the adult, and the hearing
loss is more likely to be severe and permanent than that caused by loop diuretics.
The other choices are all true. Loop diuretics are likely to interfere with ion
transport mechanisms in the inner ear, specifically in the stria vascularis, which
may produce transient edema in this tissue. The loop diuretics are effective either
by the oral or intravenous route of administration. They have been reported to be
associated with permanent hearing loss in neonates. (Best response: B)
Answer
No studies have shown that regeneration of cochlear cells occurs in humans. This
has been shown to occur in birds. Renal failure is a risk factor for hearing loss
caused either by aminoglycosides or furosemide. The higher the blood level of
salicylates is, the more severe the tinnitus will be. Brain irradiation is associated
with a greater probability and increased severity of hearing loss following
cisplatin chemotherapy. (Best response: E)
[52]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Food reduces the rate of absorption of aspirin from the stomach, and this may
result in a lower, more sustained blood level, which may be associated with a
reduction of tinnitus severity. The presence of food in the stomach does not
increase the rate of absorption of aspirin from the stomach, nor does it accelerate
the rate of elimination by the gastrointestinal tract or kidneys, nor does it alter the
rate of metabolism by the liver. (Best response: A)
Answer
Choice A has two ototoxic agents, but kanamycin is not an antineoplastic agent.
The other pairs of drugs contain at least one agent that is not considered to be
ototoxic. (Best response: E)
[53]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Although intratumor injection with cisplatin-epinephrine gel keeps other options
open, reduces the risks of ototoxicity and nephrotoxicity, and is potentially a less
invasive treatment, the probability of complete remission is not higher than with
systemic cisplatin treatment. (Best response: D)
Answer
Gentamicin will not be expected to reduce the antitumor efficacy of cisplatin. The
other responses are all true. The interaction between gentamicin and cisplatin is
likely to increase the risk of ototoxicity. The rate of renal elimination of
gentamicin is reduced when renal function is impaired. Cisplatin is not known to
reduce the antibacterial efficacy of gentamicin. (Best response: C)
[54]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
See the classic study: Mattox DE, Simmons FB. Natural history of sudden
sensorineural hearing loss. Ann Otol Rhinol Laryngol 1977;86:463–80.
(Best response: D)
Answer
Rubella was an important cause prior to widespread use of the mumps-measles-
rubella vaccine. Rubeola and mumps can cause deafness acquired in childhood
but not congenital infection transmitted in utero. Congenital herpes infection is
less common than cytomegalovirus infection (about 1% of neonates).
(Best response: A)
[55]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Common vascular disease risk factors such as hypertension and diabetes have not
been shown to be associated with increased risk for sudden sensorineural hearing
loss, nor have anemia or polycythemia. Inner ear hemorrhage does occur
spontaneously and has been associated with leukemia, sickle cell disease, and
thalassemia. (Best response: B)
5. A patient with sudden sensorineural hearing loss reports that she had
skin rash and joint pain about a month ago. Your workup should include
A. Computed tomography.
B. Otoacoustic emissions.
C. Serologic tests.
D. Complete blood count.
E. Electronystagmography.
Answer
This history suggests the possibility of Lyme disease, and confirmatory serologic
tests are indicated. Otoacoustic emissions, electronystagmography, or complete
blood count is unlikely to contribute to management. Acoustic tumor is always a
possibility with sudden sensorineural hearing loss, but computed tomography is
rarely the right choice for imaging these tumors. (Best response: C)
[56]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Wilson and colleagues’ (1980) study showed that “U-shaped” losses always
improved spontaneously, profound losses were not helped by corticosteroids, and
moderate losses doubled their recovery rate with corticosteroids.
(Best response: C)
Answer
Rubella syndrome includes heart lesions; cytomegalovirus syndrome does not.
(Best response: D)
Answer
Mumps deafness is usually unilateral, in contrast to cytomegalovirus infection,
rubella, and rubeola. Adenoviruses have not been proven to cause sensorineural
hearing loss. (Best response: E)
[57]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Hemorrhage can be documented only by viewing precontrast images; cochlear
tumors are rare and would enhance focally. Cerebrospinal fluid leaks and
cholesteatoma are nonenhancing lesions. Transient enhancement in sudden
sensorineural hearing loss is believed to reflect failure of the blood-brain barrier
secondary to inflammation. (Best response: B)
Answer
Only cytomegalovirus screening and follow-up for progressive postnatal
sensorineural hearing loss can detect cases of sensorineural hearing loss caused
by cytomegalovirus. (Best response: A)
[58]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Early observers thought that a positive response to a fistula test indicated an
opening between the middle ear and the inner ear even in the absence of
inflammatory changes. It appears that they were correct but did not have the
ability to observe small amounts of fluid owing to the lack of the operative
microscope. (Best response: A)
Answer
The triad (1) positive fistula test (Hennebert’s sign/symptom); (2) constant
dysequilibrium, however mild (eg, eyes closed walking); and (3) postural
nystagmus and/or vertigo has been tested for diagnostic accuracy for
perilymphatic fistulae (p < .001). The sensitivity of 59% suggests under
diagnosis, but the “gold histologic standard” was patency of the expected sites
(eg, fissula ante fenestram). There is the possibility of patency without
permeability, as suggested by early studies concerning proteoglycans. This would
affect the sensitivity value. Repeat histologic evaluation using appropriate
proteoglycan antigens would be useful. (Best response: B)
[59]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Observations with the patient wearing Fresnel lenses to eliminate visual fixation
can miss the fine nystagmic movements related to perilymphatic fistula.
Extremely close observation with the naked eye can be inadequate, and
microscopic observation would be quite cumbersome. Electrode recordings of the
corneal-retinal potential changes yield false-positive results. It appears that
infrared nystagmography in darkness is most adequate for this purpose. It
completely eliminates visual fixation and has an added value in that the video
recording of the eyes allows repeat observation of the test. (Best response: D)
Answer
The vestibulospinal response to fistula testing appears to be more sensitive than
the vestibulo-ocular response in that some patients with a positive vestibulospinal
response have been found to have a negative vestibulo-ocular response. The
possibility of a false-positive response owing to malingering is avoided by using
platform testing of the alleged dysequilibrium, which would indicate either an ill-
timed response or impossible combinations of platform-fixed versus sway
oriented platform motion. Also, multiple repeat testing at a single session should
result in a response decline; however, this is not absolutely reliable. The fistula
test for the vestibulospinal response is essential in an evaluation for a
perilymphatic fistula. (Best response: C)
[60]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Performing surgery after 5 days of bed rest pertains only to sudden sensory
hearing loss of perilymphatic fistula origin. Medical management for 6 weeks
pertains to all perilymphatic fistulae except those causing sudden sensory hearing
loss. Activity a few days postoperatively has caused recurrent perilymphatic
fistulae in documented reoperated patients. Some, however, may tolerate only a
brief postoperative course of rest. The risk–benefit relationships should be
considered. Maintaining physical restrictions postoperatively appears to be the
surest way to avoid recurrence of the perilymphatic fistula. Diuretics have not
been shown to be useful, although endolymphatic hydrops may be present in
some patients with perilymphatic fistulae. (Best response: D)
Answer
Perilymph indicators thus far appear unreliable, giving false negative results.
Large blanket seals ignore the small < 50 μm size of the fistula. A single small
piece of graft without the support of other graft pieces invites graft displacement,
although the accurate placement of the first small piece appears important.
(Best response: D)
[61]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
All evidence thus far indicates that an initial serum seal (clot) followed by a
fibrous tissue ingrowth is the mechanism in the sealing of the fistulous opening.
The clot in itself would not be long lasting enough without an inflammatory
reaction to allow for the development of a fibrous tissue seal. There is only
evidence (histologic) of a seal being provided by new fibrous tissue. However,
the possibility of a proteoglycan composition change has not been investigated as
a concomitant phenomenon. The hydrodynamics would be in the opposite
direction owing to the osmolality of the clot (from inner ear to middle ear).
(Best response: A)
[62]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Without careful evaluation, the mucosal folds about the round window niche can
be mistaken for a ruptured round window membrane; however, mucosa lacks the
dense fibrous character of the periphery of the round window membrane, and the
membrane is medial, not lateral, to the round window fissure. Fluid escaping from
the round window fissure would be seen to reaccumulate on repeated aspiration
from the fissure area in the presence of an intact round window membrane. No
animal experiments have resulted in chronic fistulization of the round window
membrane. Although the round window membrane appears to be the weakest
portal, experiments indicate that an extreme pressure differential is required to
cause its rupture. (Best response: A)
[63]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The lack of more refined diagnostic criteria relates to probable permeable and
nonpermeable patencies of the labyrinthine capsule, which, in turn, are probably
related to proteoglycan composition. Proteoglycan histologic identification
appears adequate in related preliminary studies of perilymphatic fistulae. The
histologic diagnostic criteria have been tested in masked studies and appear not
to be erroneous but need further study to include proteoglycan histologic analysis.
Calculations in this regard are simple and have been doubly checked by
statisticians. (Best response: B)
[64]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
It is important to recognize that a wide variety of autoimmune conditions may be
benefited by the use of immunosuppressive drugs. Rapidly progressive
sensorineural hearing loss can be associated with all of the above except diabetes,
which, in fact, would have a contraindication for the use of corticosteroids owing
to the instability of blood sugar. (Best response: C)
Answer
Although several of these choices may play a role in the actual final cause of the
hearing loss, the precise pathophysiology is not known, but the inner hair cells
and/or spiral ganglion cells are thought to be most affected by autoimmune inner
ear disease in these animal models. (Best response: B)
[65]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The antigen target of the autoimmune inner ear disease response in humans appears
to be a 68 kD inner ear protein that has been detected in several studies in a
statistically significant proportion of patients with autoimmune inner ear disease
compared with controls. Best response: A
4. Diagnostic testing for autoimmune inner ear disease includes all of the
following except
A. Otoblot to measure anti–68 kD inner ear antibodies.
B. Serum protein electrophoresis.
C. Antinuclear antibodies.
D. Lymphocyte transformation.
E. Temporal bone immunohistochemistry employing patient serum.
Answer
Serum protein electrophoresis is not considered useful in this disease. Each of the
other choices represents a potentially useful diagnostic test for determining an
autoimmune cause for deafness. Best response: B
Answer
A 75% rate of hearing improvement was seen with corticosteroids in patients with a
positive Western blot for a 68 kD antigen compared with 18% of patients who were
Western blot negative, as reported in a study by Moscicki and colleagues.
(Best response: C)
[66]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Each of the above choices has merit; however, E is not accurate. There have been
no animal models created through autoimmune mechanisms that accurately
mimic Meniere’s disease seen in humans with recurring attacks of vertigo and
fluctuating hearing loss. (Best response: E)
Answer
Otoblot for a 68 kD antigen is not uniformly helpful in all autoimmune conditions
that affect the inner ear; for example, in Cogan’s syndrome, for which the target
antigen is found to be a 55 kD antigen, or in type 4, for which there is an
associated inflammatory condition, they have been found to be otoblot negative.
(Best response: A)
[67]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
All except B are appropriate. Although elevated blood sugars are seen, urinalysis
is not a standard means of determining this side effect. (Best response: B)
Answer
All of the statements except A are correct. The correct dosage of methotrexate is
7.5 to 20 mg per week, not daily. (Best response: A)
[68]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The superior vestibular nerve innervates the superior and lateral semicircular
canals and the utricle, whereas the posterior semicircular canal and the saccule
are innervated by the inferior vestibular nerve. (Best response: C)
Answer
The classic presentation of Meniere’s disease includes episodic rotatory vertigo,
fluctuating hearing loss, aural fullness, and tinnitus. The aural fullness is not
relieved by maneuvers to open the eustachian tube. Facial numbness is not part
of the constellation of symptoms associated with Meniere’s disease.
(Best response: E)
[69]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Vestibular rehabilitation should be considered in all patients with persistent
dysequilibrium that is troublesome. Vestibular rehabilitation is critically
important in the elderly since their ability to achieve central compensation is
diminished. Vestibular suppressants should be avoided except for management
of acute vertigo. (Best response: B)
5. Which of the following is not a risk factor for the development of benign
paroxysmal positional vertigo (BPPV)?
A. Gender
B. Middle age
C. History of trauma
D. History of vestibular neuronitis
E. Ear surgery
Answer
Nearly 20% of patients seen at vertigo clinics will be given the diagnosis of
BPPV. There is no gender bias. The average age of presentation is in the fifth
decade. Ten to 15% of patients will have an antecedent history of vestibular
neuronitis, and another 20% will have a history of head trauma. Some patients
have had BPPV following ear surgery. (Best response: A)
[70]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The natural history of BPPV includes an acute onset and remission over a few
months. However, up to 30% of patients may have symptoms for longer than 1
year. The majority of patients will improve with a repositioning maneuver.
Patients may have unpredictable recurrences and remissions, and the rate of
recurrence may be 10 to 15% per year. These patients may be retreated with a
repositioning maneuver. A subset of patients who have adapted by not using
certain positions to avoid the vertigo or who have other balance disorders will
benefit from balance rehabilitation therapy. Intratympanic gentamicin does not
have a role in the management of patients with BPPV. (Best response: E)
Answer
The presentation of vestibular neuronitis includes sudden onset of vertigo with
nausea and vomiting. Patients usually have normal hearing and a normal
neurologic examination. The natural history of vestibular neuronitis includes an
acute attack of vertigo that lasts a few days with complete or at least partial
recovery within a few weeks to months. The majority of patients have complete
recovery and so have an excellent prognosis. Recurrent attacks in the same or
contralateral ear have been reported but are unusual. Some patients may later
develop benign paroxysmal positional vertigo but not Meniere’s disease. The few
patients who have persistent vestibular symptoms should have vestibular
rehabilitation. (Best response: C)
[71]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Hearing loss is present in 95% of patients with vestibular schwannomas.
Conversely, 5% of patients will have normal hearing, so unilateral vestibular or
facial complaints without hearing loss do not rule out retrocochlear disease.
Although high-frequency hearing loss is classically associated with vestibular
schwannomas, any type of hearing loss may occur. Of the patients with hearing
loss, most will have slowly progressive hearing loss with noise distortion. Twenty
percent will have an episode of sudden hearing loss. The improvement of hearing
loss with or without treatment does not rule out retrocochlear disease. The level
of hearing loss is not a clear predictor of tumor size. (Best response: E)
Answer
Cerebellopontine angle (CPA) lesions cause symptoms by compression of the
neurovascular structures in and around the CPA. The classic description of these
symptoms by Harvey Cushing included unilateral hearing loss, vertigo,
nystagmus, altered facial sensation, facial pain that later progresses to facial
palsy, vocal cord palsy, dysphagia, diplopia, respiratory compromise, and death.
This description highlights the untreated natural history of CPA tumors. Tumors
confined to the internal auditory canal (intracanalicular tumors) are not associated
with facial numbness. (Best response: C)
[72]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
A diagnosis of neurofibromatosis 2 should be entertained in all young patients
with a vestibular schwannoma. A family history of brain tumors should be
elicited. Contrast-enhanced MRI of the internal auditory canal and brain should
be obtained to exclude bilateral vestibular schwannomas and brain tumors (eg,
meningiomas). Magnetic resonance imaging of the spine should also be
performed to detect spinal tumors. Initial treatment may include observation
alone so that the patient can learn speech reading. Radiotherapy should be
discouraged in young patients with vestibular schwannomas. (Best response: D)
[73]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Socioacousis is defined as the hearing loss produced primarily by exposure to
nonoccupational noise in combination with lifestyle factors such as diet and
exercise. (Best response: E)
Answer
Additivity in dB, thus 35 dB plus 35 dB = 70 dB. Using intensity, 35 dB plus 35
dB = 38 dB or, using pressure, 35 dB plus 35 dB = 41 dB. (Best response: D)
[74]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The most prominent changes in the physiologic properties of the aging ear are
losses of auditory nerve function as indicated by increased thresholds of the
compound action potential (CAP) of the auditory nerve. The resulting shallow
input-output functions of the CAP are also reflected in shallow input-output
functions of auditory brainstem responses. Thus, what appears to be an abnormal
function of the auditory brainstem reflects only the abnormal output of the
auditory nerve. The reduced amplitudes of action potentials observed in aging
ears are probably reflective of asynchronous or poorly synchronized neural
activity in the auditory nerve. The pathologic basis of asynchronized activity in
the auditory nerve is unknown but probably involves the nature of the synapse
between individual auditory nerve fibers and the attachment to the inner hair cell,
primary degeneration of spiral ganglion cells, and reductions in the
endolymphatic potential. (Best response: D)
[75]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
If the variable of hearing loss is controlled, speech discrimination is not affected
by age. Although there are large individual differences in auditory behavior
among individuals that are predictable by individual differences in auditory
thresholds, there are many age-related declines in auditory behavior that are not
strongly associated with auditory thresholds. This is most evident using binaural
listening tasks conducted under acoustically stressful conditions. In many
binaural experiments using older subjects, age-related declines are observed that
appear to be independent of peripheral hearing loss; however, it is often difficult
to separate truly central processing disorders from disorders initiated by a
pathologic input from the aging cochlea. (Best response: B)
[76]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Both discrimination in intensity and discrimination in frequency have been shown
to decline with age only at low frequencies and independently of any hearing loss.
These results are important because they are negative effects measured in the
presence of normal hearing and may very well represent age-related declines in
information-processing capability. It remains unclear whether these age-related
declines represent age-related effects of the auditory periphery or central nervous
system. (Best response: D)
Answer
In aging animals, the endolymphatic potential is often reduced significantly and
proportionally to losses/degeneration of the stria vascularis. Moreover, in
experimental animals, hearing losses can be reduced by introducing a DC voltage
into the scala media and raising a low endolymphatic potential (ie, 15 mV) to a
value approaching 60 to 70 mV. Degeneration of the stria vascularis with the
resultant decline in the endocochlear potential has given rise to the “dead battery
theory” of presbyacusis. (Best response: C)
[77]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
One dramatic feature of age-related hearing loss is the decline of hearing levels
at frequencies higher than 3 kHz. By age 50 to 59, the hearing loss at 16 kHz is
greater than 60 dB. Hearing levels at 4 and 8 kHz exceed 50 dB by age 70 and
exceed 70 dB at 8 kHz by age 79. Hearing loss at frequencies above 8 kHz is even
more pronounced and is not predictable by hearing levels in the 1 to 4 kHz range.
(Best response: A)
Answer
In an experiment, rats were assigned to either caloric restriction, treatment with
several antioxidants, including vitamins E and C, or control groups and were
allowed to age in a controlled environment. The calorie-restricted group
maintained the best hearing, lowest quantity of mitochondrial DNA deletions, and
least amount of outer hair cell loss. The antioxidant-treated subjects had better
hearing than the controls and a slight trend for fewer mitochondrial DNA
deletions. The controls had the poorest hearing, most mitochondrial DNA
deletions, and most hair cell loss. (Best response: E)
[78]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Low-pitched or roaring tinnitus is one of the characteristic features of Meniere’s
disease. (Best response: D)
Answer
Both conditions can generate real sound. (Best response: C)
3. Masking
A. Does not play a significant role in tinnitus treatment.
B. Is underused and should be widely promoted.
C. Can be used but only together with alprazolam (Xanax).
D. Should be used only for patients with tinnitus and hyperacusis.
E. Is effective when maskers are tuned to tinnitus pitch.
Answer
Masking did not withstand the test of time and is rarely used. (Best response: A)
[79]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Nonauditory centers (the limbic and autonomic nervous systems) are always
involved in clinically significant tinnitus. (Best response: C)
Answer
The prevalence of tinnitus is approximately the same in children as in adults.
Hyperacusis has been reported in children as well. Hyperacusis is also part of
some medical conditions affecting children. (Best response: D)
Answer
Tinnitus retraining therapy always includes counseling and sound therapy. (Best
response: E)
[80]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Tinnitus retraining therapy can be and has been used effectively for patients with
various causes of tinnitus. (Best response: E)
Answer
Administration of lidocaine intravenously can abolish subjective tinnitus for a short
time but is not effective in the abolition of somatosounds. (Best response: E)
Answer
Reclassification of tinnitus into the category of neutral signals is the first step
necessary to achieve its habituation. (Best response: E)
[81]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Essential components of a cochlear implant include a microphone to pick up
acoustic signals, a speech processor to convert them into electrical signals, an
electromagnetic transducer system to transmit the electrical signal through the
skin, and an implanted electrode array. (Best response: B)
Answer
The CIS strategy filters the speech signal into a fixed number of bands, obtains
the speech envelope, and then compresses the signal for each channel. On each
cycle of stimulation, a series of interleaved digital pulses rapidly stimulates
consecutive electrodes in the array. The CIS strategy is designed to preserve fine
temporal details in the speech signal by using high-rate, pulsatile stimuli.
(Best response: C)
[82]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Initially, cochlear implantation in adults was limited to those who received no
benefit from amplification. Now the minimal benefit from conventional hearing
aids is typically defined as sentence recognition scores less than 40 to 50% correct
in the best aided condition. (Best response: D)
5. Good candidates for cochlear implants include all of the following except
A. Elderly adults.
B. Prelingually deaf children.
C. Prelingually deaf adults communicating principally with sign language.
D. Individuals with deafness owing to ototoxicity.
E. Children with deafness owing to meningitis.
Answer
Adults with prelingual deafness are generally not considered good candidates for
cochlear implantation. However, prelinguistically deafened adults who have
followed an aural/oral educational approach may receive significant benefit.
(Best response: C)
[83]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Stimulable auditory neural elements are nearly always present regardless of the
cause of deafness. Two exceptions are the Michel deformity, in which there is a
congenital agenesis of the cochlea, and the small internal auditory canal
syndrome, in which the cochlear nerve may be congenitally absent.
(Best response: E)
Answer
All of the choices are correct. The findings regarding other predictive factors have
been less conclusive. For example, Gantz and colleagues found that cognitive
ability was not associated with patient performance, whereas Cohen and
colleagues reported that higher IQs were associated with better speech perception
skills. (Best response: E)
[84]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Although it is true, for children, that the younger the age at which implantation is
performed the better the outcome is likely to be, it is also true that linguistic
experience prior to deafness is a distinct advantage. (Best response: A)
Answer
Of the five choices, only improved surgical technique has not received credit for
the progress. Of the other four, improvements in technology and refinements in
candidacy criteria probably deserve the most credit for securing for cochlear
implantation an enduring place in the (re)habilitation of the profoundly hearing
impaired. (Best response: A)
[85]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Initial management of paralytic lagophthalmos should include measures to
prevent exposure keratitis. Artificial tears and a bland eye ointment are the
mainstays of treatment. Patients with poor Bell’s phenomenon or trigeminal nerve
deficits are particularly at risk for corneal damage. (Best response: E)
Answer
Gold weight implantation for eyelid reanimation has many advantages over the
palpebral spring. The palpebral wire spring in experienced hands can afford the
capability of mimicking to some extent the spontaneous blink. However, it is
technically more difficult to perform, with a higher reported extrusion and
infection rate. (Best response: B)
3. As a general rule, how much of the lower lid can be resected without
disturbing the relationship of the inferior punctum to the globe?
A. One-tenth
B. One-eighth
C. One-sixth
D. One-quarter
E. One-half
[86]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Fibrillation potentials support the use of a nerve substitution procedure to take
advantage of the potential neurotized tone and movement of the intrinsic facial
musculature. Electrical silence indicates complete denervation and atrophy of motor
end plates. Under these circumstances, neurotized procedures are contraindicated,
and other reanimation procedures are indicated. (Best response: A)
Answer
Nerve substitution or nerve grafting procedures are contraindicated for long-
standing facial paralysis (> 2 years) owing to likely facial muscle motor end plate
degeneration. Muscle transposition, static suspension, or innervated free tissue
transfer procedures are all possible options at this point. (Best response: D)
[87]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Based on Dr. Hunt’s original papers, the sensory distributions reflected by
varicella-zoster virus recrudescence include all of the sites mentioned above, with
the exception of preauricular skin. The concha is the most common site of
vesicular eruption. (Best response: E)
Answer
Bell’s palsy has been classically defined as an “idiopathic facial paralysis” or as a
mononeuropathy of undetermined origin. Recent observations have linked the cause
to herpes simplex virus (HSV-1). Reactivation of latent HSV in the geniculate
ganglion may be the phenomenon responsible for Bell’s palsy. (Best response: B)
Answer
Although facial nerve injury is more likely with transverse temporal bone fractures
(approximately 50%), longitudinal fractures are much more common
(approximately 90% of temporal bone fractures). Therefore, longitudinal fractures
are the most common type of fracture associated with facial nerve injury.
(Best response: D)
[88]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Tumor involvement of the facial nerve should be considered if one or more of the
following are present: facial paralysis that progresses slowly over 3 weeks,
recurrent ipsilateral facial paralysis, facial weakness associated with muscle
twitching, long-standing facial paralysis (> 6 months), facial paralysis associated
with other cranial nerve deficits, or evidence of malignancy elsewhere in the
body. (Best response: C)
Answer
Electroneuronography is useful to calculate the percentage of degenerated fibers
relative to the unaffected side. Surgical decompression can be considered if
degeneration is greater than 90% within 14 days of onset and there is no voluntary
electomyographic activity. Electroneuronography can differentiate between
minor conduction blocks (neurapraxia) versus wallerian degeneration
(axonotmesis and neurotmesis), but it cannot differentiate between axonotmesis
and neurotmesis. Testing done within 3 days of paralysis may not accurately
represent the degree of injury because wallerian degeneration occurs over 3 to 5
days following injury or insult. (Best response: B)
[89]
Otorhinolaryngology Examination Items and Teaching Commentaries
1. Which of the following lingual papillae does not contain taste buds?
A. Circumvallate
B. Foliate
C. Fungiform
D. Filiform
E. All of the above contain taste buds
Answer
On average, humans have ~ 9 large circumvallate (also termed vallate; L. vallum
= rampart surrounded by a moat) papillae across the junction of the anterior two-
thirds and the posterior third of the tongue. Each papilla contains, on average, ~
250 taste buds, although large individual differences are present. The foliate (L.
folium = leaf) papillae, which consist of ridges between adjacent folds along the
posterior part of the margin of the tongue, number less than a dozen on each side.
Although estimates vary, the average number of taste buds per foliate papilla is
probably around 100 in adults. Fungiform (L. fungi = mushroom) papillae,
located over the surface of the anterior part of the tongue, vary considerably in
size and shape, some being short and cuboidal and others tall with mushroom-
like heads. The typical adult tongue contains several hundred fungiform papillae,
although not all harbor taste buds. Of individual fungiform papillae that do
contain taste buds, the number of buds ranges from 1 to 18 on those located on
the tongue tip and 1 to 9 on those located midlingually. The filiform (L. filum =
thread) papillae are the most numerous papillae on the tongue but do not harbor
taste buds. (Best response: D)
Answer
The layers of the olfactory bulb are, from the periphery inward, the olfactory
nerve cell layer, glomerular layer, external plexiform layer, mitral cell layer,
internal plexiform layer, and granule cell layer. There is no interglomerular layer
distinguished as such. (Best response: A)
[90]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Although loss of smell function has been associated with a number of systemic
diseases and metabolic disorders, most patients with such loss fall into one of
three major categories: head trauma, upper respiratory infections (eg, influenza
and the common cold), and rhinosinusitis. Of these primary causes, upper
respiratory infections are the most common. Typically, permanent hyposmia or
anosmia occurs after the age of 40 in such individuals. In a study of a large
number of consecutive patients seen at the University of Pennsylvania Smell and
Taste Center during the period from 1980 to 1986, upper respiratory infections
accounted for 26% of the cases, head trauma for 18%, and nasal and sinus disease
15%. (Best response: B)
Answer
According to a study in which the University of Pennsylvania Smell Identification
Test was administered to 1,955 persons spanning the entire age range, more than
75% of individuals over the age of 80 years evidenced major olfactory
impairment, with nearly 50% being anosmic. More than half of persons between
65 and 80 years of age evidenced major olfactory impairment, with nearly a
quarter being anosmic. Such losses are significant and place many older persons
at risk from fire, leaking natural gas, and spoiled food, as well as from
malnutrition from a lack of interest in food secondary to lack of flavor.
(Best response: C)
[91]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Drug-related adverse effects in the elderly can be quite debilitating and can lead
to decreased food intake and malnutrition. Among agents that produce altered
tastes are antilipemic agents (eg, cerivastatin, fenofibrate, atorvastatin,
gemfibrozil, lovastatin), adrenergic stimulants (eg, methyldopa), angiotensin-
converting enzyme inhibitors (eg, captopril, enalaparil), calcium channel
blockers (eg, diltiazem, amlodipine), and antiarrhythmics (sotalol, amiodarone).
Unfortunately, cessation of medication does not always result in resolution of
taste alterations, which can be quite long lasting and debilitating.
(Best response: B)
[92]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Although it has been estimated that the adult human olfactory neuroepithelium
contains ~ 6,000,000 receptor cells, an empiric determination of the size of this
region in a sample of males and females across a wide age range has never been
made. It is important to note that viruses and other pathogens produce damage to
the olfactory region over time that presumably is cumulative. Hence, the olfactory
region of adults is very heterogeneous, being interspersed with metaplastic
islands of respiratory-like epithelium. (Best response: D)
[93]
Otorhinolaryngology Examination Items and Teaching Commentaries
[94]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Furthermore, more than 600,000 cases of acquired immune deficiency syndrome
(AIDS) have been reported in the United States. (Best response: C)
Answer
Also, the incidence of AIDS is much higher in African Americans than in Whites, and
AIDS is the leading disease killer of African American men. (Best response: C)
Answer
Although the incidence in women is increasing more rapidly than in men, women
currently constitute 20% of AIDS cases. (Best response: B)
[95]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
In these regions, the transmission of AIDS is more frequently by sexual activity
than by intravenous drug use and other methods. This partially accounts for the
relatively higher incidence among women. (Best response: C)
5. In the United States, the risk of acquiring HIV from screened bank blood is
A. 1:62,000 units.
B. 1:125,000 units.
C. 1:225,000 units.
D. 1:450,000 units.
E. 1:700,000 units.
Answer
Banked blood is screened for HIV antibodies, and the rare infection would be
caused by blood from an infected individual who had not seroconverted at the
time of the donation. (Best response: C)
Answer
The CD4 receptor is a high-affinity target for binding by gp120, one of the HIV
major envelope proteins. CD4 receptors are expressed on T lymphocytes. Human
immunodeficiency virus strains tropic for activated T lymphocytes bind by the
CD4 receptor and CXCR4 chemokine coreceptor. (Best response: A)
[96]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Prevention of the cleavage of proteins and enzymes of the immature viral core is
the mechanism of action of the protease inhibitors. The other stages are part of
the viral cycle, but the protease inhibitors have little, if any, effect during these
stages. (Best response: E).
Answer
Approximately 10% of HIV-infected persons progress to AIDS within the first 2
to 3 years following infection. In contrast, 5 to 10% are so-called nonprogressors,
having stable CD4 cell counts after 15 or more years of follow-up.
(Best response: B)
Answer
Opportunistic infections have remained the proximate cause of death for nearly
all AIDS patients. The other causes are much less frequent. (Best response: D)
[97]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
More than 50% of homosexual men are infected with cytomegalovirus and may
shed it intermittently. The virus may reactivate to produce symptomatic disease
in patients with profound cell-mediated immune deficiency. In most cases of
symptomatic disease, the CD4 cell count is < 25 cells/mm3. The other choices
can be seen with relatively preserved cell-mediated immune function.
(Best response: D)
[98]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Rhinoviruses are the etiologic agents in more than 50% of cases of the common
cold. (Best response: B)
2. A 3-year-old child presents with fever and sore throat followed by the
development of small mucosal vesicles and ulcerations surrounded by
erythematous rings. The lesions are located on the anterior tonsillar
pillars and resolve without complications in 3 days. The most likely
etiologic agent is
A. Group A beta-hemolytic streptococcus.
B. Haemophilus influenzae.
C. Coxsackievirus.
D. Fusobacteria.
E. Influenza virus.
Answer
The clinical features describe herpangina, caused by coxsackievirus.
(Best response: C)
[99]
Otorhinolaryngology Examination Items and Teaching Commentaries
5. What is the most frequent site of involvement when leprosy affects the
upper respiratory tract?
A. Larynx
B. Hypopharynx
C. Nose
D. Middle ear
E. Salivary glands
Answer
The nose is by far the most frequently involved site. Mycobacterium leprae
prefers an ambient temperature of less than 37°C. (Best response: C)
[100]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Treatment of mucormycosis requires a prolonged course of amphotericin B, as
well as aggressive surgical débridement of all nonviable tissue. Antifungal azoles
are ineffective. The underlying condition must be corrected if possible.
(Best response: A)
Answer
Tuberculous otitis media typically presents with otorrhea. Other features include
granulation tissue or polyps of the middle ear, tympanic perforation, destruction
of ossicles, and a predilection for facial paralysis. (Best response: C)
[101]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The features described are consistent with the granulomatous and fibrotic stages
of rhinoscleroma. Broadening of the nasal dorsum produces the characteristic
Hebra nose. (Best response: E)
Answer
Parainfluenza viruses (types 1, 2, and 3) are the most frequent cause, accounting
for almost 75% of isolated viral agents. (Best response: B)
[102]
Otorhinolaryngology Examination Items and Teaching Commentaries
1. Which of the following statements does not support the hygiene theory
of the development of atopic diseases?
A. Childhood infections seem to hold a protective effect on the development
of allergy.
B. The youngest sibling has the greatest risk of development of allergic
sensitization.
C. Among Japanese school children, positive tuberculin responses predicted a lower
incidence of asthma and lower serum immunoglobulin (Ig)E at age 12 years.
D. Prior infection with hepatitis A was associated with a halving in the
prevalence of elevated specific IgE levels.
E. The prevalence of atopy in the former East Germany increased sharply
after reunification with the former West Germany.
Answer
A growing body of literature supports the hypothesis that childhood infections
hold a protective effect for the development of allergy. A number of factors
associated with Western living including family size, increased immunization,
and improved medical care are viewed as responsible for a decreasing number of
childhood infections. In support of the hygiene theory are studies demonstrating
an inverse relationship between frequency of allergic disorders and childhood
infection. Signals to the developing immune system may skew responses toward
allergic patterns later in life. Studies in Japan demonstrated an inverse
relationship between delayed hypersensitivity to tuberculin at age 12 years and
total and specific IgE levels. Studies of the Italian military found an association
with serologic evidence of prior hepatitis A virus infection and decreased specific
IgE levels. These support the concept that early infection can be protective in later
development of atopy. Lastly, the prevalence of allergic rhinitis in East Germany
increased in the 1990s, suggesting the possibility that factors associated with a
Western affluent lifestyle may play a role in the development of allergic disease.
Family structure and size have been shown to affect development of allergic
disease with an inverse association with family size and birth order.
(Best response: B)
[103]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Allergic rhinitis has a close relationship with asthma. Numerous studies have
shown a high incidence of allergic rhinitis in asthmatics, and control of nasal
allergies is thought to reduce asthma severity. There is growing evidence to
support the systemic response to a local allergic reaction; hence, through this
mechanism, nasal allergies could cause disease distally in the airway.
Inflammatory mediators could also be released into the airway, travel to the lower
respiratory tract, and induce inflammatory disease in that location. Challenge of
the lower airway with antigen has been shown to cause allergic inflammation in
the nose, suggesting the possibility of nasopulmonary neurogenic reflexes.
Asthmatics have been shown to have a decreased ability to condition cold, dry
air. Additionally, patients with seasonal allergic rhinitis out of season have a
reduced ability to warm and humidify air. These studies raise the possibility that
nasal conditioning capacity may affect lower airways disease.
Although allergic rhinitis frequently causes nasal obstruction and may affect
nasal breathing during sleep, this is not a proposed mechanism to explain the
relationship between asthma and allergic rhinitis. (Best response: E)
Answer
Immunoglobulin E plays a critical role in the immune response. This begins when
macrophages and other antigen presenting cells process the allergen before
presenting it to T helper cells, which then interact with B lymphocytes, leading
to their differentiation into IgE-producing plasma cells, a process involving
[104]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Chemokines have a variety of effects in the pathophysiology of allergic rhinitis.
Such effects include increasing the production of cells in the bone marrow, aiding
in the survival of cells in the nasal mucosa, synergizing with other cellular
activators, and acting as chemoattractants. Some of these inflammatory cells
elaborate substances that can cause local damage and mucosal modifications. The
chemokines are chemoattractant cytokines that play an important role in the
function and expression of leukocyte and endothelial adhesion molecules.
However, studies show that although chemokines have a profound effect on the
recruitment of cells to the tissue, they can exert a wide range of responses. In
vitro, in vivo, and challenge studies all support the importance of chemokines in
the pathophysiology of allergic rhinitis. (Best response: E)
5. Which of the following statements is not true about dust mite avoidance?
A. Bedsheets should be washed in water hotter than 130°F.
B. Using mattress covers is beneficial.
C. Use of a humidifier can decrease dust mite levels in houses.
D. Dust mites can be directly killed using commercially available products.
E. Removal of carpet can be useful.
[105]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The diagnosis of allergic rhinitis relies on a careful history to identify the
sensitizing antigen, both to establish the diagnosis and to institute the first
treatment, avoidance. Symptoms occurring in temporal relation to allergen
exposure suggest sensitization but are not diagnostic. With a classic history (eg,
sneezing each fall), empiric therapy may provide the simplest approach. In less
clear cases, allergy testing either by skin prick, intradermal, or in vitro methods
can identify allergens causing sensitization. However, individuals can show
evidence of sensitization by a positive skin test or elevated specific antibody
levels in the serum without having evidence of clinical disease. This emphasizes
the importance of a good history in the evaluation of patients with suspected
allergic disorders. Ancillary testing is often employed to evaluate for
complications of allergic rhinitis as well as related disorders such as sinusitis
(computed tomography scans) and asthma (pulmonary function testing).
Endoscopy, although not always indicated, can be useful in evaluating for
structural abnormalities (septal deviation), evidence of related diseases
(sinusitis), and other nonallergic nasal disorders. (Best response: D)
[106]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Both skin and radioallergosorbent test(RAST)can be employed in the diagnosis of
allergic rhinitis. All of the choices are disadvantages to skin testing, although in vitro
testing also has disadvantages, including cost, slightly lower sensitivity, and the time
delay between drawing the blood and obtaining the results. Data from clinical studies
comparing the results of skin testing and RAST in allergic subjects suggest a good
correlation between the two, with a higher sensitivity for skin testing.
(Best response: E)
Answer
Complete avoidance of the allergen(s) to which the patient is sensitive eliminates
symptoms of the disease. Thus, measures aimed at reducing allergen load from the
patient’s environment are effective in reducing symptoms. Simple measures can be very
effective. Filters used in air conditioning remove outdoor allergens from the air prior to
circulation inside a house. Rain profoundly reduces the levels of outdoor pollens. In the
case of cats, regular washing of the animal may help decrease allergen load. The use of
high-efficiency particulate air (HEPA) filters and of electrostatic filters effectively
removes particulates larger than 1 μm in diameter. Particles, however, must be airborne
for removal, such as pollens, whereas heavy particles that settle from the air rapidly,
such as dust mite feces, are not eliminated by these measures. Although air conditioners
can be useful, the critical factor for dust mite allergen control is maintaining a relative
humidity of less than 50%. A recent study suggested that air conditioning alone is not
always enough to maintain humidity below this critical value. Hence, dehumidifiers can
be a useful adjunct measure even in homes with air conditioning. Humidifiers must be
cleaned regularly to avoid becoming a source of mold allergens, which thrive in moist
environments. (Best response: D)
[107]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Although commonly prescribed, the various medications employed against
allergic rhinitis require careful consideration of side effects. Patients sometimes
complain of the odor of intranasal corticosteroids. This can sometimes be
alleviated by switching formulations from a particulate one to an aqueous
preparation. Budesonide (Rhinocort Aqua) and triamcinolone acetonide
(Nasacort AQ) have no odor. Although first-generation antihistamines are
effective and generally safe, their undesirable side effects of sedation,
anticholinergic effects, functional and performance impairment, and
gastrointestinal distress pose a number of concerns.
Studies show that a larger number of subjects developed impaired performance
compared with the number reporting sedation. Furthermore, impaired
performance can persist after the subjective feeling of somnolence dissipates—
hence the importance of warning patients who are taking these medications not
to perform some tasks such as operating heavy machinery or driving. In one
study, diphenhydramine caused worse impairment to driving than consuming
alcohol to the level of being legally drunk.
This poses significant public health concerns. Overdosage with oral
decongestants has been associated with hypertensive crisis. When given in
prescribed doses, however, decongestants do not induce hypertension in
normotensive patients nor do they alter the pharmacologic control of stable
hypertensive patients.
The systemic effects of intranasal corticosteroids have long been a concern. There
are studies that show decreased height in children associated with
beclomethasone use for perennial allergic rhinitis. However, another study with
mometasone showed no effect. Additionally, studies of long term effects,
including final adult height, have not been performed. Lastly, many studies have
been performed on asthmatics and are confounded by the effects of the disease
itself. The growth of pediatric patients receiving intranasal corticosteroids,
therefore, should be monitored carefully. (Best response: B)
[108]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Indications for immunotherapy have evolved over years of clinical experience.
The primary indication is symptoms not adequately controlled by avoidance
measures and pharmacotherapy. Patients with perennial symptoms may prefer
immunotherapy to daily medication. Proper resuscitative equipment should be
present because anaphylactic reactions can occur any time during treatment, even
in patients receiving maintenance dosages.
Factors that seem to contribute to increased complications, including fatalities,
seem to be labile, corticosteroid-dependent asthma that has required prior
hospitalizations, high sensitivity to allergen (as demonstrated by serum-specific
Immunoglobin E tests or skin test), and a history of prior systemic reactions.
Therefore, immunotherapy in symptomatic asthmatic patients should be
administered with extreme caution because these patients have the greatest
morbidity. Patients who are taking beta blockers should not receive
immunotherapy because, if anaphylaxis occurs, they cannot be resuscitated.
Immunotherapy should not be started in pregnant women because of the risk of
anaphylaxis and the resultant effect of hypotension on the fetus.
(Best response: B)
[109]
Otorhinolaryngology Examination Items and Teaching Commentaries
1. A 70-year-old man complains of soreness in the left vestibule over the last 3 to
4 months that has failed to respond to a variety of topical preparations. A small
ulcerated area is noted on the inner vestibule skin from which a biopsy is
taken. The histology report suggests chronic inflammation, a few basaloid
cells, and areas of necrosis. As a consequence, one should
A. Reassure him that there is nothing seriously wrong.
B. Arrange a computed tomography scan.
C. Perform a second biopsy.
D. Refer him to a dermatologist.
E. Place him on long-term oral antibiotics.
Answer
It may be difficult to obtain representative tissue from this area, particularly if
performed under local anesthesia. The presence of necrosis and basaloid cells should
suggest the possibility of a basal cell carcinoma, and the chronic inflammation and
necrosis may simply be from the center of the ulcer. Further deeper biopsy is indicated
to exclude malignancy. Imaging of this area is generally unhelpful, and long-term
systemic antibiotics are unlikely to alter the situation materially. (Best response: C)
Answer
Although collapse of the nasal bridge can occur if excessive cartilage is removed, in the
patient who feels generally unwell and who has developed some crusting and spotting
of blood from the nose, it is important to exclude granulomatous conditions such as
Wegener’s granulomatosis or sarcoidosis. This may be done with specific and
nonspecific tests such as the erythrocyte sedimentation rate, C-reactive protein,
antineutrophil cytoplasmic antigen (c-ANCA), and angiotensin converting enzyme.
Biopsy in Wegener’s granulomatosis is not pathognomonic, although a biopsy may
show you a noncaseating epithelioid granuloma in sarcoidosis. Neither a CT scan nor a
bone scan will confirm the diagnosis of these conditions. (Best response: D)
[110]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Active anterior rhinomanometry will provide information about the airway and will assist
in counseling the patient, particularly when surgical intervention is inappropriate. Nasal
inspiratory peak flow measures both sides of the nose together and has a broad range of
normality. Magnetic resonance imaging is unlikely to be helpful if the CT scan and
endoscopy are normal. The nasal and sinus mucosa has a good blood supply and generally
gives a high signal; mild inflammatory changes may persist for weeks and months after an
upper respiratory tract infection, and this may lead to a confusing overdiagnosis of disease.
Tests of mucociliary function will not clarify the cause of the obstruction and are unlikely
to be abnormal in the absence of other symptoms. (Best response: B)
Answer
Tests of mucociliary clearance are either lengthened or impossible to measure. The
normal range for a saccharin test would be 20 to 30 minutes. Nitric oxide levels in the
nose are usually higher than those in the chest as most of the gas is produced in the
paranasal sinuses. Levels are significantly lower in both areas in PCD, usually in single-
figure parts per million from the chest and double figures from the nose and sinuses.
Ciliary beat frequency from the inferior turbinates is reduced below the normal range
of 12 to 15 Hz or beats per second, uncoordinated or absent. Both the cilial ultrastructure
and cilial arrangement one to another can be abnormal in PCD, but this does not
necessarily affect all of the cilia, and as a consequence, although patients may be sub-
or infertile, some have managed to conceive naturally. Thus, advice on contraception
may be required. (Best response: B)
[111]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
In cystic fibrosis, the condition has an autosomal recessive inheritance, and the
defect primarily affects the secretions, so ciliary beat frequency and ultrastructure
are normal. Bronchiectasis and dextrocardia are features of PCD and not cystic
fibrosis. However, any child presenting with nasal polyposis should be suspected
of having cystic fibrosis and submitted to the appropriate sweat tests and
deoxyribonucleic acid (DNA) evaluation. Up to 30% of children and 50% of
adults with cystic fibrosis suffer from nasal polyposis, and the majority have some
degree of chronic rhinosinusitis. (Best response: E)
7. Septal perforations
A. May result from malignant tumors.
B. Always produce collapse of the bridge.
C. Always produce nasal symptoms.
D. Are often associated with the use of topical nasal corticosteroids.
E. Are easy to close surgically.
[112]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The differential diagnosis would include chronic rhinosinusitis, unilateral choanal
atresia, the presence of a foreign body, and any other pathology in the postnasal space.
A CT scan performed in both the coronal and axial planes would enable these conditions
to be distinguished and appropriate treatment undertaken. Although acoustic rhinometry
can help to quantify the topography of the nose, it becomes increasingly less accurate
in the posterior part of the nasal cavity and postnasal space and may be distorted by the
presence of secretions. Microbiology, although it may demonstrate the presence of
infection, particularly anaerobes in association with a foreign body, will not help
definitively to distinguish these conditions. An examination under anesthesia may be
ultimately required; it should not be undertaken without appropriate imaging. A
considerable amount of septal and turbinate surgery is undertaken inappropriately
without the elimination of other contributory or underlying pathology.
(Best response: A)
[113]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The University of Pennsylvania Smell Identification Test is well validated for sex
and age. It will quantify the degree of the loss into normal, hyposmia, or anosmia
and will help to exclude the possibility of malingering as a few correct responses
will be given by guesswork alone. Thus, a score of zero would be very suspicious
of exaggerating the loss. Evoked-response olfactometry can confirm the presence
or absence of olfaction but will not quantify it and is difficult to do without
trigeminal stimulation. Imaging can be useful to exclude inflammation, infection,
or neoplasia but will not demonstrate olfactory damage secondary to trauma. The
use of intrathecal fluorescein can be of use in identifying the site of a
cerebrospinal fluid leak after a head injury, but this can occur independently of
olfactory damage, with which it does not correlate. (Best response: D)
Answer
The facial pain may not be of great clinical significance, but it is most important
that he be examined to exclude a septal hematoma and/or the possibility that he
is developing an infection or toxic shock. (Best response: E)
[114]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The factors listed in choices A through D have been demonstrated to contribute
to the development of acute rhinosinusitis. Although there is some evidence to
suggest that gastroesophageal reflux may have a role in pediatric rhinosinusitis,
a role in the adult condition has not been demonstrated. (Best response: E)
Answer
Interleukin-4 and interleukin-5 are produced in the sinus mucosa by resident cells
and infiltrating lymphocytes. These cytokines work in concert to induce the
migration of eosinophils and prolong their survival. The presence of eosinophils
is characteristic of chronic sinus inflammation and contributes to the pathogenesis
of the disease. (Best response: B)
3. The goals of endoscopic sinus surgery include all of the following except
A. Removing all of the sinus mucosa.
B. Promoting drainage of the sinuses.
C. Removing osteitic bone.
D. Restoring normal mucociliary clearance.
E. Removing obstructive polyps.
[115]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The goal of initial therapy is to prevent disease progression and the possibility of
serious sequelae. Appropriately selected antibiotics are the mainstay of therapy
for acute sinusitis. Systemic and topical decongestants relieve nasal obstruction,
re-establish ostial patency, and ventilate the sinuses. The use of decongestants in
conjunction with antibiotics has been shown to be more effective than antibiotics
alone. (Best response: B)
[116]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
To perform an obliteration successfully, it is absolutely critical to remove all of
the mucosa from within the sinus. The gross mucosa is relatively easily stripped
from the sinus and its recesses. However, rests of mucosa exist within the small
foramina of Breschet in the bone of the anterior and posterior tables. Therefore,
all of the bony surfaces of the frontal sinus must be meticulously burred down
under microscopic visualization before placing the fat graft. (Best response: B)
Answer
A significant disadvantage of a frontal sinus obliteration procedure is the loss of
the ability to follow the status of the sinus endoscopically. This can make
assessment of postoperative frontal sinus complaints difficult and delay detection
of some late complications. Whereas computed tomography merely shows
opacification of the sinus after obliteration, magnetic resonance imaging can
differentiate fat used in the obliteration from retained mucosa, secretions, and
infection. The other choices have no role in postsurgical imaging of the frontal
sinus. (Best response: A)
[117]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The most common symptoms in chronic rhinosinusitis are nasal congestion and
discharge. Hyposmia and fatigue are also symptoms that are frequently
encountered in this patient population. As opposed to acute infectious sinusitis,
fever is seldom associated with chronic rhinosinusitis. Additionally, sinus pain is
much more characteristic of acute rhinosinusitis than the chronic form of the
disease. (Best response: C)
10. The most effective pharmacotherapeutic agents for nasal polyposis are
A. Antihistamines.
B. Topical corticosteroids.
C. Topical decongestants.
D. Nonsteroidal anti-inflammatory drugs.
E. β-agonist inhalers.
Answer
Of the choices given, the only agents that have any beneficial effect in the
management of nasal polyposis are topical corticosteroids. Nasal polyps may be
related to allergy in some patients, but antihistamines alone do not typically cause
polyps to regress. Decongestants and β-agonist inhalers have no specific role in
the treatment of nasal polyposis, and among nonsteroidal anti-inflammatory
drugs, aspirin can actually cause polyp formation in sensitive individuals.
(Best response: B)
[118]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Most headache types occur more often in women. This is true for migraines, tension
headaches, trigeminal neuralgia, and giant cell arteritis. The notable exception is
cluster headaches, which afflict men more often than women. (Best response: B)
[119]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Tension headache features include greater prevalence in women, bilaterality,
tightening or dull pain, exacerbation by stress, and association with depression.
Therefore, all of the features are correct. (Best response: E)
Answer
Cluster headaches have severe lancinating pain that often awakens patients. They
are associated with unilateral nasal congestion, rhinorrhea, and lacrimation. They
may occur with intracranial lesions or after meningitis. Therefore, (2) and (4) are
correct, and (1) and (3) are not. (Best response: B)
[120]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Giant cell arteritis is most likely to occur in women over 50 years of age, with an
elevated sedimentation rate and a temporal headache. The risk of blindness is 15%;
therefore, treatment should be initiated urgently. Confirmation of the diagnosis is made
on the histopathology of a temporal artery biopsy. (Best response: D)
Answer
Benign intracranial hypertension is characterized by papilledema, a normal neurologic
examination, elevated intracranial pressure, and no intracranial mass or ventricular
enlargement on radiographic studies. Associated symptoms include decreasing vision
and pulsatile tinnitus. Therefore, all of the features are correct. (Best response: E)
[121]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Chronic use of medication can cause headaches. Offending agents include NSAIDs,
barbiturates, codeine, hydrocodone, oxycodone, propoxyphene, ergotamine, and
dihydroergotamine. Therefore, all of the possibilities are correct.
(Best response: D)
10. Temporomandibular joint disorders have all of the following features except
A. Usually associated with organic joint disease.
B. More common in women.
C. Decreased range of motion in the temporomandibular joint.
D. Mild or moderate intensity.
E. Associated with bruxism.
Answer
Temporomandibular joint disorders occur more often in women. The pain is mild
to moderate and temporal, is exacerbated by jaw movement or bruxism, and
results in trismus, but, usually, organic disease in the joint does not exist.
(Best response: A)
[122]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Five to 15% of patients have squamous cell carcinoma associated with inverted
papilloma. The extent of involvement with squamous cell carcinoma determines the
role of adjuvant therapy. (Best response: B)
2. Fibrous dysplasia of the orbital rim and maxillary sinus is causing diplopia
and proptosis. The treatment should be
A. Radical maxillectomy.
B. Maxillectomy and orbital exenteration, with palatal prosthesis.
C. Maxillectomy with a microvascular osteocutaneous flap.
D. Partial excision with contouring/sculpting of involved areas.
E. Chemotherapy.
Answer
This disease process is treated in symptomatic patients with sculpting of the involved
bone resulting in partial excision. Enbloc resection is not indicated. (Best response: D)
3. The histology of malignant tumors of the sinonasal tract is varied; the type
with the most well-known link to environmental exposure to wood dust is
A. Squamous cell carcinoma.
B. Adenoid cystic carcinoma.
C. Adenocarcinoma.
D. Olfactory neuroblastoma.
E. Sarcoma.
Answer
Exposure to wood dust increases the relative risk of adenocarcinoma by 540 times.
However, it should be noted that squamous cell carcinoma also shares this
relationship to wood dust, with prolonged exposure resulting in a 21 times increase
in relative risk. (Best response: C)
[123]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
With CT, one has difficulty distinguishing between retained secretions and tumor
or tumor and swollen mucosa. Magnetic resonance imaging complements CT by
providing valuable information in the differentiation of normal mucosa from
neoplasm and neoplasm from retained mucus. (Best response: E)
Answer
Diagnostic and interventional angiography is valuable for therapeutic
embolization prior to resection of vascular tumors. This is typically performed
within 24 to 48 hours prior to resection. The use of embolization is valuable in
the treatment of juvenile nasopharyngeal angiofibromas. Angiography and/ or
balloon occlusion testing are performed for patients undergoing carotid resection
or bypass. In our experience, very few patients require this type of management.
(Best response: B)
6. What theoretical plane from the medial canthus of the eye to the angle
of the mandible divides the facial skeleton into two parts?
A. Ohngren’s line
B. Frankford’s line
C. Kennedy’s line
D. Osguthorpe’s line
E. Arcuate line
[124]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The role of histologic subtype has not been clearly defined. It has not been
associated with prognosis in many reports, and other authors have suggested
improved survival among adenoid cystic carcinoma and lymphoma and poorer
survival rates in undifferentiated carcinoma as well as melanoma. These data are
of limited value because of the different treatment regimens employed and the
small number of patients studied. (Best response: A)
Answer
The definition of resectability is determined with CT, MRI, and findings at
surgical exploration. Transdural extension, invasion of the prevertebral fascia,
bilateral optic nerve involvement, and gross cavernous sinus invasion are criteria
for unresectable lesions. Computed tomographic scans provide a detailed
understanding of the extent of the bone involvement and sites of bone invasion.
Magnetic resonance imaging helps define the presence of retained mucus and
swollen mucosa in areas adjacent to the tumor. This technology also allows better
definition of periorbital, dural, and brain invasion than CT alone. Neither entity
is highly sensitive and specific for subtle invasion through the orbital periosteum
or dura. (Best response: E)
[125]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The intercartilaginous incisions in combination with the piriform aperture and
complete transfixion incision allow mobilization and retraction of the nasal tip
and lower lateral cartilages out of the field. The advantage of this exposure is the
lack of external incisions. The approach does carry the risk of lip numbness
(temporary or permanent), vestibular stenosis, and oronasal or oroantral fistula.
(Best response: C)
Answer
The complication of anosmia is expected and would be viewed as a side effect.
Dacryocystitis occurs among patients who have resection of the ethmoid or
maxillary sinus. It can be minimized by performing a dacryocystorhinostomy.
Meningitis and pneumocephalus are also known complications of cranial base
surgery. The risk of pneumocephalus can be minimized with tracheostomy. The
risk of cerebrospinal fluid leak and meningitis is minimized with the use of
galeopericranial flaps for skull base reconstruction. (Best response: E)
[126]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The auricle is 85% of adult size by 3 years of age and is 90 to 95% of full size by
5 to 6 years of age, although it may elongate an additional 1 to 1.5 cm during life.
The optimal age for surgical correction is between 4 and 6 years of age. At this
age, the auricle is near or at full adult size, and the child is capable of participating
in the postoperative care of the ear. Also, the child is typically about to enter
school, and, unfortunately, children with protruding ears are commonly subjected
to severe ridicule by their young peers. (Best response: B)
Answer
The most common cause of outstanding ears is the lack of development of the
antihelical fold. This malformation of the antihelix is present in approximately two-
thirds of all outstanding ears. However, other pathologic features may also contribute
to the outstanding ear. A wide, protruding conchal wall is present in approximately one-
third of all cases. Additionally, the prominent concha is often accompanied by a
thickened antitragus. (Best response: A)
[127]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Most ear anomalies are inherited as autosomal dominant traits with incomplete
penetrance. (Best response: B)
Answer
In the mid-1960s, Mustarde described a corrective otoplasty technique that gained
quick and ready acceptance and wide popularity as it was seen as a marked
improvement over existing techniques. Horizontal mattress sutures placed in the
auricular cartilage along the scapha recreate the natural curve of the antihelix,
blending gently into the scaphoid fossa. Dimensions of the outer cartilage bites of
the horizontal mattress sutures have been described as 1 cm separated by 2 mm.
(Best response: A)
5. In Mustarde sutures, the distance between the outer and inner cartilage
bites has been described as
A. 12 mm.
B. 14 mm.
C. 16 mm.
D. 18 mm.
E. 20 mm.
Answer
The distance between the outer and inner cartilage bites is 16 mm. (Best response: C)
[128]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Once the new antihelix has been marked, 4-0 braided nylon horizontal mattress
sutures are placed sequentially, from caudal to cephalic along the neoantihelical
fold. These horizontal mattress sutures are placed through the posterior
perichondrium, auricular cartilage, and anterior perichondrium. Careful palpation
with the free hand along the anterior surface of the auricle ensures that the needle
does not pass through the anterior skin. Incorporation of the anterior
perichondrium in the horizontal mattress suture is necessary to prevent the suture
from tearing through the cartilage when it is tied. (Best response: E)
Answer
The mattress suture procedure is frequently augmented by thinning, weakening,
and, occasionally, limited incision of the posterior surface cartilage to achieve
natural and symmetric results. Thinning of the cartilage by shave excision or with
a bur and incisions through the cartilage to facilitate folding will reduce the
tension on the horizontal mattress sutures. Using a scalpel, small disks of cartilage
can be shaved from the conchal region to allow retropositioning of the auricle.
This cartilage sculpturing is often sufficient to retroposition the ear and makes
conchal setback sutures unnecessary. Excision of cartilage in this area will
weaken the cartilage, reducing overall tension on the mattress sutures that will be
placed in the antihelix region. Great care is taken to achieve partial-thickness
excision of cartilage, and through-and through excision is avoided.
(Best response: B)
[129]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Infection may occur secondarily to an unevacuated hematoma but may also result
from lapses in sterile technique or from the presence of contaminated suture.
Evolution to Perichondritis occurs in approximately 1% of all cases. Treatment
must be aggressively implemented to prevent chondritis and resulting cartilage
necrosis and auricular deformity. Antibiotic treatment must empirically cover P.
aeruginosa. Persistent infection may also necessitate the removal of permanent
sutures and débridement locally. Preoperatively, a single dose of broad-spectrum
antibiotics can minimize the risk of infection. (Best response: B)
Answer
Overcorrection of the middle portion of the ear leads to a “telephone ear”
deformity owing to the relative prominence of the superior and inferior poles.
One commonly described cause of the telephone ear deformity is over-reduction
of the hypertrophic concha. Alternatively, overcorrection of the upper and lower
poles may result in the “reverse telephone ear” deformity. The term “lop ear” is
used to describe a deformity of the helix characterized by a thin, flat ear that is
acutely folded downward at the superior pole. In the “cup ear” deformity, weak
cartilage with resulting limpness of the auricle results in cupping or deepening of
the conchal bowl. The cup ear is often smaller than normal and folded on itself.
Poor development of the superior portion of the ear results in a short, thickened
helix and a deformed antihelix. (Best response: A)
[130]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Regardless of the surgical techniques employed, complications are reported to
occur at rates ranging from 7.1 to 11.4%. Early complications include hematoma
and infection. Infection can be cellulitis or perichondritis/chondritis, which can
lead to permanent auricular deformity. Late complications include paresthesias
and hypersensitivity, suture granuloma formation, suture extrusion, hypertrophic
scarring, and keloid fomation. Esthetic complications include inadequate
correction of the antihelix, overcorrection with a “hidden” helix, telephone ear or
reverse telephone ear deformity, persistent prominence of the concha,
malposition of the lobule, sharp cartilage edges when cartilage cutting approaches
are employed, and distortion of the external auditory canal with possible stenosis.
(Best response: C)
[131]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Where facial features and landmarks join is the best place to camouflage and hide
incisions on and about the nose. (Best response: C)
2. The most versatile of the local flaps available for nasal epithelial repair are
A. Cheek advancement flaps.
B. Rotation flaps.
C. Interposition flaps.
D. Island flaps.
E. Transposition flaps.
Answer
The local transposition flaps (bilobed, rhomboid, and Z-plasty) provide the best
options for complex nasal defect repair because of their versatility, options
provided, and one-stage repair characteristics. (Best response: E)
Answer
Obvious or overt obsessive-complex traits often indicate a tendency to expect
perfection, leading to complaints about inconsequential imperfections regarding
the outcome of surgery. (Best response: A)
[132]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Normal alar cartilages are composed of three distinct anatomic segments: the
lateral, medial, and intermediate crura. (Best response: B)
Answer
It is not necessary to perform a complete transfixion incision to gain effective
access to the nose through a typical nondelivery approach. (Best response: C)
6. Overprojecting nasal tips are the result of all except one of the following:
A. Hypertrophy of the alar cartilages
B. Enlarged nasal spine
C. An overlong caudal aspect of the quadrilateral cartilage
D. Excessive fat in the nasal tip
E. Hypertrophy of the dorsal quadrilateral cartilage
Answer
By itself, an increase of the fat in the nasal tip does not create tip overprojection.
(Best response: D)
[133]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Medial osteotomies alone do not result in a totally mobile lateral nasal sidewall.
(Best response: D)
Answer
No rotation is realized by dissection in the favorable tissue planes of the nose.
(Best response: E)
9. In the postoperative care of the patient, which of the following is most correct?
A. Antibiotics should be routinely used.
B. Decongestants should be taken daily.
C. The splint should remain in place for 5 to 7 days.
D. The foot of the bed should be elevated.
E. The inside of the nose should be cleaned daily with povidone-iodine and Q-tips.
Answer
The only choice in this group that is constantly important is the application of the
splint. (Best response: C)
[134]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Spreader grafts have no effect on tip projection per se and are used for correction
of internal nasal valve collapse and for straightening the lateral lines of the nose
on frontal view. (Best response: D)
[135]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The airway is compromised by a bilateral body fracture of the mandible because
of the posterior prolapse of the fracture fragment into the upper airway owing to
the contraction of the geniohyoid and genioglossus muscles. These muscles pull
the fracture fragment posteriorly, bringing the tongue into the upper part of the
pharynx. (Best response: D)
Answer
Because of the necessity of opposing the forces of distraction, an antitension band
is needed when a Champy miniplate is used to repair a fracture in the
parasymphyseal area of the mandible. These plates should penetrate only the
lateral cortex of the mandible. Intermaxillary fixation to establish normal dental
occlusion should always be placed prior to any interosseous fixation.
(Best response: A)
[136]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Children will remodel and even reform a new condyle over a period of 1 to 2
years. Intermaxillary fixation to relieve pain is followed by a period of oral
physiotherapy to mobilize the jaws. Open reduction and internal fixation often
result in avascular necrosis of the condyle and severe temporomandibular joint
dysfunction. (Best response: D)
Answer
The periodontal pocket between the gingiva and the tooth root is in continuity
with the oral cavity. (Best response: B)
[137]
Otorhinolaryngology Examination Items and Teaching Commentaries
7. The mechanism for the production of an open bite deformity in the Le Fort
III fractures of the maxilla is
A. Bilateral fractures of the zygomatic arches.
B. A vertical fracture through the hard palate.
C. The pull of the temporalis muscles.
D. The pull of the pterygoid muscles.
E. Airway obstruction.
Answer
The open bite occurs by virtue of the medial pterygoid muscles inserting on the
angle of the mandible. The craniofacial dysjunction created by the fracture frees
the maxilla from the cranium, allowing the natural pull of the medial pterygoids
to displace the maxilla toward the mandibular angle. The force is in a
posteroinferior direction. (Best response: D)
Answer
Cranialization provides the best means of managing the through-and-through
fracture of the frontal sinus. The craniotomy to repair the intracranial injury
provides excellent exposure for resection of all of the posterior wall of the frontal
sinus and every last remaining vestige of the frontal sinus mucosa. The
enlargement of the anterior fossa cavity provides an opportunity for expansion of
edematous brain without restriction. Returning the frontal sinus anterior wall
fragments provides for future protection of the brain and restoration of the normal
forehead contour. (Best response: B)
[138]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The bulk of the medial canthal tendon comprises the tendinous extension of the
preseptal and pretarsal parts of the orbicularis oculi muscle. The orbital portion,
the most external component of the orbicularis oculi, takes origin on the bones of
the orbital rim and inserts on the periorbital skin but does not contribute to the
medial canthal tendon. (Best response: C)
Answer
The typical displacement of the avulsed medial canthal tendon is laterally because
of the retraction of the orbicularis oculi, inferiorly because of the loss of support
by Lockwood’s suspensory ligament, and anteriorly because of the lack of the
tethering action of the canthal tendon and the medial check ligament.
(Best response: B)
[139]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
In the 3 to 4 mm embryo (3 to 4 weeks), the first indications of aural ontogenesis are
the first and second branchiomeric structures and the otic placode. The placode
invaginates to first form a pit and then a vesicle detached from its surface origin.
This otocyst forms the inner ear membranous structures, with the endolymphatic
duct developing first in the 6 mm embryo, followed by the appearance of the
semicircular ducts and the cochlear diverticulum in the 15 mm embryo (6 weeks).
By the end of the third month, the cochlea is fully coiled. The cranial nerves entering
the otocyst exert an inductive influence to produce neuroepithelium. The
cochleovestibular ganglia develop from the otic placode epithelium.
(Best response: C)
Answer
Six mesodermal thickenings or hillocks surround the entrance of the first branchial
cleft. The first branchial arch cartilage (Meckel’s) forms the tragus and superior
helical crus; the remainder of the pinna derives from the second arch cartilage
(Reichert’s). The developing auricular appendage migrates from its initial position
[140]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Atresia and microtia are associated with several known syndromes felt to be
associated with inherited defects or acquired embryopathies owing to intrauterine
infection (rubella, syphilis), ischemic injury (hemifacial microsomia), or toxin
exposure (thalidomide, isotretinoin). The genetic basis of external and middle ear
anomalies generally remains poorly characterized. Aural atresia occurs in
approximately 1 in 20,000 live births. Although the inner and middle ears develop
separately, inner ear abnormalities coexist in 12 to 50% of cases. Atresia is bilateral
in 30% of cases, occurring more commonly in males and in the right ear. It is not
surprising that an embryonic insult severe enough to cause aural atresia would also
affect other organ systems. (Best response: B)
[141]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Computed tomographic studies allow determination of the degree of the canal
atresia, the thickness of the atresia plate, the extent of pneumatization of the
middle ear and mastoid, the intratemporal course of the facial nerve, and the
presence or absence of the oval window and the stapes. An unsuspected
cholesteatoma may also be apparent. Brainstem response audiometry should be
performed in all infants born with either microtia or atresia. Bilateral involvement
may cause masking dilemmas, but this does not affect auditory brainstem
responses. As the infant matures, behavioral audiometric evaluations must be
obtained to confirm the neurophysiologic tests of hearing. (Best response: D)
[142]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Early amplification, auditory training, and speech therapy can improve speech and
language skills. In children with bilateral atresia, amplification with bone-
conduction aids should be provided as soon as possible, preferably within the first
few months of life. In infants with unilateral atresia and conductive hearing loss in
the seemingly normal ear, an air-conduction aid should be fitted to the ear with a
canal. In the unilateral case with normal contralateral hearing, repair of either the
microtia or the atresia is considered elective, and there is less urgency to intervene
during childhood. When the atresia is bilateral, with acceptable-appearing auricles,
reconstructive surgery can be performed at a fairly young age. However, in cases of
microtia that require reconstruction, atresia repair should be deferred until the initial
stages of the auricular repair are completed. (Best response: D)
[143]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Before assuming the responsibility of correcting congenital conductive hearing losses
and embarking on a procedure with significant potential complications, especially in
children, the otologic surgeon must have sufficient experience to maximize the
likelihood of a successful outcome. Once the middle ear is entered, the surgeon must
decide if the chain is fixed, and if it is, where is the fixation? Is it in the epitympanum?
Is the stapes fixed? Or is it a fixation of the stapedial tendon? A gap interrupting the
ossicular chain’s continuity occurs most commonly at the incudostapedial joint. The
presence of a mobile stapes facilitates the surgery and greatly improves the surgical
result. If there is a small distance between the stapes capitulum and the long process of
the incus, a tragal cartilage graft can successfully negotiate the gap. Deficiencies of the
long process of the incus can be corrected by either interposing the reshaped incus
between the mobile stapes and the malleus handle or using an alloplastic prosthesis
designed for this purpose (type III tympanoplasty). When the stapes arch is absent,
similar procedures can be performed to bridge the gap from either the malleus handle
or the undersurface of the drumhead to the mobile footplate (type IV tympanoplasty).
A coexisting fixation of the stapes or obstruction of the oval window by the facial nerve
increases the technical difficulty, yields poorer hearing results, and increases the
chances of complications, such as sensorineural hearing loss or facial nerve injury.
(Best response: A)
[144]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Microtia surgery is technically difficult, and not infrequently, the results are
somewhat disappointing. Correction of a severe grade III microtia requires
several staged procedures. During the first stage, either a carved segment of
cartilage from the lower costochondral skeleton or an alloplastic scaffold is
placed into a subcutaneous pocket at the appropriate position. A portion of the
microtic skin tag is maintained to construct the lobule. During the second stage,
the auricle is freed from the scalp, and a split-thickness skin graft is used to create
a postauricular sulcus. At a third stage, the tragus is created. An alternative
technique for the treatment of severe grade III microtia is to use a lifelike
prosthetic ear that is attached to surgically implanted titanium posts that securely
hold the auricle in a normal anatomic position. (Best response: D)
[145]
Otorhinolaryngology Examination Items and Teaching Commentaries
[146]
Otorhinolaryngology Examination Items and Teaching Commentaries
2. All except one of the following signs are oral manifestations of leukemia:
A. Gingival hypertrophy
B. Atrophic smooth erythematous tongue
C. Necrotic ulcers of the mucous membranes
D. Pallor of the mucous membranes
E. Petechiae of the mucous membranes
Answer
In addition to being anemic and thrombocytopenic, patients with leukemia are
often neutropenic, and secondary infections of the oral cavity and oropharynx
commonly occur, resulting in necrosis and ulceration of the mucous membranes.
Leukemic infiltration of the gums is common, causing gingival hypertrophy,
edema, inflammation, and bleeding. (Best response: B)
[147]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
There are at least 40 oral manifestations of HIV infections. They include oral
candidiasis, recurrent herpetic and aphthous ulcers, angular cheilitis, hairy
leukoplakia, periodontitis, gingivitis, diffuse parotitis, and Kaposi’s sarcoma. In
children, the most common signs are oral candidiasis, diffuse parotitis, and oral
ulcers. Wickham’s striae are interlacing white lines found in lichen planus.
(Best response: E)
Answer
The carotid sheath pierces the lateral pharyngeal space. The lateral pharyngeal
space communicates with the submandibular, retropharyngeal, and parotid spaces
and is in close proximity to the masticator and peritonsillar spaces. Its location
makes it the space most frequently involved with serious infections, and it is the
most frequent route of spread of infection from one region of the neck to another.
(Best response: C)
[148]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
If a cervical malignancy is suspected, an excisional biopsy is preferred. With localized
lesions, an excisional biopsy may be curative and provides for a sufficient amount of
tissue for additional studies such as permanent and frozen sections, electron
microscopy, special stains, and tumor markers. Although needle biopsies are safe and
accurate in adults, they often do not provide enough tissue to diagnosis pediatric
malignancies, which are rare and frequently consist of embryonic tissue. Many
pathologists do not have sufficient experience with these tumors and require large
amounts of tissue to make the diagnosis. (Best response: B)
Answer
Odontogenic tumors arise from the precursors of tooth formation. The odontoma, a
hamartoma composed of dentin, enamel, and cementum, is the most common
odontogenic tumor. Other odontogenic tumors include the ameloblastoma, myxoma,
adenoameloblastoma, dementoma, and cementoblastoma. Nonodontogenic tumors
arise from tissues other than dental precursors. The torus, fibrous dysplasia, osteoma,
eosinophilic granuloma, aneursymal bone cysts, hemorrhagic bone cysts, and
cherubism are nonodontogenic tumors. (Best response: E)
[149]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Velopharyngeal insufficiency may result from adenoidectomy, especially in the
presence of a submucous or frank cleft of the palate. This is characterized by
rhinolalia aperta and reflux of liquids into the nasal airway. Adenoidectomy has
been recommended for the treatment of recurrent otitis media, otitis media with
effusion, airway obstruction caused by enlarged adenoid tissue, and pediatric
sinusitis. (Best response: E)
Answer
All are complications of adenotonsillectomy, but nasopharyngeal stenosis is the
least common. Postoperative bleeding is the most serious complication, occurring
in up to 3% of patients. Dehydration is common, especially with children, because
they will not swallow because of the severe throat pain. Hypernasal speech
commonly occurs immediately following the operation because the pain limits
motion of the tonsillar pillars and soft palate. This usually resolves in several
weeks. Torticollis is not uncommon and is usually caused by inflammation of the
paraspinus muscles. Nasopharyngeal stenosis is rare and develops when the
inferiolateral adenoid tissue is removed and there is simultaneous denuding or
excision of the posterior tonsillar pillars. Adhesions form between the raw
surfaces, resulting in scarring and obstruction. (Best response: B)
[150]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Polysomnography in a sleep laboratory is the definitive diagnostic study for sleep
apnea. It can diagnose the type of sleep apnea, its degree of severity, and any
associated physiologic changes. The multiple sleep latency test measures daytime
somnolence and not sleep apnea. Nocturnal oximetry measures oxygen levels
during sleep. Measurement of esophageal pressures during sleep is an index of
respiratory effort during sleep and is used to diagnose central sleep apnea. In
children, sleep sonography provides objective data regarding the presence and
degree of upper airway obstruction, but its ability to predict apnea is not
established. (Best response: D)
[151]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The characteristics of stridor vary with the site and degree of obstruction. Most
supraglottic lesions produce stridor during inspiration. In the supraglottis, as the
velocity of the airflow increases, the intraluminal negative pressure draws soft
tissue into the airway during inspiration, increasing the degree of obstruction.
Obstruction in the distal part of the respiratory tract increases during expiration
as the trachea and bronchi constrict. (Best response: B)
Answer
The advantage of the flexible laryngoscope in an awake patient is that the
dynamics of the supraglottis can readily be appreciated. It can also be used to
diagnose other synchronous glottic lesions, such as vocal cord paralysis and
glottic cysts. (Best response: C)
[152]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Vocal dysfunction is the most common symptom in patients with laryngeal webs.
Airway obstruction is the second most common finding, and the stridor occurs in
both inspiratory and expiratory phases of respiration. Reflux is also observed in
infants with laryngeal webs. (Best response: E)
Answer
Saccular cysts are divided into lateral wall saccular cysts and anterior saccular
cysts. Lateral saccular cysts are most frequently located in the aryepiglottic fold,
epiglottis, or lateral wall of the larynx, whereas anterior saccular cysts extend
medially and posteriorly between the true and false vocal cords and directly into
the laryngeal lumen. Although lateral neck radiography, fluoroscopy, barium
swallows, and computed tomography of the neck may be helpful, a definite
diagnosis cannot be made with them because other lesions, such as hemangiomas,
may produce identical findings. (Best response: E)
[153]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Laryngoceles are only symptomatic when filled with air or fluid, so the symptoms
are inconsistent or intermittent. The diagnosis is made with direct laryngoscopy
with the aid of radiographs, including lateral and frontal cervical views.
Best response: A
Answer
All of the choices occur in patients with laryngeal clefts. Following aspiration
and cyanosis in frequency, there is asphyxia followed by increased mucus
production, recurrent pneumonia, and airway distress. (Best response: A)
Answer
Hydrocephalus and the Arnold-Chiari malformation may be associated with
caudal displacement of the brainstem through the foramen magnum and result in
compression of the vagus nerves and traction on the cervical rootlets of the vagus
nerves. Brainstem dysgenesis appears to be the most appropriate explanation for
familial bilateral vocal cord paralysis. (Best response: D)
[154]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Some patients outgrow their subglottic stenosis. Less than 50% of patients with
congenital subglottic stenosis require a tracheostomy. Choices A, B, D, and E are
not correct statements about congenital subglottic stenosis. (Best response: C)
[155]
Otorhinolaryngology Examination Items and Teaching Commentaries
1. The most commonly encountered congenital anomaly of the head and neck is
A. Second branchial cleft cyst.
B. Cystic hygroma.
C. Thyroglossal duct cyst.
D. Thornwaldt’s cyst.
E. Choanal atresia.
Answer
Thyroglossal duct cysts are the most common anomalies of the head and neck,
followed by branchial cleft defects, lymphangioma (cystic hygroma), and
subcutaneous vascular anomalies. Thornwaldt’s cyst presenting clinically is
uncommon, whereas choanal atresia, although the most frequently encountered
congenital nasal anomaly, occurs in only 1 in 7,000 to 8,000 births.
(Best response: C)
Answer
The CHARGE association is a nonrandom pattern of congenital anomalies that
occurs with choanal atresia. Additional anomalies include coloboma, congenital
heart disease, retarded growth and development, and ear abnormalities and
deafness. Responses C, D, and E, although congenital anomalies, are not
encountered with this disorder. Cleft palate has not been specifically reported
with the CHARGE association. (Best response: B)
[156]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Chordomas arise from primitive notochordal remnants. Rathke’s pouch and the
pharyngeal hypophysis, which is anterior to Thornwaldt’s bursa, are one and the
same. This is an area of endoderm in the nasopharynx that may remain connected
to the primitive notochord but is not the site of origination of chordomas.
Craniopharyngiomas arise in the parasellar region. The craniopharyngeal canal,
which runs from the sella turcica through the body of the sphenoid and is also
associated with cysts owing to the persistence of Rathke’s pouch, is not the site
of origination of chordoma. (Best response: A)
Answer
Response A is incorrect as ectoderm alone would be inconsistent with any form
of teratoma. The same is true of mesodermal elements alone. The combination of
[157]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Of all of the responses, the only one with an intracranial connection is the basal-
type encephalocele. Nasal gliomas, by definition, are heterotopic neural tissue
that is not connected intracranially. Thornwaldt’s cysts arise in the nasopharynx
and do not have any intracranial connection. Floor-of-mouth dermoids and
cervical teratomas do not require both forms of imaging. The use of CT and MRI
for basal-type encephaloceles is essential to plan surgical removal. Both of these
studies are not necessary to make a determination regarding the removal of the
other lesions. (Best response: D)
Answer
Rathke’s cyst most commonly presents with headache followed by galactorrhea,
visual field loss, and hypopituitarism. Chordoma is a distinct possibility.
However, only 50% of chordomas occur in the spheno-occipital area. They may
present with an expanding nasopharyngeal mass, frontal headaches, cranial nerve
palsies, and pituitary abnormalities. This wider range of presenting signs and
symptoms, however, is more commonly seen in younger children than in adults.
[158]
Otorhinolaryngology Examination Items and Teaching Commentaries
8. In 50% of cases, the Pierre Robin sequence (PRS) includes the triad of
glossoptosis, micrognathia, and
A. Microcephaly.
B. Hemifacial microsomia.
C. Cleft palate.
D. Congenital facial paralysis.
E. Dextrocardia.
Answer
The PRS includes glossoptosis, micrognathia, and cleft palate in 50% of cases.
Associated findings have included cardiac defects but not specifically
dextrocardia. Möbius’ syndrome or nonprogressive congenital facial diplegia is
a subset of the PRS. Therefore, response D is a possibility, and although facial
dysmorphism has been reported in PRS, specific hemifacial microsomia as an
element of the PRS has not been reported. Therefore, response B is unlikely.
Microcephaly is not observed in PRS, although mental retardation is.
(Best response: C)
Answer
Kartagener’s syndrome is a quartet of bronchiectasis, chronic sinusitis, situs
inversus, and sterility. It is associated with ultrastructural defects in dynein
complexes. Therefore, the best response is situs solitus, normal visceral
arrangement, as opposed to situs inversus. (Best response: D)
[159]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Nonsyndromic cleft palate is felt to be attributable to multifactorial inheritance in
those patients with no obvious first or second arch anomalies or systemic organ
malformation. In addition, single-gene transmission is not consistent with
nonsyndromic malformation but rather is seen in syndromic malformation. It is
felt that environmental factors may play a role in syndromic clefting rather than
nonsyndromic cleft lip and palate. (Best response: D)
[160]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
In each of the conditions specified, a shorter vibrating margin of the vocal folds would
result, thereby increasing the frequency of vocal fold vibration. In an underdeveloped
larynx, the vocal folds would be smaller than normal for a person of a given age and gender;
consequently, the talker would have a higher than normal pitch. With a laryngeal web, the
free vibrating edge of the vocal folds is reduced, creating a higher than normal pitch. With
structural asymmetry, during closure of the vocal folds, the vocal process of one arytenoid
cartilage may slide over the other in such a manner that the posterior parts of the
membranous folds are pressed together. This reduces the length of the vibrating portion of
the vocal fold. Swelling near the anterior commissure can also reduce the vibrating length
of the vocal folds and increase the fundamental frequency of vibration. (Best response: E)
Answer
Psychological factors are often of considerable importance in functional voice
disorders. Similarly, patients whose employment settings require loud talking or
who engage in loud cheering at sporting events need to change their environment
during the course of therapy. The patient’s perception of the voice problem is
crucial since the patient hears his/her own voice differently than do other
listeners. The voice therapist must have an accurate assessment of the range of
laryngeal capabilities of the patient before structuring appropriate vocal targets
for the patient. (Best response: C)
[161]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Patients with Reinke’s edema and those who have undergone virilization treatments
experience an increase in the size (thickness) of the vocal folds. The increased thickness
results in a lower than normal pitch level during phonation. Patients who use vocal fry
are usually producing vocal sounds with a fundamental frequency below 75 Hz.
Tremulousness is often associated with a lack of vibratory control of the thickened vocal
folds and, hence, low pitch phonations. (Best response: A)
Answer
The female-to-male ratio has increased progressively, even in the presence of a
constant proportion of cases in the general population. (Best response: D)
Answer
The battery-powered artificial larynx requires the patient to activate a handheld
artificial larynx that vibrates a diaphragm that is held against the neck or pharynx.
(Best response: B)
[162]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Dysfluencies are usually associated with stuttering, rather than with functional
articulation problems. All of the other foils are types of articulation disorders.
(Best response: B)
Answer
With multiple dysmorphisms, genetic predispositions may necessitate family
birth counseling as well as other treatment considerations. (Best response: E)
[163]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Anything that brings attention to the problem of incipient stuttering usually makes
it worse. If the parents can simply accept what is a fairly typical behavior in young
children, the child usually will pass through this stage and continue to develop
communication skills in a normal manner. Only after the stuttering behavior has
been present for 6 months to a year, or if the stuttering behaviors reflect more
struggle on the part of the child, should the child be brought to the attention of a
speech-language pathologist who specializes in treatment of stuttering in
children. (Best response: C)
Answer
Deficits in verbal output and comprehension in speech, reading, and writing are
characteristic of global aphasia. Telegraphic speech and impaired writing skills
represent symptoms of transcortical motor aphasia. Motor speech output
problems are typical of Broca’s motor aphasia. A marked deficit in speech
repetition with numerous sound and word errors characterizes features of
conduction aphasia. The patient with Wernicke’s aphasia has a rather fluent but
jargon-like verbal output, but the primary problem is in comprehension.
(Best response: D)
[164]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Hoarseness, dyspnea, stridor, and intercostal retraction are symptoms or signs of
airway obstruction. Subcutaneous emphysema is a sign of airway damage but is
not specific for airway obstruction. (Best response: D)
Answer
The jaw thrust is the most appropriate positioning maneuver used to improve a
tenuous airway in a trauma patient. A head tilt/chin lift may be successful in
improving the airway but risks cervical spinal cord injury in a trauma patient.
Cricoid pressure and hyoid pressure are not positioning maneuvers that would
improve an airway. Tongue retrusion would lead to airway compromise.
(Best response: C)
[165]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
In creating a permanent tracheostoma, the skin should directly abut the tracheal
mucosa. This procedure results in the advantages of decreased granulation tissue
and a shorter tracheotomy tract as compared with a traditional tracheostomy
stoma. (Best response: A)
Answer
Subcutaneous emphysema after a tracheostomy results from closing the
tracheostomy incision too tightly. In this situation, air escaping from the trachea
cannot passively egress out of the tracheostomy incision and may be forced into
the fascial planes of the neck. Although this complication is usually self-limiting
and does not require intervention, it can progress to pneumomediastinum and
predispose the patient to mediastinitis if bacterial contamination occurs.
(Best response: B)
[166]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
When massive hemorrhage caused by innominate artery rupture occurs, the
tracheostomy tube should be removed and immediately replaced with a longer
endotracheal tube to secure the airway below the area of bleeding. Digital
pressure should be applied to compress the innominate artery against the
manubrium, and the patient should be immediately taken to the operating room
for thoracotomy and control of the bleeding vessel. (Best response: A)
Answer
Tracheostomies actually increase the risk of aspiration by decreasing the glottic
closure reflexes. Hyperinflation of a tracheostomy cuff may also cause aspiration
by compressing the esophageal lumen. A soft, solid diet results in a decreased
risk of aspiration when compared with a liquid diet. An upright position tends to
prevent aspiration. (Best response: C)
8. Which of the following statements about the carbon dioxide laser is true?
A. The carbon-dioxide laser lacks precision.
B. The carbon-dioxide laser should not be used to coagulate vessels under 0.5
mm in diameter.
C. The carbon-dioxide laser is most often used in a fiberoptic delivery system.
D. The carbon-dioxide laser is able to deliver a small spot size.
E. The carbon-dioxide laser produces a visible red beam of light.
[167]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
A 2.5 cm segment of tracheal stenosis located 2 cm below the cricoid cartilage
could be easily excised and anastomosed primarily. Endoscopic laser
vaporization is not ideal for circumferential lesions or lesions measuring more
than 1 cm in length. A laryngotracheoplasty would not be necessary in this case.
(Best response: B)
10. Which of the following has not been linked to cricoarytenoid joint
dysfunction?
A. Traumatic intubation
B. External trauma
C. Osteoarthritis
D. Rheumatoid arthritis
E. Gout
Answer
Traumatic intubation and external trauma are documented causes of arytenoid
cartilage dislocation. Inflammatory lesions such as gout and rheumatoid arthritis
have been linked to cricoarytenoid joint fixation. Osteoarthritis is not related to
cricoarytenoid joint dysfunction. (Best response: C)
[168]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Although the other phenomena related to laryngeal trauma are often present, the
mechanism of injury is most commonly the crush effect of compression of the
laryngeal framework against a rigid body posteriorly, namely the vertebral
column. (Best response: B)
Answer
A CT scan is the most valuable test in the diagnosis of a laryngeal fracture. Some
patients with minimal trauma may have laryngeal fracture despite minimal
findings on initial evaluation. A CT scan may be obtained when the airway is
stabilized, but it should be considered in all patients suspected to have laryngeal
trauma. The other radiologic studies are, in general, not appropriate, at least for
the purpose stated. (Best response: B)
[169]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
In general, a patient with arytenoid cartilage avulsion will have a laceration of the
mucosa requiring exploration. Conservative management may be appropriate for
the other situations. If a fracture of the thyroid cartilage is minimally displaced,
it may not be possible to improve the situation by operative intervention. Edema
without fracture displacement or laceration of the laryngeal mucous membrane
need not be treated surgically. Limited vocal fold mobility owing to injury but
not severance of the recurrent laryngeal nerve will likely recover without
operative intervention. Injury to the cricothyroid muscle per se is not amenable
to surgical repair. (Best response: C)
Answer
All of the above contribute to poor outcomes in patients sustaining blunt and
penetrating injuries to the larynx. (Best response: E)
Answer
All of the above injuries require stenting because they are unstable fractures or full
immobilization is needed for optimum soft tissue healing. (Best response: E)
[170]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The described injuries are minor and can be managed with conservative
measures, including elevation of the head of the bed, voice rest, and
humidification. A CT scan would be helpful in assessing the full extent of the
injuries. Open reduction is not indicated at this time because there are no mucosal
lacerations, displaced fractures, or exposed or dislocated cartilages.
(Best response: B)
Answer
This patient sustained a “clothesline”-type injury. Although he is currently stable,
he may have impending airway obstruction secondary to cricotracheal separation.
No attempt should be made to manipulate the laryngeal or subglottic airway. The
safest way to manage his airway is with a tracheostomy under local anesthesia.
(Best response: C)
[171]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Closure of all mucosal lacerations is a major tenet of managing laryngeal
fractures. Fractures should be reduced within 72 hours of injury. All viable
cartilage is preserved. Stents are used only in unstable fractures or if mucosal
grafts are used. Either wires or miniplates can be used to fixate fractures.
(Best response: C)
Answer
Supraglottic laryngectomy would be an appropriate choice if the problem is
laryngeal stenosis and not laryngeal insufficiency. (Best response: E)
Answer
Although all of the above do occur and contribute to radiation toxicity in the
larynx, the major cause of chondronecrosis is ischemia from damage to the
microvasculature. (Best response: C)
[172]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Laryngopharyngeal reflux differs from gastroesophageal reflux disease in that patients
with laryngopharyngeal reflux usually experience daytime, upright reflux. Typical
symptoms include globus, hoarseness, and chronic cough. Only one-third of patients
with laryngopharyngeal reflux admit to having heartburn. (Best response: C)
Answer
Viral laryngotracheitis is the most common laryngeal inflammatory disorder of
childhood. It is responsible for 15% of respiratory disease seen in pediatric practice.
Usually, this condition is self-limited, occurs in children under the age of 3 years, and
has a seasonal peak, with most cases occurring during the winter. (Best response: D)
[173]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Although the clinical course of adult supraglottitis (epiglottitis) is usually less
severe, persons who present with drooling usually require endotracheal
intubation. (Best response: C)
Answer
Severe immunosuppression (owing to chemotherapy or acquired immune
deficiency syndrome is associated with the development of invasive laryngeal
candidiasis, and, as expected in such patients, the infection is often more serious
and sometimes can be life threatening owing to bleeding or airway obstruction.
Isolated laryngeal candidiasis (without the involvement of any other contiguous
anatomic structures) usually occurs in patients who use corticosteroid inhalers.
(Best response: C)
[174]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Primary muscle tension dysphonia is a generic term for any “functional” voice
disorder caused by chronic vocal abuse or misuse. Secondary, or compensatory,
muscle tension dysphonia is a result of an underlying glottal insufficiency. The
glottal incompetence may be secondary to presbylaryngis, vocal fold paralysis,
or vocal fold paresis. (Best response: D)
Answer
Although surgical removal of a vocal process granuloma is seldom indicated,
there are three instances when it should be considered: (1) when the clinician is
concerned about the possibility of carcinoma, (2) when the lesion has matured
and taken on the appearance of a fibroepithelial polyp, and (3) when the airway
is obstructed. A professional voice user with significant vocal needs may also
require removal. Vocal process granulomas may take 6 months or more to heal
on antireflux therapy. A persistent granuloma at 6 weeks is not an indication for
removal. (Best response: C)
[175]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Endotracheal intubation can dislodge membranous debris and cause airway
obstruction in patients with diphtheria involving the larynx. It should be avoided.
(Best response: B)
10. Which of the following statements is not true about laryngeal tuberculosis?
A. It is one of the most common granulomatous diseases of the larynx.
B. It is usually associated with advanced pulmonary disease.
C. Its prevalence has been rising since the emergence of HIV.
D. The clinical presentation is often similar to that of a neoplastic process.
E. One-quarter of patients with laryngeal tuberculosis present with airway
obstruction.
Answer
Laryngeal tuberculosis is one of the most common granulomatous diseases of the
larynx. It is usually not associated with advanced pulmonary disease and
therefore may be mistaken for laryngeal carcinoma. Its prevalence has been
increasing since the emergence of HIV. One-quarter of patients with laryngeal
tuberculosis present with airway obstruction. (Best response: B)
[176]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
High-frequency vowel sounds such as /i/ or “ee” position the tongue base and
epiglottis high and anteriorly, optimizing the view of the larynx during flexible
endoscopy. (Best response: D)
Answer
Parkinson’s disease is characterized by reduced loudness and breathy voice
quality (hypophonia). The voice often fades into breathiness in contextual speech.
“Wet hoarseness” is characteristic of amyotrophic lateral sclerosis and results
from poor management of secretions owing to flaccidity. Staccato bursts in
speech and harsh voice quality may occur in patients with multiple sclerosis
owing to spasticity and tremor. Intermittent breaks in vowels occur in adductor
spasmodic dysphonia. (Best response: B)
[177]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Transient or permanent vocal fold paresis/paralysis has been observed in patients
with peripheral neuropathy, abductor spasmodic dysphonia, and Parkinson’s
disease. Patients with paradoxical vocal fold motion typically have normal vocal
fold motion for speech but have inappropriate adduction of the vocal folds during
the inspiratory phase of respiration. (Best response: D)
Answer
Voice therapy can improve speech intelligibility in patients with Parkinson’s disease,
increasing vocal intensity. Techniques focusing on breathing control and vocal
relaxation may be helpful in patients with muscular tension dysphonia and paradoxical
vocal fold motion. Laryngeal maneuvering can be beneficial in treatment of the
abnormal laryngeal posturing seen in mutational falsetto. (Best response: E)
[178]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Botulinum toxin injection of the thyroarytenoid muscle is currently considered
the treatment of choice for patients with adductor spasmodic dysphonia (ADSD)
owing to its high rate of effectiveness (> 90%), lack of serious or permanent side
effects, and the fact that it causes no permanent alteration of laryngeal structures.
Injection of the cricothyroid muscle is generally ineffective in ADSD but may
benefit selected patients with abductor spasmodic dysphonia. For patients with
ADSD who do not respond to botulinum toxin or who are unwilling or unable to
tolerate repeated injections, recurrent laryngeal nerve avulsion or bilateral
selective denervation may provide long-term control of symptoms. Voice therapy
alone is usually not effective for the management of ADSD but may extend the
symptomatic relief obtained from botulinum toxin injections. (Best response: A)
Answer
Type I thyroplasty provides stable yet reversible vocal fold medialization in patients
with a unilateral vocal fold paralysis, although a concomitant arytenoid adduction
procedure may be necessary in patients with a large posterior glottal gap. Collagen
injection may be useful in selected patients with a small anterior glottal gap, but
variable resorption may occur over time. Voice therapy is useful in preventing
vocally abusive compensatory behaviors but will not alone provide adequate vocal
rehabilitation for many patients. Although some authors have achieved promising
results with various recurrent laryngeal nerve anastomosis procedures, these
procedures are often technically difficult and require a prolonged period (3 to 6
months) following surgery before beneficial effects are seen. Teflon injection is now
rarely used owing to late postoperative granuloma formation. (Best response: C)
[179]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Arytenoidectomy would worsen aspiration by causing posterior glottal
incompetence. Medialization thyroplasty and Teflon injection may be helpful in
reducing aspiration in patients by reducing or eliminating glottic incompetence
during swallowing. Tracheostomy may not reduce aspiration but facilitates
pulmonary toilet and management of copious secretions. Laryngectomy provides
permanent and complete relief in patients with severe, life-threatening aspiration
but sacrifices the voice. (Best response: C)
Answer
Wallenberg’s syndrome results in vocal fold paralysis, ipsilateral reduction of
pain/temperature sensation of the face, nausea, vertigo, diplopia, and intractable
hiccupping. These findings result from occlusion of the posterior inferior
cerebellar artery. (Best response: B)
[180]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Both patients with spasmodic dysphonia and muscular tension dysphonia may
derive benefit from botulinum toxin injections; response to this treatment is not a
reliable means of differentiating these two conditions. Increased muscle tension,
inflammatory changes of the laryngeal mucosa (nodules, erythema, edema), and
abnormally increased laryngeal tension across various types of speech tasks are
characteristic of muscular tension dysphonia. Laryngeal massage and voice
therapy aimed at reducing laryngeal muscle tension are frequently effective
treatment. (Best response: C)
[181]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The most common secondary primary cancer in patients with laryngeal carcinoma
is bronchogenic carcinoma. Other sites that may be involved include any area of the
upper aerodigestive tract. The lung is also the most common site for a metachronous
second primary tumor in patients with laryngeal cancer. (Best response: B)
2. Supraglottic carcinoma
A. Arises from pseudostratified squamous epithelium.
B. Most commonly originates on the aryepiglottic folds.
C. Displays aggressive features earlier than glottic carcinoma.
D. Spreads through lymphatics of the cricothyroid membrane.
E. Rarely presents with nodal metastases.
Answer
Supraglottic carcinoma typically arises on the epiglottis and behaves aggressively
at an earlier point than most glottic carcinomas. Nodal metastases are present in
30% of patients with clinically N0 necks. Lymphatic spread occurs bilaterally,
exiting the thyrohyoid membrane with the superior laryngeal vessels to involve
cervical levels II and III first. The unique drainage pathways of the supraglottis
are attributable to an embryonic origin that is separate from the rest of the glottic
and subglottic larynx, such that inferior spread via the cricothyroid membrane
does not occur. (Best response: C)
[182]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Hoarseness is the initial symptom in glottic carcinoma. Dyspnea, dysphagia, and pain
occur with advanced tumors, owing to invasion through cartilage and extralaryngeal
structures. Later symptoms are cough, hemoptysis, halitosis, and weight loss. Patients
with supraglottic carcinoma tend not to have symptoms until the disease is more
advanced, and regional metastasis is often the first sign of illness. Distant metastasis is
reported to occur in 8 to 10% of patients on presentation with laryngeal carcinoma.
(Best response: A)
Answer
Positron emission tomography makes use of differential uptake of [18F]
fluorodeoxyglucose; tumor cells take up greater concentrations of the tracer
owing to increased metabolic demands. Positron emission tomography is more
sensitive and specific than computed tomography or magnetic resonance imaging
in detecting occult nodal disease but when used alone does not provide detailed
anatomic information. (Best response: D)
[183]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Carcinoma in situ without an invasive component is relatively rare. Early glottic
carcinomas are understaged 40% of the time. Impairment of vocal cord mobility
(T2b) leads to a 20% decrease in survival over similar tumors with normal vocal
cord function (T2a). In most institutions, radiation therapy is favored over
surgical treatment of glottic carcinoma because it has been thought to allow
superior vocal function. All T3 and T4 tumors are categorized as advanced
carcinoma. (Best response: B)
Answer
The cure rates for surgical excision, laser excision, and radiation therapy appear
to be similar for T1 and T2 supraglottic carcinoma. Contraindications to surgical
therapy include vocal fold fixation and poor pulmonary function. Many T1 and
T2 tumors metastasize early to regional lymph nodes, and bilateral regional
lymphatic treatment is necessary. Location of the tumor near the anterior
commissure carries an increased risk of cartilage invasion, which reduces the cure
rate. (Best response: E)
[184]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Laser excision of T3 supraglottic tumors is possible, and reports have
demonstrated less dysphagia and aspiration with this procedure than with open
techniques. The vocal results also appear to be improved. Treatment of the neck
is also necessary for these T3 and T4 lesions. Because the supraglottic lymphatic
drainage is bilateral, levels II, III, and IV of both sides of the neck must be
addressed. For N+ necks, level V should be treated as well. Hyperfractionated
radiation therapy appears to produce higher local cure rates than standard daily
radiation. (Best response: C)
Answer
Extensive efforts are being directed at organ preservation protocols. Studies of
laryngectomy with postoperative radiation therapy compared to induction
chemotherapy with radiation therapy have shown similar survival rates, with 64%
laryngeal preservation in the nonsurgical group. The morbidities of surgery and
chemotherapy/radiation therapy are significant but quite different.
(Best response: B)
[185]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The most common site of distant metastasis is the lung, followed by the liver and
bone. Metastasis to bone typically portends a survival time of less than 4 months;
metastasis to lung has an average survival of 12 months. Parastomal tumor
recurrence carries a poor prognosis, although recurrences above the equator of
the stoma may be resectable. Lesions with the highest risk of distant metastasis
are those in the supraglottis that extend to the hypopharynx and piriform sinus.
Glottic primaries are the least likely to metastasize. Dysphagia associated with
advanced, recurrent laryngeal cancer is probably best palliated with a gastric
feeding tube. (Best response: D)
[186]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The largest incidences of nasopharyngeal carcinoma are observed in Asian
populations, particularly in southern areas of China. Other ethnic groups at higher
risk include southeastern Asian countries, northern Africa, and certain Native
American populations. Black, Hispanic, and Caucasian populations have the
lowest incidences. (Best response: C)
Answer
Patients with poorly differentiated nasopharyngeal carcinoma or the histology
associated with WHO type III, the classic lymphoepithelioma, have the best
prognosis, with 20 to 40% higher long-term survival. WHO type I lesions are well
differentiated, and patients with them fare worse with currently available
treatment. (Best response: B)
[187]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
An MRI with gadolinium will help differentiate tumor from other soft tissue changes
that may simply be postobstructive in the nasal cavity or paranasal sinuses. In the
workup of a patient for nasopharynx carcinoma, a CT with contrast would also be
helpful to demonstrate skull base erosion. A coronal paranasal sinus CT would not
likely give enough information at the skull base to be considered a useful adjunctive
study. (Best response: B)
Answer
A phase III clinical trial has demonstrated much better disease free survival using a
combination of cisplatin and radiation compared with radiation alone and is now
considered standard treatment by most practitioners. (Best response: B)
[188]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Cisplatin is clearly superior. Some of these other agents have been tried. 5-Fluorouracil,
by itself, is not very successful. The combination of cisplatin and 5-fluorouracil has
merit. (Best response: B)
Answer
Prepubescent and pubescent males are at the highest risk for juvenile
nasopharyngeal angiofibroma. (Best response: D)
[189]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The complicated anatomy of the nasopharynx and its relationship to other
complicated regions of the skull base, as well as its composition of soft tissue and
bone, are factors supporting both imaging modalities. These studies are often
complementary and not overlapping in the workup of patients with these lesions.
The other statements are not true. (Best response: C)
[190]
Otorhinolaryngology Examination Items and Teaching Commentaries
1. Squamous cell carcinoma (SCC) at high risk for bilateral regional lymph
node metastases includes all of the following primary sites except the
A. Midline lip.
B. Floor of the mouth.
C. Oral tongue.
D. Base of the tongue.
E. Alveolar ridge.
Answer
Midline structures of the oral cavity and oropharynx commonly drain to
lymphatic channels in both sides of the neck. Primary sites of SCC of the oral
cavity at high risk for bilateral regional lymph node metastases include the
midline of the lip, floor of the mouth, and oral tongue. Primary sites of SCC of
the oropharynx at high risk for bilateral regional lymph node metastases include
the base of the tongue, soft palate, and midline posterior pharyngeal wall.
Squamous cell carcinoma of the alveolar ridge does not readily metastasize to
regional lymphatics. (Best response: E)
2. The most likely reason for the higher proportion of squamous cell
carcinoma of the oral cavity and oropharynx in Southeast Asia
compared with that in the United States is
A. Genetic differences in the P53 mutation.
B. Cultural differences in tobacco consumption.
C. Differences in occupational exposure.
D. Epidemiologic errors in reporting.
E. None of the above.
Answer
Geographic differences in tobacco consumption may explain the higher
proportion of cancers arising from the oral cavity and oropharynx worldwide
compared with that in the United States. Such cultural practices include reverse
smoking, consumption of betel and paan, and bidi smoking. (Best response: B)
[191]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Choices B, C, D, and E all accurately describe verrucous carcinoma. True
verrucous carcinoma does not have metastatic potential. (Best response: A)
Answer
The 5-year survival rate of patients with metastases to cervical lymph nodes is
approximately 50% that of patients without regional lymph node metastases.
(Best response: C)
Answer
It has been shown that the delay in diagnosis for primary tumors of the oral cavity is
greatest for floor of the mouth cancer and shortest for tongue cancer. Establishing a
diagnosis of cancer of the hard palate is often confounded by the considerable delay
before patients present complaining of symptoms. Likewise, in the oropharynx,
cancers of the base of the tongue and tonsil tend to be of more advanced stages before
patients seek treatment. The symptoms of dysarthria and pain with eating associated
with carcinoma of the oral tongue tend to result in patients presenting at an earlier
stage of disease. (Best response: B)
[192]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Lymph node metastases from primary tumors of the oral cavity and oropharynx
occur in a predictable fashion through sequential spread. Regional lymph nodes
at highest risk for metastases from primary SCC of the oral cavity include those
at levels I, II, and III. In light of the morbidity associated with the radical neck
dissection, there has been a trend toward selective, rather than comprehensive,
neck dissection, based on the predictable pattern of cervical lymph node
metastases. Supraomohyoid neck dissection, selective lymphadenectomy
clearing cervical nodal levels I, II, and III, has been recommended for N0 patients
with primary SCC of the oral cavity. Anterolateral neck dissection clearing levels
II, III, and IV has been advocated for N0 necks with an oropharyngeal primary.
(Best response: D)
7. The preferred method of treatment for stage III and IV tumors of the
buccal mucosa is
A. Combination therapy using surgery with postoperative radiation therapy.
B. Combination therapy using concomitant chemotherapy and radiation therapy.
C. Surgery alone.
D. Radiation therapy alone.
E. Combination therapy using surgery and chemotherapy.
Answer
As is the case with most tumors of the oral cavity and oropharynx, surgical
resection is recommended for stage I and II tumors, with combination therapy
using surgery and postoperative radiotherapy for stage III and IV tumors.
(Best response: A)
[193]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Branches from the glossopharyngeal (IX) nerve provide sensory innervation to the
retromolar trigone, so patients with carcinoma of the retromolar trigone may present
complaining of pain referred to the ipsilateral ear. (Best response: C)
9. Which primary tumor of the oral cavity or oropharynx demonstrates the most
sensitive response to radiation therapy?
A. Alveolar ridge
B. Hard palate
C. Retromolar trigone
D. Posterior pharyngeal wall
E. Tonsil
Answer
Of all of the tumors in the oral cavity and oropharynx, cancers of the tonsil are the most
radiosensitive, particularly exophytic lesions. (Best response: E)
Answer
The thin, pliable nature of the radial forearm free flap makes it an ideal method of
reconstruction for this type of defect. It is a reliable flap that minimizes the chance of
tethering the tongue, compared with a local tongue flap. The bulky nature of the pectoralis
major myocutaneous flap makes it a less suitable choice for this type of intraoral
reconstruction. The fibular osteocutaneous free flap is a useful flap for reconstruction
following segmental mandibulectomy. The deltopectoral flap was commonly used for head
and neck reconstruction prior to the introduction of the pectoralis major myocutaneous flap
and microvascular free tissue transfer. (Best response: C)
[194]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The fascia covering the parotid and submandibular glands arises from the superficial
layer of the deep cervical fascia. A condensation of this fascia occurs between the
two glands and forms the stylomandibular ligament. (Best response: C)
2. The most consistent landmark that a surgeon can easily use in identifying
the facial nerve near the skull base is
A. The digastric muscle.
B. The tragal pointer cartilage.
C. The point halfway between the mastoid tip and the angle of the mandible.
D. The tympanomastoid suture.
E. The stylomastoid foramen.
Answer
The most consistent landmark typically used in surgical identification of the facial
nerve at the skull base is the Tympanomastoid suture. The stylomastoid foramen
from which the facial nerve exits the skull base is located at the deep extent of
this suture line. (Best response: D)
[195]
Otorhinolaryngology Examination Items and Teaching Commentaries
4. With regard to the minor salivary glands, which of the following statements
is false?
A. Minor salivary glands may be located in the oral cavity and oropharynx.
B. Minor salivary glands typically drain into a series of collecting ducts, which
eventually drain into the floor of the mouth adjacent to the lingual frenulum.
C. Most neoplasms arising from the minor salivary glands are malignant.
D. Minor salivary glands can be both mucus and serous producing.
E. There are hundreds of minor salivary glands in the upper aerodigestive tract.
Answer
There are indeed hundreds of minor salivary glands located throughout the upper
aerodigestive tract. Each individual gland typically drains through its own small
ductule directly into the adjacent mucous membrane. (Best response: B)
Answer
Classic mumps is caused by the Rubulavirus, a paramyxovirus. The paramyxoviruses
are ribonucleic acid viruses that include the measles, parainfluenza, and respiratory
syncytial viruses. Although a variety of viruses may cause parotitis, the
paramyxoviruses are the viruses most commonly cultured. (Best response: C)
[196]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Patients with HIV infection can develop multiple lymphoepithelial cysts in both
parotid glands. The appearance of these cysts on computed tomographic scanning
is unique and found only in patients with HIV infection. (Best response: C)
Answer
The gold standard for the treatment of Wegener’s granulomatosis is
cyclophosphamide and glucocorticoids. Trimethoprim and sulfamethoxazole also
have been beneficial when the upper respiratory tract has been involved.
Methotrexate and corticosteroids have been used in milder forms of Wegener’s
granulomatosis. (Best response: D)
[197]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Staphlococcus aureus is the most common microorganism associated with acute
bacterial sialadenitis. Streptococcus viridans is a common infectious agent in
chronic and recurrent sialadenitis. (Best response: D)
Answer
The most common malignant tumor of the submandibular glands is the adenoid
cystic carcinoma. It is the second most common of the malignant salivary gland
tumors. It does not tend to metastasize to lymph nodes early but does produce
distant metastases late. The 5-year survival rate is usually quite high, but the 15-
and 20-year survival rates approximate 30%. Part of the difficulty in local control
of adenoid cystic carcinoma is attributable to its tendency for extension over long
distances through perineural invasion and propagation. (Best response: C)
[198]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The only other interpretation is secondary pituitary hyperthyroidism, which is not
an option in the choices for this item. (Best response: E)
Answer
There is truth in each statement. The fetus initiates iodine metabolism by 10
weeks’ gestation and the fetal pituitary-thyroid axis is generally independent of
maternal thyroid function. However, hypothyroidism during pregnancy can
apparently harm the neuropsychological development of the fetus. Mild maternal
hypothyroidism alone has been associated with lower IQ scores in offspring.
(Best response: C)
[199]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Bacterial thyroiditis is extremely rare and would probably impair thyroid
function. Riedel’s struma is also rare but is associated with irreversible, profound
hypothyroidism and a stony hard, irregular, fibrous gland. Early Hashimoto’s
disease is characterized by mild thyrotoxicosis owing to release of thyroid
hormone from damaged follicles, with development of hypothyroidism in the late
or chronic stage. The described case is typical of de Quervain’s granulomatous
thyroiditis. (Best response: B)
Answer
Medullary carcinoma does not take up radioiodide, so ablation with radioisotope
is not effective. Because of the propensity for local microvascular invasion, late
recurrence, and metastatic disease, aggressive surgical intervention is
recommended. (Best response: E)
[200]
Otorhinolaryngology Examination Items and Teaching Commentaries
6. A colleague calls for your urgent assistance in the operating room, being
unable to locate the recurrent laryngeal nerve. This most likely suggests
the anomaly occurring in 1 of 400 cases of
A. Carotid sinus syndrome with an aberrant course of the recurrent laryngeal nerve.
B. Coarctation of the aorta.
C. Anomalous retroesophageal right subclavian artery.
D. Anomalous retroesophageal left subclavian artery.
E. Transposition of the great vessels.
Answer
This is a classic anomaly, occurring almost always on the right, in which a right
subclavian artery arises from the left descending aorta. In such cases, the inferior
laryngeal nerve passes directly from the vagus to the larynx and is susceptible to
injury in dissection. Carotid sinus syndrome has nothing to do with the recurrent
laryngeal nerve, and coarctation of the aorta and transposition of the great vessels
are unrelated congenital anomalies. (Best response: C)
Answer
If calcium infusion is not required in the first 72 hours, it will probably be
unnecessary. However, transient hypocalcemia can be severe in 8% of patients
within the first 96 postoperative hours. (Best response: C)
[201]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Crystal clear aspirate suggests a parathyroid cyst, whereas yellow fluid usually
points to a transudate. A rapidly growing tumor can produce bloody fluid, as can
aspiration of a blood vessel. A chocolate, green, or turbid aspirate is suggestive
of degeneration. (Best response: D)
9. Which of the following direct tests of thyroid function would yield the
most information in the evaluation of a patient with hyperthyroidism?
A. Thyroid radioactive iodine uptake (RAIU) by thyroid scintiscan with 131I
B. RAIU by thyroid scintiscan with 123I
C. Thyroid suppression test
D. Thyrotropin stimulation test
E. 99m technetium pertechnetate scintiscan
Answer
The most commonly used direct test of gland function is the RAIU, using 123I as
the agent of choice because of lower radiation dosage. Iodine 131 is used to
overcome photon attenuation by bone if evaluating substernal thyroid or
metastatic thyroid cancer. The thyrotropin stimulation test involves RAIU
following administration of thyroid-stimulating hormone to differentiate between
primary thyroid insufficiency and pituitary hypofunction. The technetium 99m
pertechnetate scintiscan is used to assess thyroid enlargement or cold nodules if
RAIU is blocked or contraindicated. Finally, the thyroid suppression test is RAIU
performed after 7 days of triiodothyronine administration to evaluate thyroid
hyperfunction. (Best response: C)
[202]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
For patients under 40 years old with encapsulated follicular carcinoma, thyroid
lobectomy with isthmusectomy is performed, with total thyroidectomy reserved
for patients over 40 years old. For invasive carcinoma, total thyroidectomy and
thyroid ablation with 131I are most commonly practiced. In the presence of
palpable cervical metastases, choices D and E are appropriate.
(Best response: B)
[203]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
The true vocal folds comprise the glottis, which is immediately inferior to the
supraglottis. (Best response: E)
Answer
Verrucous carcinoma is a highly differentiated variant of squamous cell
carcinoma. (Best response: B)
Answer
Paragangliomas are the only laryngeal neoplasm with a female predominance.
(Best response: D)
[204]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCAs) are the
predominant ANCAs in Wegener’s granulomatosis. Elevation of the c-ANCA is
highly specific for Wegener’s granulomatosis. Confirmation of the diagnosis is
made by biopsy of lesions in the upper respiratory tract in which the necrotizing
vasculitis can be demonstrated. (Best response: C)
Answer
The physical findings of multiple sites of cartilage deformity are suggestive of
relapsing polychondritis, for which dapsone may be useful. (Best response: C)
6. A 2-year-old child presents with rapid onset of a high fever, sore throat,
muffled voice, & respiratory distress. She looks uncomfortable & is sitting up,
leaning forward, & drooling. The most likely causative microorganism is
A. Haemophilus influenzae.
B. Staphylococcus aureus.
C. Moraxella catarrhalis.
D. Streptococcus pneumoniae.
E. Epstein-Barr virus.
Answer
The clinical presentation is that of acute epiglottitis. Haemophilus influenzae is
the predominant causal microorganism. (Best response: A)
[205]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Twenty-four-hour multichannel ambulatory esophageal PH monitoring is the most
sensitive study for extraesophageal reflux; esophagoscopy with biopsy, barium
esophagram, nuclear medicine scintiscan, and bronchoscopy with washings for fat-
laden macrophages may be supportive of the likelihood of reflux. (Best response: E)
Answer
Verrucous carcinoma rarely metastasizes; surgical resection is the treatment of
choice. (Best response: E)
Answer
The lack of a rash makes an allergic cause less likely. Angiotensin converting
enzyme inhibitors are the most common medications precipitating edema in
acquired angioedema. The effects of kinase II, which stimulates the conversion
of angiotensin I to the vasoconstrictive angiotensin II and inactivates bradykinin,
a potent vasodepressor, are blocked by angiotensin converting enzyme inhibitors.
(Best response: B)
[206]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
C1-INH concentrate is the most reliable in the acute management of airway
obstruction owing to hereditary angioedema. Nevertheless, mechanical relief
of airway obstruction may be required in the acute situation. Epinephrine,
corticosteroids, and antihistamines are less reliable in this problem. Attenuated
androgens such as danazol and stanozolol are useful in the long-term
management of hereditary angioedema, as are antifibrinolytic medications,
such as ɛ-aminocaproic acid and tranexamic acid, and C1-INH concentrate.
(Best response: D)
[207]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Tracheobronchial trauma can occur at every level of the trachea and almost all of
the major bronchi, but more than 80% of the injuries are within 2.5 cm of the
carina. The cervical trachea is protected by the mandible and sternum anteriorly
and by the vertebrae posteriorly. Tracheobronchial disruption has an estimated
overall mortality of 30%; 15% of patients sustaining cervical tracheal disruption
die from hypoxia within 1 hour of injury. (Best response: D)
Answer
The clinical presentation is suggestive of sarcoidosis. The angiotensin converting
enzyme level appears to correlate with disease activity but should not be used in
isolation. Biopsy is needed to confirm the diagnosis. (Best response: D)
[208]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
An elevated level of chloride in sweat confirms a diagnosis of cystic fibrosis.
(Best response: A)
Answer
A vascular ring will encircle the trachea and esophagus, causing the indentations
described in this radiographic study. Both an aberrant right subclavian artery with
a left aortic arch and an aberrant left subclavian artery with a right aortic arch will
be evident as a small retroesophageal indentation with a normal trachea. A
“pulmonary sling” is the only vascular anomaly that passes between the trachea
and esophagus, causing an anterior esophageal indentation with a posterior
tracheal indentation. An anomalous innomate artery will cause anterior tracheal
compression. (Best response: E)
[209]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Bacterial tracheitis is an acute, life-threatening disease in children and is most
commonly caused by Staphylococcus aureus. (Best response: E)
Answer
Mycetomas are most commonly caused by Aspergillus species. (Best response: C)
[210]
Otorhinolaryngology Examination Items and Teaching Commentaries
Answer
Children who have aspirated foreign bodies may present with any of the above
combinations of findings on history, physical examination, or radiographs. (Best
response: E)
Answer
Leiomyomas account for more than half of all benign nonepithelial tumors of the
esophagus. They are intramural encapsulated tumors more often found in the
middle or lower esophagus. Leiomyomas often produce widening of the lower
part of the mediastinum and appear as a mass in the posterior part of the
mediastinum in chest radiographs. (Best response: C)
[211]
Otorhinolaryngology Examination Items and Teaching Commentaries
[212]