ENT — Distinction Level Exam Answers
Questions 1 to 5 | Detailed MBBS-style writing | A4 two-column print layout
Q1. Fill in the blanks
  • Griesinger sign is seen in lateral sinus thrombosis.
  • BPPV is most commonly due to pathology in the posterior semicircular canal.
  • In cochlear implantation the electrode is placed in the scala tympani.
  • Merciful anosmia is a clinical feature of atrophic rhinitis (ozena).
  • Tympanogram Type As is seen in otosclerosis.
  • BERA is an acronym for Brainstem Evoked Response Audiometry.
Memory hook: Griesinger = sinus thrombosis, BPPV = posterior canal, BERA = brainstem hearing test.
Q2. Multiple choice questions
i) The most common cause of bilateral conductive deafness in a child is:
  • Otitis media with effusion
OME or glue ear is the commonest cause of conductive hearing loss in children. Eustachian tube dysfunction causes persistent middle-ear fluid and reduced tympanic membrane mobility.
ii) Treatment of choice for early vocal nodule is:
  • Voice rest and speech therapy
Early nodules are due to vocal abuse. The first-line management is conservative treatment: voice hygiene, speech therapy, and correction of misuse. Surgery is reserved for resistant or mature nodules.
iii) Histopathologically the most common malignant tumour of upper aerodigestive tract is:
  • Squamous cell carcinoma
Squamous cell carcinoma is the commonest malignancy in the upper aerodigestive tract because the mucosa is lined by stratified squamous epithelium and is exposed to major carcinogens such as tobacco and alcohol.
iv) Type I Isshiki thyroplasty indicates:
  • Medialization of the vocal cord
Type I thyroplasty is a medialization procedure used mainly for unilateral vocal cord paralysis and glottic insufficiency. It improves phonation by bringing the paralyzed cord toward the midline.
Memory hook: OME makes the child deaf by glue; early nodules need voice therapy; SCC is the commonest aerodigestive cancer; Type I thyroplasty medializes the cord.
Q3. A 55-year-old male farmer with hoarseness for 3 months and severe respiratory distress, chronic smoker, SpO₂ 88%
a) Differential diagnosis
  • Laryngeal carcinoma — most likely diagnosis
  • Vocal cord paralysis due to recurrent laryngeal nerve palsy
  • Laryngeal edema / inflammatory laryngeal obstruction
  • Laryngeal papillomatosis
  • Laryngeal tuberculosis
  • Laryngeal foreign body or upper airway obstruction
  • Subglottic stenosis or benign laryngeal tumour
In an adult smoker, hoarseness lasting more than 3 weeks is cancer until proven otherwise. The presence of progressive breathing difficulty and noisy breathing strongly suggests an obstructive laryngeal lesion, often glottic or supraglottic carcinoma.
b) How will you evaluate the patient further?
  • Emergency airway assessment first: respiratory rate, work of breathing, stridor, saturation, mental status
  • Indirect / flexible fibreoptic laryngoscopy to visualize the larynx and glottis
  • Direct laryngoscopy with biopsy for histopathological confirmation
  • CT scan neck and, if required, chest imaging for local extension and nodal disease
  • Chest X-ray or chest CT for pulmonary spread and associated pathology
  • Routine blood investigations including CBC, renal function, blood sugar, and baseline fitness tests before intervention
  • Neck examination for cervical lymph nodes
  • Assessment of vocal cord mobility, airway narrowing, and involvement of supraglottis or subglottis
If the patient is unstable, airway comes before complete work-up. Endoscopy should be done with caution in a compromised airway.
c) Management plan
  • Immediate management: oxygen, head-up position, monitor saturation, prepare for airway securing
  • If severe obstruction exists, tracheostomy may be required to secure the airway
  • Definitive treatment depends on stage and site of laryngeal cancer:
    • Early glottic lesion: radiotherapy or conservative endoscopic surgery
    • More advanced disease: partial laryngectomy or total laryngectomy with neck dissection as indicated
  • Adjuvant radiotherapy / chemotherapy as per stage and tumour burden
  • Speech rehabilitation after surgery, especially after total laryngectomy
  • Nutritional support, smoking cessation, physiotherapy and counseling
The management of laryngeal cancer must address both the immediate airway problem and the long-term oncological treatment.
d) Possible complications
  • Progressive airway obstruction and asphyxia
  • Aspiration and recurrent chest infection
  • Malnutrition and weight loss
  • Regional lymph node metastasis
  • Local spread to hypopharynx, trachea, thyroid, strap muscles
  • Distant metastasis, especially to lungs
  • Post-treatment voice disability and swallowing difficulty
e) Risk factors and why?
  • Smoking — strongest risk factor; tobacco smoke contains carcinogens that injure laryngeal mucosa
  • Alcohol — acts synergistically with tobacco and increases mucosal carcinogen exposure
  • Age and male sex — disease is more common in older men
  • Occupational exposure to dust, fumes, chemicals, wood smoke
  • Chronic laryngitis / reflux causing persistent irritation
  • Voice abuse may worsen symptoms, though not a primary cause of carcinoma
Memory hook: Hoarseness > 3 weeks in a smoker = laryngeal cancer until proven otherwise.
Q4. Write briefly on (Any Five)
a) Bell’s palsy
  • Idiopathic acute lower motor neuron facial nerve palsy
  • Sudden unilateral facial weakness with inability to close eye, loss of forehead wrinkling and drooping of mouth angle
  • May be associated with post-auricular pain, altered taste, hyperacusis, tearing abnormality
  • Diagnosis is clinical; rule out stroke and ear disease
  • Treatment includes corticosteroids early, eye protection, lubricants and physiotherapy
  • Most patients recover spontaneously or with treatment
ENT point: facial nerve involvement can occur after viral reactivation in the facial canal.
b) Complications of otitis media
  • Intratemporal complications: mastoiditis, subperiosteal abscess, facial nerve palsy, labyrinthitis, petrositis
  • Intracranial complications: meningitis, extradural abscess, subdural abscess, brain abscess, lateral sinus thrombosis, otitic hydrocephalus
  • Complications occur because infection spreads through bone, venous channels or preformed pathways
c) Newborn hearing screening
  • Screening is done to detect congenital hearing loss early before speech delay occurs
  • Methods used:
    • Otoacoustic emission (OAE)
    • BERA / ABR when indicated
  • Preferably done within the first few days or weeks of life
  • High-risk babies need repeat testing and follow-up
  • Early diagnosis allows early intervention, hearing aid fitting or cochlear implantation
d) Management of allergic rhinitis
  • Avoidance of allergens and environmental control
  • Antihistamines for sneezing, itching and watery rhinorrhea
  • Intranasal corticosteroids are the most effective long-term therapy
  • Nasal saline irrigation for symptom relief
  • Leukotriene receptor antagonists in selected cases
  • Immunotherapy for resistant or recurrent disease
  • Treat associated asthma, sinusitis or conjunctivitis if present
e) Laryngomalacia
  • Most common cause of congenital stridor
  • Due to flaccidity of supraglottic structures causing inspiratory collapse
  • Inspiratory stridor begins in early infancy and increases with crying, feeding or supine posture
  • Usually self-limiting and improves as larynx matures
  • Severe cases may need supraglottoplasty
f) Thyroglossal cyst
  • Midline neck swelling due to persistence of thyroglossal duct
  • Moves with swallowing and also with protrusion of the tongue
  • Often appears after infection or enlarges slowly
  • Treatment is Sistrunk operation, which removes cyst, tract and central part of hyoid bone
  • Simple excision has high recurrence rate
Memory hook: Bell’s palsy = LMN facial weakness; OME causes hearing loss in children; laryngomalacia causes infant stridor; thyroglossal cyst moves with swallowing and tongue protrusion.
Q5. Explain why (Any Three)
a) Blockage of Eustachian tube causes different types of otitis media
  • The Eustachian tube ventilates the middle ear and equalizes pressure.
  • When blocked, the middle ear becomes a closed cavity with negative pressure.
  • Negative pressure leads to transudation of fluid and the development of otitis media with effusion.
  • Persistent fluid predisposes to bacterial growth and recurrent acute otitis media.
  • Chronic obstruction and repeated infection can result in chronic suppurative otitis media, tympanic membrane retraction and cholesteatoma formation.
  • Thus, Eustachian tube dysfunction is the common pathway in many forms of otitis media.
Memory hook: Blocked ET → negative pressure → fluid → infection → chronic ear disease.
b) Modified radical mastoidectomy is performed for management of cholesteatoma
  • Cholesteatoma is an unsafe chronic ear disease with keratinizing epithelium that expands and erodes bone.
  • The essential principle of surgery is complete removal of disease.
  • Modified radical mastoidectomy removes cholesteatoma from mastoid and middle ear while preserving or reconstructing the hearing mechanism as much as possible.
  • It exteriorizes the disease and creates a safe, dry ear.
  • The procedure is chosen when the disease is extensive, recurrent, or associated with ossicular destruction and mastoid involvement.
  • Hence, the operation is not merely to improve hearing; it is mainly to eradicate disease and prevent complications.
Memory hook: Cholesteatoma eats bone, so surgery must remove the disease and make the ear safe.
c) Left recurrent laryngeal nerve palsy is seen more commonly than right
  • The left recurrent laryngeal nerve is longer than the right.
  • It loops under the aortic arch and ascends in the tracheoesophageal groove to the larynx.
  • The longer intrathoracic course exposes it to more pathology such as mediastinal tumors, aortic aneurysm, enlarged left atrium, lymphadenopathy and lung malignancy.
  • The right recurrent laryngeal nerve loops around the subclavian artery and has a shorter course, so it is less often affected.
  • Therefore, left vocal cord paralysis is more commonly encountered clinically.
Memory hook: Left RLN has the longer path around the aortic arch, so it is more vulnerable.
d) Juvenile angiofibroma is seen in males only and why it bleeds profusely?
  • Juvenile nasopharyngeal angiofibroma occurs almost exclusively in adolescent boys because it is hormonally influenced and arises from the posterior nasal cavity / nasopharynx at the sphenopalatine region.
  • It is a highly vascular tumour, but the vessels are abnormal and lack a normal muscular coat.
  • The tumour stroma is fibrous, but the feeding vessels are numerous and fragile.
  • Because of this rich vascularity and absence of proper contractile vessel wall, even minor trauma or biopsy can produce profuse bleeding.
  • That is why suspected angiofibroma should never be biopsied casually and should be evaluated radiologically first.
Memory hook: Juvenile angiofibroma = male teenager + very vascular tumour + dangerous bleeding.
Distinction point: In exam answers, always add the anatomical basis and the practical clinical consequence.
Q6. A 35-year-old female with bilateral nasal blockage for 5 years; endoscopy shows grape-like glistening masses in both nasal cavities
a) Probable diagnosis and differentials
Bilateral, pale, glistening, grape-like masses strongly suggest nasal polyps rather than a unilateral choanal lesion. A good exam answer should mention that antrochoanal polyp is usually unilateral and arises from maxillary sinus.
b) Etiopathogenesis
Pathogenesis summary: chronic inflammation → mucosal edema → prolapse of mucosa → polyp formation.
c) Clinical features
Memory hook: Bilateral pale grape-like nasal masses with loss of smell = ethmoidal polyposis until proved otherwise.
d) Further evaluation
CT scan is important before surgery because it shows the extent of sinus disease and helps plan endoscopic sinus surgery.
e) Management plan and follow-up
Memory hook: Polyps are treated by shrinking inflammation first, then removing disease endoscopically if needed, and long-term follow-up prevents recurrence.
Q7. Write briefly on (Any Five)
a) Otomycosis
Memory hook: Otomycosis is the itchy fungal ear of humid climates.
b) Cochlear implant
Memory hook: Cochlear implant is an artificial hearing pathway for the deaf ear.
c) Obstructive sleep apnea
Memory hook: OSA is snoring with pauses and daytime tiredness.
d) Investigations for dysphagia
Memory hook: Dysphagia work-up must answer: where is the block, why is it blocked, and is it structural or motility-related?
e) Management of foreign body airway
Memory hook: Airway foreign body = first save the breath, then remove the object.
f) Rhino-orbital-cerebral mucormycosis
Memory hook: Mucormycosis is the black fungal emergency that spreads from nose to orbit to brain.
Q8. Write short notes on
a) Counselling about the hazards of tobacco to a group of school children
Memory hook: Tobacco steals breath, voice, teeth, stamina and future health.
b) Ototoxicity
Memory hook: Ototoxicity attacks hearing first, balance next, and is often drug-related.
c) Management of epistaxis
Memory hook: Epistaxis is managed front to back — pressure, cautery, packing, then surgery if needed.
d) Indications and complications of tonsillectomy
Memory hook: Tonsillectomy is done for repeated infection or obstruction, and bleeding is its most feared complication.