ENT & EYE OSCE Totes

(Dropbox)

ENT Topics to study

DDx U/L , B/L nasal
obstruction
Tonsillitis + Tonsillectomy
Quinsy
Thyroid Diagnostic
Eye Topics to Study
algorithm
Glaucoma
Menieres disease
ASOM, CSOM Visual fields Kaplan
Pupillary reactions
Oral Cavity Cancers
Retinitis pigmentosa
Laryngeal Cancers
AA notes
Neck Masses
Jatoi DDx
DNS
Dacryocystitis
Septoplasty, SMR
Optic disc DDx
Audiogram
DDx SNHL, CHL Optic Neuritis
Lid lesions
OSAS
TC 300 - selective
Nasal polyps, FESS
Laryngeal nodule, polyps
Thyroid cancer
MNG
Nose Lesions (benign,
malignant)
Otosclerosis
Dysphagia DDx
Hoarsness - DDx

List of ENT OSCE Stations

Ear exam
Nose exam
Oral cavity exam
Neck exam
Posterior rhinoscopy
Hx Menieres disease (vertigo, tinnitus)
Thyroid patient counseling (Goitre)
Hx Sore throat (quinsy)
Laryngeal nodule
Audiogram Carhart notch
Hx Progressive hearing loss
Hx OSAS
Hx Hoarseness
Hx Dysphagia
Hx Blocked nose
Counselling for FNAC -> follicular cells
1. Suspicion of malignancy: 60 75%
2. Follicular neoplasm: 15 30%
3. Suspicion of Hurthle cell neoplasm
4. FLUS ( follicular lesion of undetermined significance) : 5 10%, repeat
FNAC

List of Eye Osce Stations

Hx for acute angle closure glaucoma (painful red eye)

Counseling for Retinitis Pigmentosa
Hx for gradual loss of vision
Hx for dacryocystitis (watery eye)
Hx for retrobulbar neuritis/MS (pain on eye movements)
Hx for Adies pupil/ciliary ganglionitis
Ocular Movements
Visual fields and defects
Pupillary exam
Ophthalmoscopy
Visual Acuity
Chalazion
Anterior Chamber findings
1. Corneal opacification
2. Pseudophakia
3. Cataract
4. Pterygium/pinguecula
5. Arcus senilis
6. Xanthelasma
7. Laser peripheral iridotomy
8. Entropion/ectropion
9. Ptosis (CN-3 palsy
(inspection + red reflex + pupil + lid eversion)

1). Menieres Disease History:

Meet, greet, consent

Age. Usually comes in 55-60 years. Males> females
P/C: Vertigo, Hearing loss
HOPC:
1. Vertigo ( onset, duration of episode, aura, Associated symptoms like
vomiting/bradycardia/cold sweats, Tullios phenomenon ask if loud
noise produced vertigo)
2. Hearing loss ( fluctuating, distortion of sound, intolerance to loud
sounds, diplacusis- perception of a single auditory stimulus as 2
separate sounds)
3. Tinnitus ( ask if there is any change in intensity/pitch of tinnitus right
before the attack)
4. Aural fullness
5. Emotional stress before the attack or preceding viral illness
6. Loss of consciousness/seizures/ any neurological deficit
7. Aggravating and relieving factors
Risk factor assessment/PMH
1. Ask about allergies
2. Fluid retention ( ask about any Rx that may cause this)
3. Hypothyroidism
4. H/O trauma or ear surgery
5. Any recent viral infection ( measles, mumps, etc)
6. H/O otosclerosis or syphilis
Family History
Ask about chocolate/coffee/smoking/alcohol/salt intake > may lead to
Menieres
Drug History: aminoglycosides, diuretics
Menstrual History
Quick review of symptoms

Most important thing pointing towards Menieres is periods of NO symptoms

between episodes. Dr. Anwar Sohail said that the patient will recount the first
episode of vertigo very dramatically and will remember every detail. Both these
things in the history will help you differentiate it from a possible central lesion
causing vertigo.
First line of treatment is Betahistine (vasodilator), given thrice daily orally. May
be combined with Stematil (vestibular sedative ) and diuretics.
Causes of vertigo: perilymph fistula, Vestibular neuronitis, Menieres,
labyrinthitis, BPPV, schwannoma
How to diagnose: history -> exam (otoscopy, hearing tests, nystagmus)-> test
(audiometry, speech audiometry, electrocochleography - SP/AP>30, caloric test,
glycerol dehydration test,). Definitive diagnosis is by histopath.

Management: Start with conservative measures -> drugs -> surgery -> Meniett
device (intermittent low pressure pulse therapy, brings relief from symptoms of
vertigo)

2). Ear Examination

Meet, greet, consent

Start with normal ear
Inspect ear front, side, retroauricular sulcus
Look behind ear and also observe mastoid for swelling, tap it for
tenderness
Palpate pinna, pull and ask about tenderness ( Otitis externa)
Pick up otoscope ( like a pen)
Examine and comment on appearance of tympanic membrane
Check for hyperacusis on both sides. Rub patients hair and ask: yeh
awaz aa rahi hai? Itni zor say?
Pneumatoscopy TM mobility
Rinnes. Explain to the patient what youre about to do. Record findings
Webers. If patient cannot understand forehead, put on teeth. Record
findings just in case you forget.
Fistula test: Press on tragus gently and check for any nystagmus. Check
Bilaterally. Sit on the level of the patient while doing this.
Facial nerve exam
Mention vestibular exam (nystagmus, cerebellum)
Mention ant. + post. rhinoscopy
Neck nodes
Thank patient

Boundaries of Mc.Ewans triangle: temporal line, post. Sup. Part of extl. auditory
meatus, tangent between the two
Tuning fork interpretation eg. R. CHL

DDx - CHL : wax furuncle, foreign body, ASOM, serous otitis media, retracted
tympanic membrane, otosclerosis, CSOM

DDx SNHL: Menieres, acoustic neuroma, labyrinthitis, presbycusis, ototoxic drugs,

trauma to 8th nerve
Causes of otitis media: recurrent URTI, exanthematous fever, chronic rhinitis,
sinusitis, packing for epistaxis, allergies, traumatic change to tympanic membrane
Branches of facial nerve in temporal bone : From the intl. acoustic meatus to the
stylomastoid foramen -> nerve to stapedius, superficial petrosal, chorda tympani
3). Neck station

Meet, greet, consent, sanitize

Note any hoarseness
Inspect from front and sides. Ask patient to swallow to visualize movement of
the thyroid.
Ask patient to protrude tongue. Check for thyroglossal duct cyst
Examine from behind. Check thyroid (thyroid cartilage, cricoid cartilage, lobes
ask patient to swallow again, assess temperature, consistency, margins,
nodularity, fixidity).
Check lymph nodes. Submental, submandibular, preauricular, postauricular,
occipital, anterior cervical, posterior cervical, jugulodigastric, supraclavicular
Examine from front. Palpate trachea (position). Check for laryngeal crepitus.
Hold thyroid cartilage and move it from side to side. Crepitus should be felt
normally.
Auscultate thyroid for bruit.
Percuss over sternum for retrosternal goiter
Mention for thyroid must assess thyroid status (hands, eyes, feet)
Thank patient

Boundaries of levels of the neck:

Lev
el
1a
1b
2a
2b
3
4
5a
5b
6

Boundaries
Mandible, ant. bellies of digastric, hyoid
Mandible, post. belly of digastrics, stylohyoid, hyoid
Stylohyoid, spinal accessory nerve, carotid bifurcation ,
sternohyoid
Spinal accessory nerve, post. border of SCM, skull base
Sternohyoid , carotid bifurcation, line from cricoid, post. border
of SCM
Sternohyoid, line from cricoid, clavicle, post. border of SCM
Post. border of SCM, ant. border of trapezius, line from cricoid
Post. border of SCM, ant. border of trapezius, line from cricoid,
clavicle
Carotid arteries laterally, hyoid, suprasternal notch

Structures that can be damaged at level 1: submental

lymph nodes, submandibular gland, submandibular lymph nodes, mandibular
branch of facial nerve, lingual nerve, hypoglossal nerve
What cancers drain to level 6: larynx, trachea, thyroid, esophagus
Thyroglossal duct cyst surgery? Sistrunk procedure -> surgical resection of the
duct to the base of the trunk and removal of the central portion of the hyoid bone.
Base of tongue to medial segment of hyoid + tongue tissue removed
Laryngeal CA TNM:

Ddx Neck masses:

Type
Congenital

Inflammatory
infectious

Inflammatory non
infectious
Neoplastic

Examples
Branchial cleft cyst, thyroglossal duct cyst, laryngocele,
plunging rannula, lymphangioma, hemangioma,
teratoma, dermoid cyst, thymic cyst, SCM tumors of
infancy
Reactive viral lymphadenopathy, HIV associated
cervical/persistent gen. lympadenopathy, bacterial
lymphadenopathy (suppurative, toxoplasmosis,
tularemia, brucellosis), granulomatous diseases (cat
scratch, actinomycosis, TB, sarcoidosis), fungal
infections
Sinus histiocytosis, Kawasaki disease, Castleman
disease
Metastatic SCC, thyroid masses, lymphoma, salivary

neoplasm, paraganglioma, lipoma, solitary fibrous

tumor
4). Nose Exam

Meet, greet, consent

Inspection: sides and top
Palpate nasal bone for deformity, tenderness
Palpate paranasal sinuses for tenderness
Check for patency of each nostril. Close one nostril. Put the posterior
rhinoscopy mirror under the other and ask the patient to exhale from nose. If
nostril is patent, the mirror will fog over. Repeat on the other side.
Sense of smell
Put on head mirror and focus on nostrils
Pick up Killian speculum and insert it in the nose while it is closed. Use one
hand to stabilize the nose. Probe test if mass is present it is carried out by
anesthetizing the nose with a spray and palpating the lesion/area to
determine its character and mobility
Comment on turbinates, secretions, septum and any gross pathology. Repeat
for the other nostril. Take out speculum while its open.
Pick up post. Rhinoscopy mirror (long stick with a mirror).
Warm it, feel how warm it is yourself and make patient feel it too. The
purpose of this is to avoid condensation from the expired air
Explain this step to the patient. Insert mirror in the oral cavity, all the way to
the back
Turn the mirror upwards to examine the post. nasal space
Focus light to visualize the nasopharynx
Thank the patient

Ddx for U/L nasal obstruction:

Vestibule

Furuncle
Vestibulitis
Atresia
Nasoalveolar cyst
Papilloma
Sq.cell CA

Nasal Cavity

FB
DNS
Hypertrophic
turbinates
Concha bullosa
Antrochoanal polyp
Syncechia
Rhinolith
Bleeding polypus of
septum
Benign/malignant
tumors of nose/

Nasopharynx

U/L choanal atresia

paranasal sinuses
U/L sinusitis

Ddx for B/L nasal obstruction:

Vestibule
B/L vestibulitis
Collapsing nasal
alae
Stenosis of nares
Congenital
atresia of nares

Nasal Cavity
Acute rhinitis
Chronic rhinitis and
sinusitis
Rhinitis
medicamentosa
Allergic rhinitis
Atrophic rhinitis
Rhinitis sicca
Hypertrophic
turbinates
DNS
Nasal polyps
Septal haematoma
Septal abscess
B/l choanal atresia

Nasopharynx
Large choanal polyp
Thornwaldts cyst
Adenoid
hyperplasia
Adhesions b/w soft
palate and post.
Pharyngeal wall
Large
benign/malignant
tumors

Picture of inverted papilloma (nasal tumors that originate in the mucosal membrane
of the nose and paranasal sinuses)

DNS diagnosis, surgery and complications

Surgery (DNS): septoplasty, submucous resection
Complications (DNS): headache, sinusitis, middle ear infection, OSAS

Types of polyps: ethmoidal polyp and antrochoanal (Killian) polyp

Rx for ethmoidal polyp: conservative -> antihistamine, short steroid course.
Surgery->intra/extranasal ethmoidectomy, FESS

5). Oral Exam

Meet, greet, consent

Listen for hoarseness, stridor
Do the exam sitting down, at the level of the patient
Adjust headlight
Inspect lips
Ask the patient to open their mouth to check for trismus
Pick up 2 tongue depressors and use them to inspect all the sub sites of the
oral cavity
Inspect inner aspect of lips, buccal mucosa, gingival mucosa, tongue,
underside of the tongue, floor of mouth, hard palate, buccal mucosa,
retromolar trigone, tonsillar area, position of uvula
Opening of Whartons/submandibular duct is at the floor of the mouth
Opening of Stensons/parotid duct is opposite the upper 2 nd molar
Then wear gloves and palpate the floor of the mouth bimanually to check for
tenderness of the submandibular gland, parotid, Stensons duct, any lesion
Say aah + gag reflex
Neck nodes
Indirect laryngoscopy (IDL)
Thank patient

Management of tongue lesion?

Subsites of oral cavity: mucosal lip, buccal mucosa, hard palate, alveolar ridge, floor
of mouth, retromolar trigone
Premalignant lesions of oral cavity: leukoplakia, erythroplakia, melanosis, mucosal
hyperpigmentation
Difference between IDL and DL:
Structures
seen

IDL
Larynx, laryngopharynx,
oropharynx

DL
Larynx and hypopharynx

Patient
position
Invasiveness
Use as
therapy

TNM oral cancers:

Seated across doctor

Seated with head tilted up

Non-invasive
Not therapeutic

Invasive
Therapeutic

6). Tonsillitis history

Meet, greet, consent, age

Presenting complaint
Ask about:
1. Sore throat ( duration of symptom)
2. Difficulty in swallowing ( Child may be refusing to take meals)
3. Episodes of fever
4. Earache (for a small child ask if he/she pulls at their ear as if showing
irritation). Ipsilateral may be in quinsy peritonsillar abscess
5. Lethargy, headaches, gen. body aches
To assess need for tonsillectomy:
1. Recurrent infections ( ask how many times a year the child has to be
put on antibiotics)
2. Snoring during sleep, mouth breathing

3. Speech of child ( muffled and thick speech -> hot potato voice ->
quinsy)
Trismus: bacha pooray mun khol pa raha hai? Eg, during eating, etc. Points
towards quinsy
PMH
FH
DH
Allergies/addictions
Summarize
Thank patient

7). Sleep Apnoea Station

Meet, greet, consent

Presenting complaint ( will usually be spouse complaining of excessive
snoring)
Ask about:
1. Excessive day time sleeping
1. General fatigue
2. Memory loss
3. Irritability and depression
4. Kabhi tv dekhtay ya gari chalatay tou nahi aankh lap jati?
5. Weight gain history
Risk factor assessment
1. If male ask what collar size they wear ( >17 inches is a risk factor)
2. Ipsilateral nasal mass ( difficulty in breathing), otitis media and weight
loss -> all together, point towards nasopharyngeal carcinoma
3. Any recent trauma to nose -> points towards septal deviation
4. Use of alcohol, sedatives or smoking
Review of systems
PMH, DH, FH
Allergies/addictions
Summarize
Thank patient

8). History for Acute angle closure glaucoma

P/C: Pain
HOPC: SOCRATES
S: in or around eye
A: redness, photophobia, blurred vision, haloes (rainbows around lights),
nausea, vomiting, watering eyes, pain on eye movements
E: stress, dim light, mydriatic drugs -> all cause mydriasis
Has it happened before?
ROS: urine, stool, sleep, appetite, weight loss
PMH: any uveitis? Joint pains? Comorbids? Previous episodes? Use of glasses?
FH: glaucoma in family? Comorbids? Myopia in family?

DH: mydriatics or any other eye Rx

SH: alcohol, smoking, stress

Diagnosis of ACG: Examining iridocorneal angle by gonioscopy

Difference in pupil of glaucoma and uveitis: In glaucoma it is mid-dilated and fixed,
regular. In Uveitis it is miotic with posterior synechae.
Management of ACG:

IV acetazolamide
Topical pilocarpine
Beta blockers
Iridotomy/ iridectomy with with YAG laser or surgery
Additional measures for PAS
If cataract present it may help to extract and replace

Ddx for red eye (painful):

Conjunctivitis
Keratitits
Scleritis
Episcleritis
Endopthalmitis
Panopthalmitis
Iridocyclitis
Sub conj hemorrhage
Corneal foreign body
Acute congestive glaucoma

Mydriatic drugs:

Sympathomimetics
Parasympatholytics (atropine)
Scopolamine
5HT2a mediated psychadelics
SSRIs
Cocaine
Amphetamines

9). Counseling of RP patient

What is RP?
A group of hereditary disorders of photoreceptors (mainly affects rods)
characterized by night blindness -> complete blindess in 50%
Variation in genetic groups (age of onset and prognosis 10 to 30 years)
1. Isolated ( no FH)

2. AD (50% chance, late onset)

worsening prognosis
3. AR (25% chance, early onset)
4. X-linked (early onset)
No effective treatment. Cant be stopped or progression slowed
Vit A and E can delay onset of blindness
Use dark glasses and avoid bright sunlight exposure
Use of low vision aids eg. Magnifying glasses and telescopes
Associated disorders: cataract, deafness (30%), primary open angle
glaucoma
May cause RD
Central vision is ultimately lost so pick jobs accordingly
Online support groups
Helpful information
Genetic counseling
Systemic diseases: Ushers, abetalipoproteinemia, Lawrence Moon syndrome

10). History taking of Chronic Dacryocystitis

P/C: watering eye 6 months

HOPC: Pain, site (med. side of orbit), redness, swelling, discharge, vision,
mattening of lashes, stickiness, worsening in cold + wind, trauma, atresia,
inductional stenosis in elderly, allergy, chronic sinus disease, drugs (topical)
PMH: previous episodes, use of glasses, Hx of surgery, comorbids, periorbital
radiation
ROS
FH: eye complaints, comorbids
DH: eye drops, nasal decongestants, chemotherapy

Diagnosis:

Clinical picture
Blood counts
Fluorescein dye disappearance test
Jones test I and II
DCG ( to find exact location)
DSG (follows passage of drop of technetium isotope applied to lat.
conjunctival sac)

DCR complications (silicon stent used, removable):

Hemorrhage
Injury to common canaliculus
CSF leak
Injury to orbital content
Failure to adequately drain -> persistent epiphora
Infection

Late -> fibrosis and synechiae -> needs additional surgery

Lester Jones tube insertion: Lacrimal bypass tube -> permanent -> daily clean
Common organisms: Staphylococcus, Streptococcus
DDx for Epiphora ( inc. lacrimation due to occlusion)

Punctum block
Canalicular block
Nasolacrimal duct obstruction
Ectropion

Tx: Repair of occluded nasolacrimal duct requires surgery to connect mucosal

surface of lacrimal sac to nasal mucosa by removing intervening bone. This is
dacryocystorhinostomy. + antibiotics
11) History Taking of Retrobulbar Neuritis/ Suspected MS

P/C: Pain on eye movements

HOPC:
1. SOCRATES
2. Preceding viral illness? Flu-like symptoms?
3. Vision loss? Characteristic relapsing and remitting symptoms?
4. Swelling or red eye?
5. Change in colour perception?
6. Uhthoffs phenomenon: exacerbated by heat or exercise. Characteristic
of MS.
7. Pulfrich effect: objects moving in straight line appears to have curved
trajectory (shows asymmetric conduction between optic nerves)
8. Previous episodes: recurrent attack?
9. Neurological problems, eg. Transient facial/body numbness or
weakness
PMH: previous episodes, neurological, MS, comorbids
FH: similar episodes, MS, comorbids
ROS
SH: alcohol, smoking, stress
DH: Rx for MS

Management of Optic Neuritis: MRI to find other silent plaques of demyelination.

Counselling before scan. Steroid treatment to speed up recovery (methylpred 250
mg QID x 3 days, then oral tapering)
Types of Optic Neuropathy: Inflammatory, Ischemic, traumatic, mitochondrial,
infiltrative, compressive
Optic Neuritis: demyelinating, parainfectious, infectious, noninfectious

12). History taking of OSAS (Obstructive sleep apnoea syndrome)

P/C: snoring
HOPC: sleep apnoea, waking up during sleep - how many times?, sleeping
position, duration, nocturia, accidents in the past, excessive day time
sleepiness, irritability, morning headache, fatigue, memory loss,
sweating/gasping at night, obesity
ROS: sore throat ( tonsillitis) + other causes of obstruction, any other ENT
problem, weight , SOB, chest pain, GERD, palpitations
PMH: comorbids
FH: comorbids, obesity
SH: smoking, alcohol, coffee, stress
Mens. H: Postmenopausal + HRT -> increases risk
DH: sleeping pills, hypnotics

Criteria for diagnosis: Cessation of breathing for > 10 s. >5 times per night =>
OSAS. RDI: normal <5. Mild 5 14. Moderate 15-29. Severe >30. Gold standard for
diagnosis is polysomnography.
Investigations: Epworths sleepiness scale, BMI, collar size, H&N exam, Mullers
maneuver, test for HTN, hypothyroid, test for cephalometric radiograph. EEG, EMG,
ECG , pulse oximetry, EDM, nasal and oral airflow, sleep positions, bp, esophageal
pressure
Mullers maneuver: Flexible endoscope passed through the nose and the pt. asked
to inspire vigorously with nose and mouth closed. Look for collapse of soft tissue at
level of base of tongue and just above soft palate. Level of pharyngeal obstruction
can be found.
Management: Change in lifestyle, positional therapy, intra-oral device ( MAD
mandible advancement device , TRD- tongue retaining device), CPAP
Surgical Options: Tonsillectomy, nasal surgery, oropharyngeal surgery, genioplasty
with hyoid suspension, maxillomandibular osteotomy, uvulopalatopharungoplasty
(UPPP)
Gold standard tracheostomy
13). History taking of Squint

P/C: Squint
HOPC:
1. How long?
2. Constant or intermittent? Noncomitant/concomitant
3. Same eye or alternating?
4. Refractive error?
5. Congenital cataract?

6. Corneal opacities?
7. Retinal abnormalities?
8. Abnormal head posture?
9. Any associated nerve defects like ptosis or dilated pupil?
10.Any Hx of trauma?
11.Congenital or acquired?
12.B: prenatal, natal, postnatal
I: immunization up to date?
N:breastfeeding? Any vitamin deficiencies?
D: developmental milestones
PMH: any hospital admissions? Diseases?
FH: squint in family? Refractive error?
ROS
DH
SH

14). History taking of Sore Throat

P/C: Sore throat since when?

HOPC: throat pain, dysphagia, odynophagia, fever, malaise, rhinorrhea,
hoarsness, voice change, cough, earache, headache, trismus, bad taste, bad
breathe, drooling, snoring, breathing difficulty stridor, hot potato voice
Rheumatic fever => sore throat, polyarthritis, chest pain, SOB, palpitations,
chorea, rash
PMH: recurrent attacks, how many episodes/year
FH
ROS
SH
DH

How to differentiate between tonsillitis and quinsy?

In quinsy/peritonsillar abscess, there is usually a degree of trismus, the anterior
arch on the affected side is pushed medially and the palate bulges toward you.
Distant complications of tonsillitis?
Acute: Chronic tonsillitis, Peritonsillar abscess, parapharyngeal abscess, otitis
media, rheumatic fever, acute glomerulonephritis, subacute bacterial endocarditis
Chronic: Peritonsillar abscess, parapharyngeal abscess, intratonsillar abscess,
tonsilloliths, tonsillar cyst, Rheumatic fever, acute glomerulonephritis, eye and skin
disorders?
Blood supply of tonsils:
Ascending palatine an tonsillar -> from facial artery

Descending palatine -> from maxillary artery

Ascending pharyngeal -> from external carotid artery
Dorsal lingual -> from lingual artery
15). Counseling of patient with Multinodular Goiter

Risk factors:
1. Iodine deficiency
2. Genetics (TG, MNG-I)
3. Smoking
4. Stress
5. >
Danger signs: compressive symptoms, functional nodules, pain + fixed to
skin, males, FHx, H/O irradiation, >4cm, fast growing, rapidly filling cyst after
aspiration
Rapid symptoms -> bleeding into nodule
Associations: Cowden syndrome, hamartomas, breast CA, skin tags, follicular
or papillary CA, Gardner syndrome (familial colonic polyposis + tumors
external to GIT eg, thyroid cancer)
Malignant potential -> 4 to 17 % chance
If cold nodule seen -> 10% chance
Iodine supplementation: salt water sea food, iodized salt, yoghurt, eggs
Treatment options: If small -> anti-thyroid drugs. If large, compressive,
substernal, malignant -> thyroidectomy + radioactive iodine + lifetime
replacement

16). History Taking Progressive hearing loss

P/C: progressive hearing loss

HOPC:
1. Since when
2. Onset
3. U/L or B/L
4. Hearing with background noise (roll over)
5. Otalgia, otorrhea, vertigo, tinnitus, fullness
6. H/O trauma -> TM perforation
PMH: ear infection/surgery, DM, HTN, IHD
FH: comorbids, FHx of deafness what age
DH: ototoxic drugs ( antibiotics, diuretics, salicylates, chemotherapy)
ROS: esp. mood -> depression
SH: occupation, exposure to loud noises, H/O smoking

Presbycusis: Outer hair cell loss, ganglion cell loss, atrophy of stria vascularis,
stiffness of basilar membrane
Audiogram:

17) History taking Hoarseness

P/C: hoarseness
HOPC: onset, vocal abuse, GERD, dysphagia, more in morning/evening/constant*,
otalgia, dyspnea, odynophagia, pain, throat clearing, cough, chest pain, hemoptysis,
fever, Hx of trauma/foreign body
PMH: surgery -> intubation, RLN damage. Comorbids esp. hypothyroidism ->
myxedema, allergies
FH: comorbids + cancer Hx
ROS: malaise, weight loss -> cancer?
SH: occupation -> vocal abuse, smoking, alcohol
DH: sedatives?
* constant -> larynx. Morning -> GERD. Evening -> myasthenia, RLN palsy
Category
1.
Infections
2.
Paralysis
3. Tumors

4.Congeni
tal
5. Trauma

DDx for hoarseness

Examples
Laryngitis, TB, syphilis, scleroma, fungal infection
Of recurrent, sup. Laryngeal or both nerves
Papilloma, hemangioma, chondroma, fibroma,
leukoplakia, carcinoma, vocal cord nodules, vocal
polyp, laryngocele
Laryngeal web, cyst, laryngocele
Submucosal hemorrhage, laryngeal trauma, foreign
body, intubation

18). History Taking - Dysphagia

P/C: Dysphagia
HOPC:
1. onset( sudden -> foreign body on preexisting stricture)
2. progression
3. partial/complete
4. effect on solids (stricture) and/or liquids (paralysis*)
5. where does food stick
6. odynophagia
7. regurge ->aspiration
8. cough or dyspnea
9. intermittent -> spasm
10.hoarseness
11.worse in evening (hiatal hernia, myasthenia gravis -MG)
12.GERD (hiatal hernia)
13.Intolerance to spicy foods -> ulcers
14.Xerostomia
ROS: weight loss
PMH: comorbids, MS, MG
FH: cancer
SH: smoking, alcohol , iron deficiency (Plummer Vinson syndrome)
DH

*lung -> RLN paralysis. Nose-> palatal paralysis

Plummer-Vinson Syndrome: post cricoid dysphagia, esophageal webs, long standing
iron deficiency anemia
DDx of Dysphagia
Preoesophag Oral
eal cause
Phase

Mastication disturbance
Lubrication disturbance
Tongue mobility
disturbance

Pharynge
al Phase

Defects of Palate
Lesions of buccal cavity
+ floor of mouth
Obs. Lesions of Pharynx
Inflammatory conditions

Spasmodic conditions
Paralytic conditions

Trismus, fractures of mandible, tumors of

upper/lower jaw, TMJ disorders
Xerostomia post radiation, Miculiczs
disease
Tongue paralysis, painful ulcers, tongue
tumors, lingual abscess, total
glossectomy
Cleft palate, oronasal fistula
Stomatitis, ulcerative lesions, Ludwigs
angina
Tumors, obs. Hypertrophic tonsils
Acute tonsillitis, abscess(peritonsillar,
retro or paraphrangeal), acute
epiglottitis, oedema larynx
Tetanus, rabies
Soft palate paralysis due to diphtheria,
bulbar palsy, cerebrovascular accidents

Oesophageal
Causes

Atresia, foreign body, strictures, tumors

Hypermotility disorders, e.g. achalasia, scleroderma, ALS
Hypomotility disorders e.g. cricopharyngeal spasm
Outside
Hypopharyngeal diverticulum, hiatus hernia, cervical osteophytes,
wall
thyroid lesions, mediastinal lesions, vascular rings
19). History Taking Blocked nose

Lumen
Wall

P/C: blocked nose

HOPC:
U/L ,B/L or alternating
Onset
Duration
Frequency
Aggravating/relieving factors
Associated sneezing
Nasal discharge -> colour
Facial pain -> sinusitis
Headache
Ear pain
Snoring
Sleep apnoea
Anosmia or hyposmia
Cough
Eye symptoms
Epistaxis
Post nasal drip
Voice change
Trauma
PMH: trauma, surgery, allergies -> asthma
ROS
FH: DNS, allergies, comorbids
DH: decongestants-> rhinitis medicamentosa, aspirin -> vasomotor rhinitis
SH: smoking

Rhinitis medicamentosa: Condition of rebound nasal congestion brought on by

extended use of topical decongestants and certain oral medications that
constrict blood vessels in the nose
20). Visual Fields

Meet, greet, consent

One eye at a time at one arm distance
Gross fingers in each quadrant
Check fields preferably red top
Study visual field defects Kaplan

21). Pupils

Meet, greet, consent

Give distant target
Inspect: size, shape, asymmetry, heterochromia
Direct and consensual light reflex
RAPD (swinging light test)
Accommodation

Causes of Heterochromia
Hypochrom Congenit Simple, Congenital Horners syndrome, Waardenberg syndrome
ia
al
Acquired
Fuchs heterochromic iridocyclitis, non-pigmented tumors,
trauma
Hyperchro
Congenit Ocular melanosis, iris nevus, iris hamartoma, iris ectropion
mia
al
syndrome
Acquired
Pigmented tumors, siderosis bulbi, rubeotic iridis, long standing
hyphema, drug induced (xalatan/latanoprost )

Causes of miosis: Drugs, morphine, syphilis, Horners syndrome, Argyll Robertson

pupil, uveitis
Causes of mydriasis: sympathomimetics, parasympatholytics , traumatic iridoplegia,
acute congestive glaucoma, third nerve palsies
22). Visual Acuity

Meet, greet, consent

One eye at a time
Snellens chart + pinhole if <20/20 (pinhole allows estimation of the best
improvement you can get with refractive error correctin lenses)
Near vision chart
Colour vision Ishihara chart

If pt. cant read the first line even -> half the distance (20/200) -> counting
fingers -> perception of light
For children:

Sheridan-Gardiner test (older kids)

Hundreds of thousands cake decoration
Cardiff acuity cards (1-3 years)

If vision is very near optokinetic nystagmus

23). Chalazion Exam

Meet, greet, consent

Examine lid (inspection)
Evert lid
Palpation: size, margins, consistency, tenderness, mobility, fixidity
Transillumination
Lymph nodes esp. pre, post auricular + central

DDx lid swelling: allergic reaction (local/systemic), blepharitis, chalazion, stye,

insect bite, herpes simplex blepharitis, herpes zoster, cavernous sinus
thromobosis, oribital cellulitis, periorbital cellulitis, hyperthyroidism with graves
ophthalmopathy, hypothyroidism
Difference between stye and chalazion: A chalazion is a chronic sterile
granuloma residing within the eyelid that originates from an obstructed
meibomian gland of the tarsal plates, it is painless. A stye (internal hordeolum) is
a painful, localized infection or inflammation of the eyelid margin involving hair
follicles of the eyelashes (glands of Moll and Zeiss).

Management of chalazion: Antibiotics are not indicated since chalazion is a

granulomatous condition. Small chalazia often resolve without intervention. For
larger lesions, frequent hot compresses may allow them to drain although
typically most clear spontaneously in weeks to months. Symptomatic patients
with recalcitrant lesions can be referred to an ophthalmologist for incision and
curettage or direct glucocorticoid injection
24). History of Chronic Vision Loss

P/C: chronic vision loss

HOPC:
1. Since when
2. Onset
3. Progression
4. Night/day vision or both
5. Blurring or loss of vision
6. Better in dim or bright light
7. Near/far or both
8. Pain
9. Redness
10.Discharge
11.Photophobia
12.Glare
13.Trauma
PMH: spectacles, trauma, surgery
FH: glaucoma, myopia, comorbids
DH: eye drops
ROS
SH: smoking

DDx: glaucoma, refractive errors, cataract, corneal dystrophy, retinal dystrophy,

visual pathway, DM, HTN
25). Risk Factors Thyroid Cancer

Hx: Age <20 or >45 year

Male gender
Hx of radiation
FH +ve, MEN, Gardner Syndrome, Cowden disease
Rapid growth
Painful
Compressive symptoms
Low iodine intake

Examination

Hard nodule/firm
>4cm

Fixed
Recurrent or rapidly filling cyst after aspiration
+ve lymph nodes
Fixed vocal cord

26). Opthalmoscopy

Meet, greet, consent

Distant direct opthalmoscopy 67 cm
Fundoscopy
Do both sides

CDR?
mm

N=0.4

size of optic cup= 0.2 0.4 mm

size of optic disc= 1.5 2

Difference between direct and indirect ophthalmoscopy:

No. of fibres in optic nerve: 770,000 to 1,700,000. Avg 1, 000, 000

Cause of grey reflex: RD
DDx white reflex (leukocoria): RB, cataract, Coats disease, toxocariasis, ROP,
PPHV
27). Ocular Movements

Meet, greet, consent

Smooth pursuit (ask about diplopia + pain)
Saccades (horizontal + vertical
Convergence (disjugate movements)

ENT OSCE Freddy totes

There will be 3 stations with 3 minutes per station. You will go in groups of 3. All
patients were simulated in our year.
Ear Examination

Start with meet, greet and consent

Inspect both ears, including the retroauricular sulcus B/L
Palpate the cartilage of the pinna and the mastoid and ask about tenderness
Perform the fistula test/tragus pressing. Press on the tragus. Hold for a few
seconds and release. Principle: Pressure changes in the external auditory
canal are transmitted to the labyrinth via the fistula which produces
nystagmus
Pick up the speculum, insert it into the auditory canal and visualize. Keep
commenting on what you see.
Attach the black rubber tip on the head of the otoscope and insert it into the
ear. Pull it outwards, backwards and upwards. Remember to tell the patient
what you are about to do, mention that it might be slightly painful. Comment
on the tympanic membrane, cone of light, transparency and ossicles.
Sometimes you may be asked to do pneumatoscopy. Pneumatic
otoscopy is an examination that allows determination of the mobility of a
patient's tympanic membrane (TM) in response to pressure changes. The
normal tympanic membrane moves in response to pressure. Immobility may
be due to fluid in the middle ear, a perforation, or tympanosclerosis, among
other reasons
Proceed to Rinnes and Webers then. The patient will simulate findings. At the
end, the doctor will ask you to tell the diagnosis; whether it is conductive or
sensorineural and on which side.
Question: which branches of the facial nerve run in the temporal bone?

Answer: Sup. Petrosal, Nerve to stapedius and Chorda tympani

Question: Mernieres disease and its symptoms
Answer: Episodic vertigo, Sensorineural hearing loss, tinnitus, aural fullness

Nose Examination

Meet, greet, consent

Wear the head mirror, fix it properly
Inspect. Ask for tenderness. Look for any external nasal deformity. Lift the
nose and look at the turbinates.
Palpate the nasal bridge and the sinuses for tenderness
Perform Cottles maneuver. Pull skin at cheek, if breathing easier then the
blockage is at the vestibule
Examine nasal cavities using speculum. Comment on what you see.
Perform posterior rhinoscopy. Heat depressor, check that it is clear, then use
Patency. Put the mirror in front of each nostril and ask them to breathe out
Question: what is the treatment of B/l nasal ethmoidal polyps?
Answer: Start off with nasal decongestants, nasal steroid sprays (Rhinoclinal).
Then CT scan. Then you would go for FESS.

Neck Examination
Do NOT turn on the light.
Start with meet, greet, consent
Inspect from front and sides. Check for scars/masses
Ask patient to swallow and visualize
Ask patient to stick tongue out and visualize. Thyroglossal cyst becomes
prominent
Examine lymph nodes
Check for laryngeal crepitus. Move the trachea side to side with posterior
pressure. If this is absent there could be a mass in the retrolaryngeal space or
the hypopharynx. The trachea is immobile in laryngeal fixation by cancers.
Thyroid examination, complete with physical signs.
Sternal percussion to check for retrosternum expansion of thyroid
Q: Levels of the Neck
Q: What areas drain to level 6?
A: Larynx, trachea, thyroid, esophagus
Q: Boundaries of level 2, 3, 4, 6 (all triangles)
Oral Cavity Examination

Meet, greet, consent

Inspection of external opening
Check buccogingival sulcus
Use the tongue depressor
Look at all subsites

aah test
Look at posterior pharyngeal walls and tonsils
Wear gloves, perform bimanual palpation of glands and parotid massage
Q: Difference between a rannula and a plunging rannula?
A: Rannula: Obstruction of sublingual salivary glands, treatment is either
marsupilization or surgical excision depending on the size. If small excision,
if large marsupilization.
Plunging rannula: pseudocyst caused by obstruction of sublingual salivary
gland with extension into the neck. Treatment is total excision with removal of
the salivary gland
1. Q: Treatment of Sialolithiasis?
A: Wait and watch, sometimes they resolve spontaneously
Hydration dehydration
Compresses and massages
Secretagogues
Sialoendoscopy/Lithotripsy
Surgical removal of stone
Remember to say you will check for lymph nodes in all stations. In neck dont
forget supraclavicular nodes and mention that youll check for axillary nodes
too.