1. When a mandibular fracture is transferred to an emergency room, under what is mandibular fracture treated?

• a) Primary survey

• b) Secondary survey

• c) Primary survey with IMF

• d) Resuscitation room
  Correct Answer: a) Primary survey
  Explanation: All trauma patients, including those with mandibular fractures, are first assessed using the primary survey (ABCDE - Airway, Breathing, Circulation, Disability, Exposure) to identify and treat immediately life-threatening conditions.

2. Pathognomic sign of mandibular fracture:

• a) Malocclusion

• b) Hematoma (Sublingual)

• c) Tenderness and swelling at site

• d) Inability to open mouth
  Correct Answer: a) Malocclusion
  Explanation: While other signs are common, a change in the patient's normal bite (malocclusion) is the most characteristic and definitive sign of a displaced mandibular fracture.

3. With rigid internal fixation by bone plates it is expected that healing takes place by:

• a) Primary healing

• b) Fibrous healing

• c) Scarification

• d) Exuberant callus formation
  Correct Answer: a) Primary healing
  Explanation: Rigid internal fixation (compression plates) minimizes movement at the fracture site, allowing the bone to heal directly without forming a large callus, a process known as primary bone healing.

4. Battle sign is:

• a) Subconjunctival ecchymosis

• b) Sublingual ecchymosis

• c) Palatal ecchymosis

• d) Ecchymosis in the mastoid region
  Correct Answer: d) Ecchymosis in the mastoid region
  Explanation: Battle's sign is bruising over the mastoid process behind the ear, a classic indicator of a basilar skull fracture.

5. Most common complication that occur in open reduction of fracture is:

• a) Infection

• b) Non union

• c) Fibrous union

• d) Hemorrhage
  Correct Answer: a) Infection
  Explanation: Any open surgical procedure carries a risk of introducing bacteria. Infection is the most common complication of open reduction and internal fixation (ORIF).

6. Lefort 1 fracture is characterized by:

• a) Bleeding from the maxillary antrum

• b) Anterior open bite

• c) Angle class II skeletal relationship on fracture site

• d) Malocclusion
  Correct Answer: d) Malocclusion
  Explanation: A Le Fort I fracture (a horizontal fracture separating the alveolar process from the rest of the maxilla) invariably results in malocclusion due to the displacement of the tooth-bearing segment.

7. In which mandibular fracture does the tongue fall backwards?

• a) Symphysis fracture

• b) Bilateral mandibular body fracture

• c) Bilateral Parasymphysis fracture

• d) Bilateral angle fracture
  Correct Answer: c) Bilateral Parasymphysis fracture
  Explanation: The genioglossus muscle, which protrudes the tongue, attaches to the genial tubercles. Bilateral fractures in the parasymphysis region can cause this muscle to lose its anterior attachment, allowing the tongue to fall back and obstruct the airway.

8. Following bilateral mandibular fracture in the canine region (Parasymphysis), the following muscle will tend to pull the mandible back

• a) Anterior belly of digastric, geniohyoid and genioglossus

• b) Geniohyoid, genioglossus and mylohyoid

• c) Mylohyoid, hyoglossus and sternhyoid

• d) Hyoglossus, myohyoid and genioglossus
  Correct Answer: b) Geniohyoid, genioglossus and mylohyoid
  Explanation: These suprahyoid muscles pull the anterior mandibular fragment posteriorly and inferiorly, contributing to the airway compromise seen in these fractures.

9. Anterior open bite occurs in fracture of

• a) Bilateral condyle

• b) Bilateral angles

• c) Unilateral condyle

• d) Lefort 1
  Correct Answer: a) Bilateral condyle
  Explanation: Bilateral condylar fractures cause a loss of posterior vertical height, leading to premature contact of the molars and an anterior open bite.

10. The main causative organism in Ludwig angina is

• a) Streptococcus viridans

• b) Staphylococcus albus

• c) Staphylococcus aureus

• d) Streptococcus hemolyticus
  Correct Answer: d) Streptococcus hemolyticus (Typically Group A β-hemolytic Streptococcus)
  Explanation: Ludwig's angina is most commonly a polymicrobial infection, but β-hemolytic streptococci are frequently the primary causative agents.

11. The facial space involve in Ludwig angina are

• a) Unilateral-Submandibular and sublingual space

• b) Bilateral Submandibular and sublingual space

• c) Unilateral-submandibular, sublingual and submental

• d) Bilateral-submandibular, submental and sublingual space
  Correct Answer: d) Bilateral-submandibular, submental and sublingual space
  Explanation: By definition, Ludwig's angina is a bilateral infection of the submandibular, sublingual, and submental spaces.

12. Which of the following is the cause for multiple sites of osteomyelitis of the jaw?

• a) Peritonsillar abscess

• b) Local trauma

• c) Haematogenous infection

• d) Buccal space infection
  Correct Answer: c) Haematogenous infection
  Explanation: Hematogenous spread of bacteria through the bloodstream is the mechanism that can lead to osteomyelitis at multiple, non-contiguous sites.

13. In Ludwig angina classical sign is

• a) Tongue is raised and falls back causing respiratory embarrassment

• b) That submandibular and sublingual space is involved though tongue may not be raised

• c) That submental sublingual and submandibular space involved bilaterally

• d) Board like brawny induration of mandible with tongue falling back and causing respiratory embarrassment
  Correct Answer: d) Board like brawny induration of mandible with tongue falling back and causing respiratory embarrassment
  Explanation: This option best describes the classic "woody" or board-like hardening of the floor of the mouth and the key life-threatening complication: airway obstruction.

14. In Ludwig angina incision should be placed deep until

• a) Mylohyoid muscle

• b) Anterior belly of digastric

• c) Geniohyoid

• d) Mucus membrane of floor of mouth
  Correct Answer: d) Mucus membrane of floor of mouth
  Explanation: The goal of surgical drainage in Ludwig's angina is to release the tension in all involved spaces. The incision must go through all tissue layers until the mucosa of the floor of the mouth is reached to ensure complete decompression.

15. Osteomyelitis begins as inflammation of

• a) Cortical bone

• b) Periosteum

• c) Medullary bone

• d) Periosteum and inner cortex
  Correct Answer: c) Medullary bone
  Explanation: Osteomyelitis typically begins in the medullary (marrow) space, where the blood supply is richest, and then spreads to the cortex and periosteum.

16. An acute alveolar abscess should be treated with

• a) First antibiotics for three days then incision and drainage

• b) Incision and drainage with broad spectrum antibiotics

• c) Broad spectrum antibiotics and analgesics

• d) Antibiotics and proteolytic drugs like chymotrypsim
  Correct Answer: b) Incision and drainage with broad spectrum antibiotics
  Explanation: The primary treatment for an abscess is to establish drainage. Antibiotics are an important adjunct but cannot replace the need to evacuate the pus.

17. Which of the following conditions are susceptible to osteomyelitis?

• a) Paget' disease

• b) Fibrous dysplasia

• c) Radiation

• d) All of the above
  Correct Answer: d) All of the above
  Explanation: All these conditions compromise the blood supply (radiation) or alter the normal bone architecture (Paget's, fibrous dysplasia), making the bone more vulnerable to infection.

18. Treatment of chronic osteomyelitis consists of:

• a) Culture sensitivity and prolonged antibiotic therapy

• b) Culture sensitivity with antibiotic therapy and hyperbaric oxygen therapy

• c) Sequestromy, surgical exploration and prolonged antibiotic thereafter culture sensitivity

• d) Sequestromy, antibiotics after sensitivity and hydrocortisone therapy
  Correct Answer: c) Sequestromy, surgical exploration and prolonged antibiotic thereafter culture sensitivity
  Explanation: Chronic osteomyelitis requires surgical removal of all dead bone (sequestrum) and debridement of infected tissue, followed by a long course of culture-directed antibiotics.

19. Best treatment for large cyst

• a) Marsupialization

• b) Enucleation

• c) Marsupialization followed by enucleation

• d) Encleation followed by marsupialization
  Correct Answer: c) Marsupialization followed by enucleation
  Explanation: For very large cysts, marsupialization (creating a window) first allows the cyst to shrink, reducing its size and minimizing the risk of damaging vital structures during a subsequent definitive enucleation.

20. In an otherwise asymptomatic cystic swelling if there is sudden neurapraxia in inferior alveolar nerve region it can be due to

• a) Infection of cyst

• b) Expansion of periosteum due to cyst

• c) Neuritis

• d) Neuralgia
  Correct Answer: a) Infection of cyst
  Explanation: A sudden onset of nerve dysfunction (neurapraxia) in the setting of a known cyst is highly suggestive of an infection within the cyst, which causes inflammation and pressure on the nerve.

21. A patient present with a non-vital tooth and swelling in labial sulcus, on aspiration straw coloured fluid is present a tentative diagnosis would be

• a) Nasopalatine cyst

• b) Solitary bone cyst

• c) Keratocyst

• d) Periapical periodontal cyst
  Correct Answer: d) Periapical periodontal cyst (Radicular Cyst)
  Explanation: A non-vital tooth is the etiology. A radicular cyst, which is filled with straw-colored fluid, is the most common cyst arising from the apex of a non-vital tooth.

22. In a 48yrs old patient the treatment of Dentigerous cyst with impacted molar lying near lower border of mandible, would be

• a) Enucleation with primary closure and IMF

• b) Marsupialization with extraction of molar

• c) Marsupialization with IMF

• d) Enuceation with secondary closure
  Correct Answer: b) Marsupialization with extraction of molar
  Explanation: Due to the risk of pathological fracture from removing a large amount of bone near the lower border, marsupialization is the safer initial approach. The impacted tooth is typically removed as part of the procedure or later.

23. Eruption cyst should be treated

• a) Immediately with enucleation

• b) By marsupialization

• c) With no active treatment

• d) With antibiotics
  Correct Answer: c) With no active treatment
  Explanation: An eruption cyst is a benign, fluid-filled sac over an erupting tooth. It usually resolves on its own without any intervention as the tooth erupts through it.

24. A 14 yrs old female patient presented with swelling on right side of face in maxillozygomatic area... ground glass appearance this is characteristic picture of

• a) Osteoma

• b) Ossifying fibroma

• c) Fibrous dysplasia

• d) Osteosarcoma
  Correct Answer: c) Fibrous dysplasia
  Explanation: The classic presentation of a young patient with a slow-growing, painless swelling and a "ground glass" radiographic appearance is pathognomonic for fibrous dysplasia.

25. Following a lower molar extraction, a patient develops transient Bell's palsy. This may be penetration of local anesthetic solution into

• a) Maxillary artery

• b) Buccinator muscle

• c) Temporlis muscle

• d) Parotid gland
  Correct Answer: d) Parotid gland
  Explanation: An inferior alveolar nerve block injection given too far posteriorly can penetrate the parotid gland, where the facial nerve (CN VII) resides, causing a temporary facial paralysis.

26. According to FDI, a lower right first molar is denoted as:

• a) 46

• b) 47

• c) 37

• d) 45
  Correct Answer: a) 46
  Explanation: In the two-digit FDI World Dental Federation notation, the first digit indicates the quadrant (4 = lower right) and the second digit indicates the tooth (6 = first molar).

Section A: Single Best Answer (20 Marks)

Q1. Concerning the universal notation:

• a. 17 is upper left third molar tooth

• b. 17 is lower left third molar tooth

• c. 32 is upper left third molar tooth

• d. 32 is lower left central incisor tooth

✅ Correct Answer: b) 17 is lower left third molar tooth
Explanation: In the Universal Numbering System, tooth #1 is the upper right third molar. The count continues across the upper arch to #16 (upper left third molar), then down to #17 (lower left third molar), and across the lower arch to #32 (lower right third molar).

Q2. The upper left second deciduous molar in FDI notation is:

• a. 14

• b. 65

• c. 54

• d. 24

✅ Correct Answer: b) 65
Explanation: In the two-digit FDI system, the first digit represents the quadrant (5 = primary upper left, 6 = primary upper right, 7 = primary lower left, 8 = primary lower right). The second digit represents the tooth (4 = second molar). Therefore, the upper left second deciduous molar is 65.

Q3. Trimodal distribution of trauma deaths:

• a. Trauma deaths show a bimodal distribution

• b. Within the first 24 hours, Multiple Organ Failure is the leading cause of mortality

• c. Immediately cause include(major internal injury, heart and brain injury)

• d. Death is inevitable

✅ Correct Answer: c) Immediately cause include(major internal injury, heart and brain injury)
Explanation: The classic trimodal distribution describes peaks of death: 1) Immediately (seconds to minutes) from major vascular or CNS injury; 2) Early (minutes to hours) from internal hemorrhage; 3) Late (days to weeks) from sepsis or organ failure.

Q4. Advanced trauma life support (ATLS) concept

• a. A detailed history is essential to begin the evaluation

• b. Treat the greatest threat to life first

• c. “ABCDE” approach may not be necessary

• d. The lack of a definitive diagnosis should impede the application of an indicated Treatment

✅ Correct Answer: b) Treat the greatest threat to life first
Explanation: The core principle of ATLS is to identify and treat life-threatening conditions in order of priority using the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, without waiting for a definitive diagnosis.

Q5. Classification of mandibular fractures:

• a. Angle fracture is the most common accounting for 24.5%

• b. Posterior open bite is common

• c. Unrestricted mouth opening is a feature

• d. Condylar fractures are the most common accounting for 29.1%

✅ Correct Answer: d) Condylar fractures are the most common accounting for 29.1%
Explanation: The condylar process is the most common site for mandibular fractures, followed by the angle and the body. Restricted mouth opening (trismus), not unrestricted, is a common feature.

Q6. Burkitts Lymphoma:

• a. Is Hodgkin’s Lymphoma

• b. Can be derived from B- or T cells

• c. Is a non-malignant tumor

• d. Treatment is by surgery

✅ Correct Answer: d) Treatment is by surgery (Note: This is a poorly worded question. The best available answer is d, but standard treatment is high-dose chemotherapy, with surgery often used for biopsy/debulking.)
Explanation: Burkitt lymphoma is a high-grade B-cell non-Hodgkin lymphoma. While chemotherapy is primary, surgical intervention is a critical part of the management, especially for abdominal tumors or obtaining a biopsy.

Q7. Purpose of a biopsy:

• a. Helps in verifying a clinical impression

• b. May not help in the formulation of a treatment plan in evaluating treatment

• c. Aids to arrive at an early and accurate diagnosis in 50% of cases

• d. May not help to determine whether a disease is a local or a systemic process

✅ Correct Answer: a) Helps in verifying a clinical impression
Explanation: The primary purpose of a biopsy is to obtain a definitive histopathological diagnosis, which verifies or refutes the clinical impression and is absolutely essential for formulating the correct treatment plan.

Q8. Treatment of oral tumors:

• a. Radiotherapy is a primary treatment modality in all cases

• b. Status of the dentition has significant effect on post-treatment quality of life among patients

• c. In children don’t extract mobile primary teeth that are expected to exfoliate during treatment

• d. Radiotherapy- neoadjuvant is(after surgery/ irradiation)

✅ Correct Answer: b) Status of the dentition has significant effect on post-treatment quality of life among patients
Explanation: The health and status of the dentition critically impact functions like chewing and speech after cancer treatment, severely affecting quality of life. Radiotherapy is not first-line for all cases, and neoadjuvant means before primary treatment.

Q9. Concerning fibrous dysplasia

• a. Teeth involved in the lesion usually remain firm but may be displaced

• b. The chief radiograph is feature is a "fine-glass" opacification

• c. Treatment is by radiotherapy

• d. Polyostotic Fibrous dysplasia may involve one bone

✅ Correct Answer: a) Teeth involved in the lesion usually remain firm but may be displaced
Explanation: Teeth within fibrous dysplasia are typically vital and firm but are often displaced by the expanding bone. The radiographic feature is "ground-glass" (not "fine-glass"). Radiotherapy is contraindicated due to sarcoma risk. Polyostotic means multiple bones.

Q10. Oral Kaposi's sarcoma:

• a. Iatrogenic type is related to loss of humoral immunity

• b. Aids related runs a rapid course with good prognosis

• c. In classic type oral lesions are frequently seen

• d. Endemic/African type is divided into four subtypes

✅ Correct Answer: d) Endemic/African type is divided into four subtypes
Explanation: The African/Endemic type is classified into nodular, florid, infiltrative, and lymphadenopathic subtypes. The iatrogenic type is related to cell-mediated immunity (e.g., transplant patients). AIDS-related KS has a poor prognosis.

Q11. Anterior epistaxis can be controlled by all the following means EXCEPT:

• a. Embolization

• b. Anterior nasal packs

• c. Insertion and inflation of Foleys Catheter in the posterior nares

• d. Cautery of the bleeding point

✅ Correct Answer: c) Insertion and inflation of Foleys Catheter in the posterior nares
Explanation: 🚫 Why Foley catheter in posterior nares is incorrect:

• This technique is used for posterior epistaxis, not anterior.

• Posterior bleeds arise deeper (e.g., Woodruff’s plexus) and may require posterior packing or balloon tamponade, like a Foley catheter.

• Using it for anterior bleeds is unnecessary and inappropriate.

Q12. Antibiotic used to treat Quinsy:

• a. Ciprofloxacin

• b. Cloxacillin

• c. Clindamycin

• d. All the above

✅ Correct Answer: d) All the above
Explanation: Quinsy (peritonsillar abscess) is often polymicrobial. Broad-spectrum coverage is required, and all listed antibiotics (or combinations thereof) can be appropriate choices depending on local guidelines and severity.

Q13. In a child with unilateral otorrhea, all of the following can be considered as a cause EXCEPT:

• a. Swimmer’s ear (Otitis Externa)

• b. Serous otitis media

• c. Chronic suppurative otitis media

• d. Otomycosis

✅ Correct Answer: b) Serous otitis media
Explanation: Serous otitis media (Otitis Media with Effusion) presents with fluid in the middle ear without perforation or discharge (otorrhea). All other options directly cause unilateral ear drainage.

Q14. Cause of mixed hearing loss:

• a. Temporal bone trauma

• b. Temporal bone malignancy

• c. HIV

• d. Ototoxicity

✅ Correct Answer: a) Temporal bone trauma
Explanation: Temporal bone fractures can simultaneously disrupt the ossicular chain (causing conductive loss) and damage the cochlear nerve or inner ear (causing sensorineural loss), resulting in a mixed hearing loss.

Q15. The following can cause hot potato speech EXCEPT:

• a. Laryngeal papilloma

• b. Nasopharyngeal carcinoma

• c. Peritonsillar abscess

• d. Retropharyngeal abscess

✅ Correct Answer: a) Laryngeal papilloma
Explanation: Laryngeal papilloma affects the vocal cords, leading to hoarseness or dysphonia, not the muffled resonance typical of hot potato speech. It’s a voice disorder, not a resonance or articulation issue caused by oropharyngeal space compromise.

Q16. Which of the following is a branch of the facial nerve:

• a. Lingual nerve (Branch of V3)

• b. Infraorbital nerve (Branch of V2)

• c. Nerve to stapedius muscle

• d. Nerve to mylohyoid (Branch of V3)

✅ Correct Answer: c) Nerve to stapedius muscle
Explanation: The facial nerve (CN VII) gives off several branches within the temporal bone, including the nerve to the stapedius muscle, which dampens loud sounds.

Q17. Which is NOT true concerning Aural polyp:

• a. Causes ear obstruction

• b. Caused by Foreign body

• c. Can be sign of malignancy

• d. Is fleshy and pale in un safe ear

✅ Correct Answer: d) Is fleshy and pale in un safe ear
Explanation: In an unsafe ear (indicating underlying cholesteatoma or malignancy), an aural polyp is typically red and friable (bleeds easily). A pale, fleshy polyp is more characteristic of a benign inflammatory process in a "safe" ear.

Q18. Myringotomy may be beneficial for children with the following EXCEPT:

• a. Persistent otitis media

• b. Speech delay with middle ear diffusion

• c. Recurrent otitis media

• d. Acute Mastoiditis

✅ Correct Answer: d) Acute Mastoiditis
Explanation: Acute mastoiditis is a serious complication of otitis media that requires urgent surgical intervention (mastoidectomy) and IV antibiotics. A simple myringotomy is insufficient to drain the mastoid air cells.

Q19. The Eustachian Tube:

• a. is about 2.6 cm long in adults

• b. has a longer cartilaginous portion than the auditory canal

• c. the bony portion forms the outer two thirds

• d. has respiratory epithelium

✅ Correct Answer: d) has respiratory epithelium
Explanation: The Eustachian tube is lined with ciliated, pseudostratified columnar (respiratory) epithelium. The cartilaginous portion makes up the inner two-thirds, not the bony portion.

Q20. The following are acute complications of rhinosinusitis EXCEPT:

• a. Subperiosteal abscess

• b. Cavernous sinus thrombosis

• c. Periorbital cellulitis

• d. Mucocele

✅ Correct Answer: d) Mucocele
Explanation: A mucocele is an chronic complication that forms from the slow, expansive accumulation of mucus due to sinus ostial obstruction. The other options are acute, infectious complications.

Section B: True or False (80 Marks)

Q1. Ossifying fibroma:

• a. A malignant bone neoplasm that has potential for excessive growth, bone destruction and recurrence. False

• b. Maxillary lesion tends to involve antrum True

• c. There is no evidence that ossifying fibromas ever undergo malignant change True

• d. Surgical removal using curettage or enucleation is treatment of choice True

Explanation:

• a) Ossifying fibroma is a benign fibro-osseous lesion.

• b) In the maxilla, it commonly expands into and involves the maxillary sinus (antrum).

• c) Malignant transformation is not a feature of ossifying fibroma.

• d) Conservative surgical enucleation or curettage is the standard treatment.

Q2. Ameloblastomas:

• a. Are the least common clinically significant benign odontogenic tumors False

• b. Are slow-growing tumors True

• c. Frequently present resorption of the roots of teeth adjacent to the tumor is seen True

• d. Treatment ranges from conservative curettage to watchful neglect False

Explanation:

• a) Ameloblastoma is the most common significant benign odontogenic tumor.

• b) They are typically slow-growing but locally aggressive.

• c) Root resorption of adjacent teeth is a common radiographic feature.

• d) Watchful neglect is never appropriate. Treatment is surgical, ranging from marginal resection for small lesions to segmental resection for large ones due to high recurrence with simple curettage.

Q3. Mucoepidermoid carcinoma:

• a. If the trigeminal nerve is involved, the patient may exhibit a facial palsy False

• b. High grade lesions should be treated aggressively to avoid recurrence True

• c. Neck dissections may not be performed for lymph node removal and staging in high-grade lesions False

• d. Is the most common malignant tumor of the salivary glands in children True

Explanation:

• a) The facial nerve (CN VII) is the nerve of concern in the parotid. Trigeminal nerve (CN V) involvement would not cause facial palsy.

• b) High-grade tumors behave aggressively and require wide resection, often with adjuvant radiotherapy.

• c) Neck dissection is absolutely indicated for high-grade lesions due to the high risk of nodal metastasis.

• d) Mucoepidermoid carcinoma is indeed the most common salivary gland malignancy in children.

Q4. Pleomorphic adenoma:

• a. Originates from ductal and myoepithelial elements. True

• b. Male-to-female ratio of 3:2. False

• c. the most common intraoral site is the anterior. False (Incomplete statement, but likely false as the parotid is most common)

Explanation:

• a) It is a "mixed tumor" histologically, arising from both ductal and myoepithelial cells.

• b) The ratio is reversed; it is more common in females (closer to a 3:2 female:male ratio).

• c) The most common site is the parotid gland (~80%). The most common intraoral site is the palate, not the anterior region.

Q5. Carcinoma of the tongue:

• a. Its more common in men True

• b. The anterior lateral tongue is a common site True

• c. Treatment of stage III on the tongue is total glossectomy False

• d. Stage II is T2 N1M1 False

Explanation:

• a) There is a strong male predominance due to risk factors like tobacco and alcohol.

• b) The lateral border of the tongue is the most frequent site.

• c) Stage III may be treated with hemiglossectomy or partial glossectomy combined with neck dissection and/or radiotherapy. Total glossectomy is typically reserved for very advanced (T4) lesions.

• d) Stage II is defined as T2 N0 M0. The presence of nodal (N1) or distant (M1) metastasis immediately places the cancer in Stage IV.

Q6. Concerning biopsies:

• a. Exfoliative cytology is only for surface cells True

• b. Submit x-ray (or radiologic findings) to pathologist for osseous lesions True

• c. Remove tissue from the centre or active area rather than the periphery False

• d. The commonest fixative used is normal saline False

Explanation:

• a) Exfoliative cytology collects cells that are shed from a surface.

• b) Radiographs provide crucial context for the pathologist interpreting bony lesions.

• c) A biopsy should include the interface between the lesion and normal tissue, as the center may be necrotic.

• d) The standard fixative is 10% neutral buffered formalin. Saline is used to keep tissue moist for fresh samples, not for fixation.

Q7. Concerning Le Fort II fractures:

• a. Clinical features include a step on the infra orbital rim and at the buccal sulcus above True

• b. Anterior open bite is a feature True

• c. Occipital mental standard view (Water's view) is ideal True

• d. Diplopia may occur after fractures of the middle third of the facial skeleton True

Explanation:

• a) A step deformity on the infraorbital rim is a key sign of a Le Fort II (pyramidal) fracture.

• b) The disimpacted maxilla can rotate downward and backward, causing an anterior open bite.

• c) The Waters' view (occipitomental) is the best plain radiograph to visualize the midface and sinuses for Le Fort fractures.

• d) Diplopia (double vision) is a common complication due to orbital floor involvement or extraocular muscle entrapment.

Q8. Mandibular fractures:

• a. Most common facial fractures True

• b. Midline shift is rare False

• c. Use extra osseous wires False

• d. Should accomplish several goals restoration of occlusion, function and facial Balance True

Explanation:

• a) The mandible is the most commonly fractured bone of the face.

• b) Midline shift is a common finding in symphyseal or bilateral body fractures.

• c) Modern treatment uses internal rigid fixation with plates and screws. Extra-osseous wiring is an outdated technique.

• d) The primary goals of treatment are to restore pre-injury occlusion, function, and facial symmetry.

Q9. The following are causes of Otitis media with effusion:

• a. HIV True

• b. Allergic Rhinitis True

• c. Down Syndrome True

• d. Gastro esophageal reflux True

Explanation: All are correct. OME (fluid in the middle ear without infection) is caused by Eustachian tube dysfunction, which can be due to:

• a) HIV: Immunocompromise leading to recurrent infections.

• b) Allergic Rhinitis: Inflammation and edema blocking the tube.

• c) Down Syndrome: Anatomical abnormalities and poor muscle tone.

• d) Gastro esophageal reflux: Refluxate irritating the tube opening.

Q10. The following are found in the medial wall:

• a. Facial canal False (Located in the posterior wall)

• b. Pyramidal eminence False (Located in the posterior wall)

Explanation: The medial wall of the middle ear is also the lateral wall of the inner ear. Key structures include the promontory (basal turn of cochlea) and the oval and round windows. The facial canal and pyramidal eminence are located in the posterior wall.

Q11. The following are acute complications of rhinosinusitis:

• a. Subperiosteal abscess True

• b. Cavernous sinus thrombosis True

• c. Periorbital cellulitis True

• d. Mucocele False

Explanation:

• a, b, c) These are all acute, infectious complications of rhinosinusitis.

• d) A mucocele is a chronic complication resulting from long-term obstruction of a sinus ostium.

Q12. Skeletal framework of the nasal septum include the following:

• a. Perpendicular plate of the ethmoid True

• b. Quadrilateral plate of the ethmoid False (Not an anatomical term; likely a distractor)

• c. Vomer True

• d. Maxillary crest True

Explanation: The bony nasal septum is composed of the:

• a) Perpendicular plate of the ethmoid bone (superiorly).

• c) Vomer (inferiorly and posteriorly).

• d) The crests of the maxillary and palatine bones (form the floor).

Q13. Ear cerumen:

• a. produced from ceruminous glands in outer 1/3 of ear canal True

• b. Dry wax is determined by a dominant gene False

• c. Wet wax is determined by a recessive gene False

• d. Wet wax is seen in Europeans and Africans True

Explanation:

• a) Cerumen is a mixture of secretions from ceruminous and sebaceous glands in the outer cartilaginous portion.

• b, c) The type of cerumen (wet vs. dry) is an autosomal recessive trait. Dry wax is recessive, wet wax is dominant.

• d) Populations of African and European descent predominantly have the dominant wet, sticky cerumen.

Q14. Indications for Myringotomy:

• a. Otitis media with Effusion (OME) that is persistent True

• b. Persistent acute otitis media True

• c. Glue ear (a synonym for OME) True

• d. Eustachian Tube dysfunction True

Explanation: All are correct. Myringotomy with tube insertion is indicated to ventilate the middle ear and prevent fluid accumulation in cases of chronic Eustachian tube dysfunction and its consequences (OME, persistent infection).

Q15. Branches of Woodruff's plexus:

• a. Sphenopalatine artery True

• b. Greater palatine artery True

• c. Ascending pharyngeal artery False

• d. Posterior nasal artery True

Explanation: Woodruff's plexus is a vascular anastomosis on the posterior lateral nasal wall, primarily fed by the:

• a) Sphenopalatine artery (terminal branch of maxillary artery).

• b) Greater palatine artery (anastomoses upwards).

• d) Posterior nasal artery (a branch).

• c) The ascending pharyngeal artery is a branch of the external carotid that supplies the pharynx, not a primary contributor to Woodruff's plexus.

Q16. Subsites of the glottic region:

• a. Posterior commissure False (Supraglottic)

• b. Aryepiglottic folds False (Supraglottic)

• c. Vallecula False (A site in the oropharynx/hypopharynx)

• d. Ventricular bands (False vocal cords) False (Supraglottic)

Explanation: This question is tricky. All listed options are NOT glottic. The glottis consists only of the true vocal cords and the anterior and posterior commissures. The other structures are supraglottic or in other regions.

Q17. Regarding the process of decannulation:

• a. Deliberate and temporal removal of a tracheostomy tube True

• b. Reasons for tracheostomy resolved True

• c. Tolerating cuff deflation for a minimum of 6 hrs False (Typically requires 24-48 hours)

• d. Maintaining O₂ saturation True

Explanation:

• a) Decannulation is the planned, temporary removal of the tube to assess readiness for permanent removal.

• b) The original indication for the tracheostomy must be resolved.

• c) The patient must tolerate cuff deflation and tube occlusion for a much longer period, often 24-48 hours, not just 6 hours.

• d) The patient must maintain adequate oxygenation without the tracheostomy tube.

Q18. Regarding Tracheostomy in Intensive Care Unit:

• a. Higher doses of sedation is required False

• b. Preservation of cough reflexes False

• c. More efficient pulmonary toilet True

• d. Reduced duration of ventilation True

Explanation:

• a) A key benefit is often that less sedation is needed as the patient is more comfortable than with an endotracheal tube.

• b) A tracheostomy tube bypasses the upper airway and impairs the cough reflex and mucociliary clearance.

• c) It allows for easier and more effective suctioning of secretions (pulmonary toilet).

• d) It can facilitate weaning from the ventilator, potentially reducing the total duration of mechanical ventilation.

Q19. Regarding otomycosis, predisposing conditions include:

• a. Long-term antibiotics True

• b. Diabetes mellitus True

• c. Steroid therapy True

• d. Immune competence False

Explanation:

• a, b, c) Antibiotics disrupt normal bacterial flora, diabetes provides a sugar-rich environment, and steroids are immunosuppressive; all predispose to fungal (otomycosis) overgrowth.

• d) Immuno****compromise is a risk factor, not competence.

Q20. The common causes of epistaxis include:

• a. Atherosclerosis True (Causes vessel fragility)

• b. Foreign body in the nose True (Causes trauma and infection)

• c. Anticoagulants True (Impair clotting)

• d. Bleeding dyscrasias True (e.g., hemophilia)

Explanation: All are well-known causes of epistaxis.

SECTION A: ESSAY QUESTIONS (20 Marks)

Answer one question only from each specialty.

MAXILLOFACIAL - Choose One:

a. Sign and Symptoms of mandibular fractures. What are the treatment options?

Correct Answer / Key Points to Include:

Signs and Symptoms:

• Pain and tenderness over the fracture site.

• Malocclusion (inability to bite properly; the most pathognomonic sign).

• Step deformity palpable at the inferior border of the mandible.

• Ecchymosis (bruising) in the floor of the mouth (sublingual hematoma) or submental region.

• Trismus (inability to open mouth fully).

• Paraesthesia or anaesthesia of the lower lip (if the inferior alveolar nerve is injured).

• Gingival or mucosal laceration adjacent to a tooth (indicating an open fracture).

• Deviation of the jaw on opening (often seen in unilateral condylar fractures).

Treatment Options:

• Closed Reduction and Intermaxillary Fixation (IMF):

  • Indication: Non-displaced, favourable fractures.

  • Methods: Arch bars, eyelet wires, or Ivy loops to wire the teeth together (maxilla to mandible) for 4-6 weeks.

• Open Reduction and Internal Fixation (ORIF):

  • Indication: Displaced, unfavourable, comminuted, or edentulous fractures.

  • Methods: Surgical exposure of the fracture and stabilization using titanium mini-bone plates and screws or reconstruction plates via an intraoral or extraoral approach.

• Supportive Care: Antibiotics (for open fractures), analgesics, and liquid/soft diet.

b. Ameloblastoma, signs and symptoms and treatment plan.

Correct Answer / Key Points to Include:

Signs and Symptoms:

• Slow-growing, painless expansion of the jaw (initially asymptomatic).

• Facial asymmetry and deformity as the tumor enlarges.

• Loosening or displacement of teeth.

• Paraesthesia of the lower lip (if in the mandible and nerve is involved).

• Radiographic Features: Classically a multilocular "soap-bubble" or "honeycomb" radiolucent lesion. Root resorption of adjacent teeth is a common feature.

Treatment Plan:

1. Diagnostic Confirmation: Incisional biopsy for histopathological diagnosis.

2. Imaging: Orthopantomogram (OPG) and CT Scan to determine the exact size, extent, and cortical perforation.

3. Definitive Surgical Treatment: Due to its locally aggressive nature and high recurrence rate with conservative treatment:

   • Resection with 1.0 - 1.5 cm surgical margins is the gold standard.

   • This often requires a segmental mandibulectomy or maxillectomy.

4. Reconstruction: Immediate reconstruction is performed using a reconstruction plate or a vascularized free bone graft (e.g., fibula free flap).

5. Long-term Follow-up: Regular clinical and radiographic review for at least 10 years to monitor for recurrence.

EAR NOSE AND THROAT - Choose One:

a. JORRP (Juvenile Onset Recurrent Respiratory Papillomatosis)

Correct Answer / Key Points to Include:

• Definition: A disease characterized by the growth of benign, recurrent papillomas (warts) in the respiratory tract, caused by the Human Papillomavirus (HPV), most commonly types 6 and 11.

• Clinical Features:

  • Hoarseness, weak cry, and stridor (noisy breathing) are the most common initial symptoms.

  • May progress to airway obstruction and respiratory distress.

  • The larynx is the most common site, but disease can spread to the trachea, bronchi, and lungs.

• Management:

  • Diagnosis: Direct laryngoscopy and biopsy.

  • Primary Treatment: Repeated surgical debridement using microdebriders or CO₂ laser ablation to remove papillomas and maintain a patent airway. The goal is disease control, not cure.

  • Adjuvant Therapy: Used for aggressive disease (e.g., Cidofovir - intralesional injection, Interferon).

• Prognosis: Variable. Disease often regresses at puberty but can require numerous surgeries during childhood.

b. Indications and post operative care for tracheostomy

Correct Answer / Key Points to Include:

Indications:

• Prolonged Mechanical Ventilation (e.g., >2 weeks intubation).

• Upper Airway Obstruction (e.g., tumors, trauma, bilateral vocal cord paralysis, severe infection like Ludwig's angina).

• Failed Intubation in an emergency.

• Inability to Protect Airway or Manage Secretions (e.g., coma, neurological disorders, bulbar palsy).

• Major Head & Neck Surgery (prophylactically).

Post-Operative Care:

• Securing the Tube: The tracheostomy tube must be securely tied with trachy tapes to prevent accidental dislodgement (decannulation), especially in the first 48-72 hours before a tract has formed.

• Suctioning: Regular, aseptic suctioning of the inner cannula and the trachea itself to remove secretions and maintain tube patency.

• Humidification: Administering humidified oxygen/air to prevent thickening of secretions and crusting, which can block the tube.

• Cuff Management: The cuff should be inflated only if there is a risk of aspiration or if mechanical ventilation is required. It must be deflated regularly to prevent tracheal wall ischemia.

• Stoma Care: The skin around the stoma should be kept clean and dry to prevent infection and breakdown.

• First Tube Change: Should be performed by an experienced clinician, typically after 5-7 days when the tract is mature.

2019 ENT PAPER2

Q1.

A 65-year-old male patient had a swelling polypoid in nature in the left nasal cavity, diagnosed by many physicians as a unilateral nasal polyp. He also complained of left decreased hearing and tinnitus. One week ago, a very small swelling appeared in the neck on the left side. The swelling was not tender and firm.

a) Diagnosis and reason why (3)
Answer: Nasopharyngeal Carcinoma (NPC).

Explanation:

• NPC typically affects middle-aged to elderly patients (not adolescents, unlike JNA).
  
  

• Unilateral nasal obstruction with a mass in the nasal cavity is a presenting feature.
  
  

• Hearing loss and tinnitus are due to Eustachian tube obstruction.
  
  

• A firm, non-tender cervical lymph node is characteristic of metastatic spread.
  
  

• JNA (juvenile nasopharyngeal angiofibroma) occurs in adolescent boys and does not explain cervical lymphadenopathy in a 65-year-old man.
  
  

b) Findings on examination (2)
Answer:

• Irregular/fleshy nasopharyngeal mass visible on nasoendoscopy.
  
  

• Ipsilateral cervical lymphadenopathy (firm, non-tender).
  
  

• Possible middle ear effusion on otoscopy (serous otitis media).
  
  

Explanation:
NPC presents as a posterior nasal mass, may bleed slightly, and frequently shows nodal spread. Serous otitis media is common due to Eustachian tube involvement.

c) Investigations (2)
Answer:

• Nasopharyngoscopy with biopsy for histological confirmation.
  
  

• Imaging with CT or MRI of head and neck to assess tumor extent and nodal disease.
  
  

Explanation:
Unlike JNA (where biopsy risks massive bleeding), NPC requires biopsy for definitive diagnosis. Imaging helps in staging and treatment planning.

d) Treatment (3)
Answer:

• Radiotherapy (gold standard for NPC, very radiosensitive).
  
  

• Chemoradiotherapy for advanced stages or nodal disease.
  
  

• Neck dissection only for persistent lymph nodes after radiotherapy.
  
  

Explanation:
NPC is radiosensitive, so radiotherapy is the primary treatment. Chemotherapy improves survival in advanced disease. Surgery is limited and not the main modality.

Q2.

A 25-year-old male patient complained of sore throat, fever, and bilateral earache of 3 days duration. He then developed very high fever (40°C), severe left earache, inability to open the mouth, drooling of saliva, and minimal difficulty in respiration. He underwent a minor surgical intervention with relief of all symptoms except the sore throat.

a) Diagnosis and reason why (3)
Answer: Peritonsillar Abscess (Quinsy).

Explanation:

• Starts as acute tonsillitis (sore throat, fever, bilateral earache).
  
  

• Progresses to peritonsillar abscess with:
  
  

  • Severe unilateral earache → referred otalgia via glossopharyngeal nerve (CN IX).
    
    

  • Trismus → spasm of medial pterygoid due to peritonsillar inflammation.
    
    

  • Drooling of saliva and respiratory difficulty → obstruction from swelling.
    
    

  • Hot potato voice (muffled).
    
    

• Relief after minor surgical intervention (incision and drainage) confirms abscess.
  
  

b) Findings on examination (2)
Answer:

• Unilateral bulging, erythematous peritonsillar area with uvular deviation to opposite side.
  
  

• Trismus, muffled “hot potato” voice, and tender ipsilateral cervical lymphadenopathy.
  
  

Explanation:
Peritonsillar abscess pushes the tonsil medially and uvula contralaterally. Voice changes and trismus are classical features.

c) Investigations (2)
Answer:

• Clinical diagnosis → usually sufficient based on classic presentation.
  
  

• Imaging (ultrasound or CT neck) → if extension to parapharyngeal/deep neck space is suspected.
  
  

• Needle aspiration with culture/sensitivity → guides antibiotic choice.
  
  

Explanation:
Peritonsillar abscess is mainly a clinical diagnosis, but imaging and aspiration may be required in atypical or complicated cases.

d) Treatment (3)
Answer:

• Incision and drainage (or needle aspiration) to evacuate pus.
  
  

• IV antibiotics → broad-spectrum covering aerobes & anaerobes (e.g., penicillin + metronidazole, or clindamycin).
  
  

• Supportive therapy → analgesia, IV fluids, steroids (to reduce edema and trismus).
  
  

Explanation:
Drainage is the definitive treatment. Antibiotics and supportive care are essential to control infection and improve recovery. Tonsillectomy may be considered in recurrent cases.

Q3.

A 7-year-old boy was seen by an ophthalmologist for headache that has been present for the last few months. Headache was maximum between the eyes. However, there was no ocular cause for such a headache. The child was referred to an ENT specialist who noticed nasal intonation of voice and bilateral nasal obstruction. The mother reported that her child snores during his sleep and has repeated attacks of chest infection.

a) Diagnosis and reason why (3)
Answer: Adenoid Hypertrophy.

Explanation:

• Hyponasal voice (nasal intonation) and bilateral nasal obstruction → classical signs of enlarged adenoids obstructing the choanae.
  
  

• Snoring and mouth breathing at night → due to blocked nasopharyngeal airway.
  
  

• Recurrent chest infections → from chronic mouth breathing, reduced nasal filtration, and postnasal drip.
  
  

• Headache between the eyes → related to nasal obstruction and sinus involvement (especially ethmoidal/sinus congestion due to adenoids).
  
  

b) Findings on examination (2)
Answer:

• Child is a mouth breather with open mouth posture and may have “adenoid facies” (long face, high-arched palate, malocclusion).
  
  

• Nasal speech (hyponasal voice).
  
  

• Postnasal drip, congested nasal mucosa, and sometimes middle ear effusion.
  
  

• On posterior rhinoscopy or nasoendoscopy → enlarged adenoids seen obstructing choanae.
  
  

Explanation:
Examination shows both local effects (nasal obstruction, postnasal drip) and secondary effects (facial changes, middle ear disease).

c) Investigations (2)
Answer:

• X-ray nasopharynx lateral view → shows “adenoid shadow” obstructing airway.
  
  

• Nasoendoscopy → direct visualization of adenoids (gold standard).
  
  

• Audiometry / tympanometry → if ear symptoms present (serous otitis media).
  
  

Explanation:
X-ray is a simple tool for children, while endoscopy gives a direct and more accurate assessment.

d) Treatment (3)
Answer:

• Medical treatment (for mild cases): nasal saline, antibiotics for infection, nasal steroids (short term).
  
  

• Adenoidectomy → definitive treatment for significant obstruction, snoring, recurrent infections, or adenoid facies.
  
  

• Adenoidectomy + grommet insertion → if associated with recurrent otitis media with effusion.
  
  

Explanation:
Medical therapy may provide temporary relief, but surgery is the treatment of choice in children with complications or persistent symptoms.

Q4.

A 30-year-old female has been suffering from seasonal nasal obstruction for the last few years. A watery nasal discharge and attacks of sneezing have been associated with this nasal obstruction. Two weeks ago, she had an attack of common cold, refused medical treatment, and two days later developed pain over the forehead and mild fever. She did not receive any treatment and recently developed severe headache with high fever (40°C), became severely irritable, and could not withstand light. On examination, there was marked neck and back stiffness.

a) What is the probable diagnosis? (3)
Answer: Bacterial meningitis secondary to frontal sinusitis.

Explanation:

• Seasonal nasal obstruction and sneezing → allergic rhinitis.
  
  

• Acute common cold → sinus blockage → acute frontal sinusitis.
  
  

• Spread of infection intracranially → meningitis.
  
  

• Features of meningitis: severe headache, fever, photophobia, irritability, neck stiffness.
  
  

b) Explain the above manifestations (3)
Answer:

• Allergic rhinitis causes chronic mucosal edema, leading to sinus obstruction.
  
  

• Acute sinusitis developed, untreated, leading to spread of bacteria.
  
  

• Infection spread to the meninges → meningitis signs (neck stiffness, photophobia, high fever).
  
  

c) Management (4)
Answer:

• Admit patient immediately.
  
  

• IV broad-spectrum antibiotics (e.g., ceftriaxone + vancomycin ± metronidazole).
  
  

• CT/MRI brain and sinuses to assess for abscess or complications.
  
  

• Supportive care: IV fluids, antipyretics, monitoring for raised ICP.
  
  

Explanation:
Meningitis secondary to sinusitis is a medical emergency requiring prompt antibiotics and imaging.

Q5.

A 10-year-old child complained of right mucopurulent otorrhea for the last 2 years. He suddenly became feverish, and this was associated with diminution of the ear discharge. A few days later, there was tenderness over the right mastoid. The retroauricular sulcus was preserved. There were no neurological disturbances.

a) What is the probable diagnosis? (3)
Answer: Acute mastoiditis complicating chronic suppurative otitis media (CSOM).

Explanation:

• Long history of ear discharge → CSOM.
  
  

• Sudden fever + reduction of discharge → blocked drainage, pus retained in mastoid.
  
  

• Mastoid tenderness but sulcus preserved → early mastoiditis (before subperiosteal abscess).
  
  

b) Explain the manifestations (3)
Answer:

• CSOM predisposes to secondary infection of mastoid air cells.
  
  

• When drainage is blocked → pressure buildup → fever and pain.
  
  

• Mastoid tenderness is early sign; absence of sulcus obliteration = no abscess yet.
  
  

c) Management (4)
Answer:

• Admit and start IV broad-spectrum antibiotics (e.g., ceftriaxone or amoxicillin-clavulanate).
  
  

• Aural toileting + topical antibiotic drops.
  
  

• CT temporal bone to assess mastoid involvement.
  
  

• If no improvement → myringotomy ± mastoidectomy.
  
  

Explanation:
Medical therapy is first-line. Surgery is needed if infection persists or complications arise.

Q6.

A 3-year-old boy presented to the ENT specialist with inability to close the right eye and deviation of the mouth angle to the left side upon crying, for 2 days. His mother reported severe right ear pain 5 days earlier, which improved with antibiotics.

a) What is the probable diagnosis? (3)
Answer: Facial nerve palsy secondary to acute otitis media.

Explanation:

• Facial nerve passes through middle ear (via fallopian canal).
  
  

• Acute otitis media can cause inflammation and compression of the nerve.
  
  

• LMN facial palsy signs: inability to close eye, mouth deviation.
  
  

b) Explain the manifestations (3)
Answer:

• Severe ear pain → acute otitis media.
  
  

• Inflammation in middle ear → compresses facial nerve.
  
  

• Leads to facial asymmetry: weak right side, mouth pulled left.
  
  

c) Management plan (4)
Answer:

• Continue systemic antibiotics for AOM.
  
  

• Add oral steroids to reduce nerve inflammation.
  
  

• Eye protection (artificial tears, patching) to prevent keratitis.
  
  

• ENT follow-up for nerve recovery and hearing assessment.
  
  

Explanation:
Most facial palsy from AOM resolves with medical treatment. Surgery (myringotomy/mastoidectomy) is reserved for refractory or complicated cases.

Q7.

A 56-year-old male presents with a history of hoarse voice for 1 year, difficulty in breathing for 2 months, and a neck swelling on the right side of the neck. He smoked for 15 years until last year.

a) Provisional diagnosis and 2 differential diagnoses (3)
Answer:

• Provisional diagnosis: Laryngeal Carcinoma (most likely squamous cell carcinoma).
  
  

• Differential diagnoses:
  
  

  1. Laryngeal papillomatosis (benign but recurrent wart-like growths).
     
     

  2. Chronic laryngitis (long-standing irritation from smoking).
     
     

  3. Tuberculosis of the larynx.
     
     

Explanation:

• The risk factors (male, smoker, age >50) strongly suggest carcinoma.
  
  

• Hoarseness lasting >3 weeks in a smoker is a red flag for laryngeal cancer.
  
  

• Neck swelling indicates possible metastatic cervical lymph node.
  
  

• Difficulty in breathing points to airway obstruction by a progressive mass.
  
  

• Differentials are less common in this age group but considered in atypical cases.
  
  

b) Investigations (5)
Answer:

1. Indirect or flexible laryngoscopy → to visualize the laryngeal lesion.
   
   

2. Direct laryngoscopy with biopsy (under GA) → histopathological confirmation.
   
   

3. CT scan or MRI of neck and chest → to evaluate tumor extent, airway involvement, cartilage invasion, and nodal/distant spread.
   
   

4. Chest X-ray → to rule out pulmonary metastasis or second primary from smoking.
   
   

5. Staging workup (TNM staging) → includes PET-CT where available.
   
   

Explanation:
Biopsy is essential for confirmation. Imaging defines extent, invasion, and nodal spread. Staging is critical for planning treatment.

c) Treatment (3)
Answer:

• Early-stage disease (Stage I–II): Radiotherapy or endoscopic laser cordectomy (voice-preserving).
  
  

• Advanced disease (Stage III–IV): Total laryngectomy ± neck dissection followed by adjuvant radiotherapy/chemoradiotherapy.
  
  

• Voice rehabilitation: Post-laryngectomy speech therapy using esophageal speech, electrolarynx, or tracheoesophageal puncture (TEP) prosthesis.
  
  

Explanation:
Treatment depends on stage. Radiotherapy and conservative surgery are used for early lesions, while total laryngectomy is often required for advanced cases. Rehabilitation of voice is essential for quality of life.

Q8.

A 45-year-old woman presents with epistaxis to the OPD. She denies any history of trauma but reports that this incident is the 4th one this year.

a) Classify epistaxis (2)
Answer:

1. Anterior epistaxis → bleeding from Kiesselbach’s plexus (Little’s area) on the anterior nasal septum.
   
   

   • Accounts for 90–95% of cases.
     
     

   • Usually mild, recurrent, and easy to control.
     
     

2. Posterior epistaxis → bleeding from branches of the sphenopalatine or posterior ethmoidal arteries in the posterior nasal cavity.
   
   

   • Less common but more severe, often requiring hospitalization.
     
     

Explanation:
Anterior epistaxis is most common and often recurrent in middle-aged patients. Posterior epistaxis is dangerous, occurs in older or hypertensive patients, and is harder to control.

b) What are the investigations to order in this patient? (5)
Answer:

1. Full blood count (FBC) → to assess anemia and platelet count.
   
   

2. Coagulation profile (PT, aPTT, INR) → to detect bleeding disorders.

• PT (Prothrombin Time): Assesses the extrinsic and common clotting pathways. Used to monitor warfarin therapy.

• INR (International Normalized Ratio): Standardized PT. Target range: 2.0–3.0 for most anticoagulated patients.

• aPTT (Activated Partial Thromboplastin Time): Evaluates the intrinsic and common pathways. Used to monitor heparin therapy.

🧠 Mnemonic: PETI — PT = Extrinsic, aPTT = Intrinsic

3. Blood pressure measurement → to check for hypertension as a contributing cause.
   
   

4. Nasal endoscopy → to localize the bleeding site and rule out tumors or vascular malformations.
   
   

5. Liver function tests (LFTs) → if chronic liver disease suspected as cause of coagulopathy.
   
   

Explanation:
Recurrent epistaxis without trauma warrants systemic evaluation (blood disorders, hypertension, liver disease) and local assessment (endoscopy).

c) List 3 modalities of treatment for epistaxis (3)
Answer:

1. First-line (conservative): Pinching the nose, topical vasoconstrictors (xylometazoline/adrenaline), chemical or electrical cautery of bleeding point.
   
   

2. Second-line: Anterior or posterior nasal packing, or endoscopic cauterization.
   
   

3. Third-line: Surgical arterial ligation (sphenopalatine or ethmoidal artery) or endovascular embolization.
   
   

Explanation:
Treatment is stepwise: start with conservative methods, escalate to packing if bleeding persists, and finally consider surgical or interventional radiology approaches in refractory cases.

Q9.

Having rotated in the ENT department during your 6th year of medical school, you feel that you are prepared to manage nasal foreign bodies that present to you as the intern on call. You quickly remind yourself of the basics for this condition by noting down the following:

a) Instruments required to remove FB from the nose (2)
Answer:

• Headlight (for illumination).
  
  

• Nasal speculum (for visualization).
  
  

• Bayonet forceps.
  
  

• Suction apparatus.
  
  

• Probe or hook.
  
  

• Wax curette.
  
  

Explanation:
Proper visualization and suitable instruments are essential for safe removal. Headlight and speculum allow hands-free access, while forceps, curette, or suction help in extraction depending on the type of FB.

b) Possible complications that may arise (2)
Answer:

• Aspiration of the foreign body into the airway.
  
  

• Local infection or sinusitis.
  
  

• Rhinolith formation (if FB is neglected for long).
  
  

• Septal perforation or mucosal trauma.
  
  

Explanation:
Foreign bodies can migrate, cause chronic inflammation, or lead to secondary complications. Prompt removal prevents these outcomes.

c) When to call your senior (2)
Answer:

• If the patient is an uncooperative child requiring sedation or GA.
  
  

• If the FB is difficult to visualize or remove.
  
  

• If there is significant nasal bleeding.
  
  

• If the FB has been aspirated into the airway.
  
  

Explanation:
These situations carry risks (airway compromise, complications of removal) and need senior or anesthetic support.

d) How a neglected foreign body in children presents (2)
Answer:

• Unilateral, foul-smelling, purulent nasal discharge.
  
  

• Sometimes blood-stained discharge and nasal obstruction.
  
  

Explanation:
This is the classic presentation of a retained FB, often leading to suspicion in children when there is persistent unilateral nasal discharge.

e) Type of FB that should be managed urgently (2)
Answer:

• Button batteries → cause rapid tissue necrosis, mucosal burns, and septal perforation within hours due to electrical and chemical injury.
  
  

• Magnets → if more than one is inserted, they can attract across the septum, causing pressure necrosis and perforation.
  
  

Explanation:
Button batteries and magnets are ENT emergencies due to their potential for severe local destruction.

Q10.

You are doing a morning round post-call in the ENT ward and discover that the patient who had a tracheostomy procedure done last night is breathing noisily.

a) What is the possible cause of the noisy breathing? (2)
Answer:

• Tracheostomy tube obstruction by thick secretions, mucus plug, or blood clot.
  
  

• Malposition or kinking of the tube.
  
  

Explanation:
Noisy breathing in a fresh tracheostomy is most commonly due to obstruction. In the early post-op period, secretions and blood clots are common culprits, while tube displacement can also cause airway compromise.

b) What is your next step? (3)
Answer:

1. Suction the tracheostomy tube immediately to clear secretions.
   
   

2. If not relieved → remove and clean the inner cannula (or replace with a new one).
   
   

3. If obstruction persists → remove and replace the entire tracheostomy tube promptly, while ensuring the airway is maintained.
   
   

Explanation:
Management must be quick and stepwise to restore airway patency. Suctioning is first-line. If that fails, inner cannula cleaning or tube replacement is necessary. Delay can lead to respiratory arrest.

c) Explain possible complications of tracheostomy during this period. (5)
Answer:

• Early complications (within 24–48 hrs):
  
  

  • Hemorrhage (from tracheal or thyroid vessels).
    
    

  • Tube obstruction (secretions, clot).
    
    

  • Subcutaneous emphysema.
    
    

  • Pneumothorax or pneumomediastinum.
    
    

  • Accidental decannulation or misplacement.
    
    

• Intermediate complications:
  
  

  • Tracheitis or local infection.
    
    

  • Tracheal ulceration and granulation tissue.
    
    

• Late complications:
  
  

  • Tracheal stenosis.
    
    

  • Tracheoesophageal fistula.
    
    

  • Tracheo-innominate artery fistula (rare but catastrophic hemorrhage).