KFP – Ear, nose, throat and oral health (ENT)

Margaret Wallace, aged 52, presents with a three-week history of persistent hoarseness. She reports no significant sore throat or cough but notes that her voice is increasingly raspy and that she struggles to speak by the end of the day. She denies dysphagia, odynophagia, haemoptysis, weight loss or fevers. She does not feel short of breath or have chest pain. She works as a secondary school drama teacher and reports frequent use of her voice throughout the day.

Medications: None regularly

Allergies: Nil known

Past history: Gastro-oesophageal reflux disease (intermittent symptoms, not on treatment)

Social history: Non-smoker, drinks 1–2 glasses of wine most weekends, no recreational drug use

Examination findings: Vitals normal. Throat appears unremarkable on inspection. Voice is hoarse. No cervical lymphadenopathy. Flexible nasendoscopy is not available in your clinic.

What is the most appropriate next step in management? Select two (2) from the following list:

Thomas Nguyen, aged 4, is brought in by his mother with a 24-hour history of fever, right ear pain, and reduced hearing. He has been irritable and not sleeping well. His mother reports a similar episode two months ago, which resolved without antibiotics. He has otherwise been well and is up to date with immunisations.

Past history: Frequent upper respiratory tract infections in winter; no history of grommets or ear surgery

Social history: Attends daycare four days per week; non-smoker household

Examination findings: Temperature 38.4°C. Right tympanic membrane is erythematous, bulging, and lacks light reflex. Left ear normal. No mastoid tenderness. Cervical lymphadenopathy noted.

What is the most appropriate management? Select three (3) from the following list:

Helen Mirkovic, aged 68, presents with a six-month history of a persistent sensation of a lump in her throat. She describes it as ‘something stuck’ rather than pain, and notes that it worsens when swallowing saliva but not when eating. She denies weight loss, dysphagia, odynophagia or voice change. She has a 40-pack-year smoking history and drinks wine with dinner most nights. She has not seen a doctor in many years.

Medications: None

Past history: Hypertension (not on treatment)

Family history: Father died of laryngeal cancer aged 72

Examination findings: Vitals within normal limits. Neck examination reveals no palpable masses or lymphadenopathy. Oral cavity appears normal. No signs of infection or dental pathology.

What are the most appropriate next steps in management? Select three (3) from the following list:

Jared Douglas, aged 27, presents with a five-day history of increasing right-sided facial pain, nasal congestion, and purulent nasal discharge. He reports a dull headache localised to his forehead and right cheek, worse on bending forward. He also describes a postnasal drip and a reduced sense of smell. He has tried over-the-counter nasal decongestant spray and paracetamol with minimal relief. He is otherwise healthy with no significant past medical history.

Medications: Occasional ibuprofen

Allergies: Nil known

Examination findings: Temperature 37.8°C. Tenderness over the right maxillary sinus. Purulent discharge visible in right nasal passage. Oropharynx clear. No cervical lymphadenopathy. No periorbital swelling or visual disturbance. Cranial nerves intact.

What are the most appropriate next steps in management? Select two (2) from the following list:

Sofia El-Amin, aged 35, presents with a painful swelling under her jaw on the left side that started two days ago. She describes a dull ache that becomes worse when eating, particularly sour or acidic foods. She has had no fever but reports feeling ‘run down’ over the past week. She has no dental pain. She is otherwise well, with no significant medical history.

Medications: Oral contraceptive pill

Allergies: Nil known

Examination findings: Afebrile. Tender, firm swelling palpable over the left submandibular area. No cervical lymphadenopathy. Intraoral examination reveals purulent discharge from the left Wharton’s duct on bimanual palpation. Oral hygiene is good. No dental caries or periodontal disease noted.

What are the most appropriate management steps? Select three (3) from the following list:

Emily Tran, aged 14, presents with a two-day history of worsening sore throat, difficulty swallowing, fever, and a muffled voice. Her mother reports she has had fevers up to 39.0°C and now refuses to eat or drink. Emily has a history of recurrent tonsillitis but has never been hospitalised for it. She is not taking any regular medications.

Allergies: Nil known

Examination findings: Temperature 38.8°C. Emily appears unwell and is drooling slightly. She has trismus and a ‘hot potato’ voice. Oropharyngeal examination reveals swelling of the left soft palate and deviation of the uvula to the right. Cervical lymphadenopathy is present.

What are the most appropriate next steps in management? Select three (3) from the following list:

James Weston, aged 67, presents with gradual bilateral hearing loss over the past year. He reports difficulty following conversations, especially in noisy environments, and needs the television volume louder than his wife prefers. He denies tinnitus, vertigo, ear pain, or discharge. He has no history of noise exposure and has never worked in loud environments.

Medications: Atorvastatin, perindopril

Past history: Hypertension, hyperlipidaemia

Family history: Non-contributory

Social history: Retired schoolteacher. Non-smoker, drinks 1–2 glasses of wine weekly.

Examination findings: Normal otoscopy bilaterally. Rinne test positive bilaterally; Weber test localises to midline. No cranial nerve deficits.

What are the most appropriate next steps in management? Select three (3) from the following list:

Chloe Zhang, aged 9, is brought in by her mother due to persistent mouth ulcers and a sore tongue. The ulcers have been present intermittently over the last three months, with the current episode lasting over a week. Chloe finds eating painful and has been eating less. There is no history of fever, diarrhoea, skin rash, or trauma. She brushes her teeth twice daily and has seen the dentist within the past year.

Medications: None

Allergies: Nil known

Past history: Mild eczema

Dietary history: Mostly vegetarian diet; avoids red meat

Examination findings: Chloe appears well but reluctant to open her mouth due to discomfort. Multiple small round ulcers with erythematous halos are visible on the buccal mucosa and lateral tongue. No gingivitis, lymphadenopathy, or skin lesions. Nails and conjunctiva appear pale.

What are the most appropriate next steps in management? Select three (3) from the following list:

Michael O’Rourke, aged 59, presents with a three-month history of progressive right-sided nasal obstruction and intermittent epistaxis. He reports a sensation of fullness in the right side of his face but denies pain, fever, or significant nasal discharge. He has not had any recent trauma or infections. He is a lifelong smoker and works as a stonemason. He has not seen a doctor in several years.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: External nasal exam appears normal. Anterior rhinoscopy reveals a unilateral friable mass obstructing the right nasal passage. No lymphadenopathy. Facial sensation and cranial nerves are intact.

What are the most appropriate next steps in management? Select two (2) from the following list:

Isla Murphy, aged 6, is brought in by her father due to concerns about noisy breathing during sleep. He reports that Isla snores loudly most nights and sometimes pauses in her breathing followed by gasping. She sleeps poorly, is tired during the day, and has trouble concentrating at school. Her appetite is good, and her weight is on the 75th percentile. She has no significant medical history.

Medications: None

Past history: Recurrent tonsillitis (5 episodes in the past year)

Family history: Mother had childhood tonsillectomy

Examination findings: Vitals normal. Enlarged tonsils (grade 3+) and mildly enlarged adenoids on posterior nasal inspection. No signs of acute infection. No facial asymmetry. ENT findings otherwise normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Leah Abdou, aged 22, presents with a 48-hour history of a painful right ear, decreased hearing, and a feeling of fullness. She reports that she recently returned from a beach holiday and spent a lot of time swimming. She denies fevers or systemic symptoms. She has no significant past medical history and is otherwise well.

Medications: Nil

Allergies: Nil known

Examination findings: Tenderness on traction of the right pinna and tragus. External ear canal is erythematous, swollen, and filled with moist debris. Tympanic membrane is not visible due to swelling. No lymphadenopathy or mastoid tenderness. Left ear is normal.

What are the most appropriate management steps? Select three (3) from the following list:

Lucas Petrovic, aged 3, is brought in by his mother due to concern about delayed speech. She reports that Lucas says only a few single words and often seems to ignore her when spoken to. He is otherwise healthy, attends childcare two days per week, and has no behavioural concerns. He had multiple ear infections as a toddler but none recently.

Medications: None

Past history: Recurrent otitis media in infancy, not treated with grommets

Family history: Father had speech delay as a child

Examination findings: Normal growth and development. Otoscopy reveals dull, retracted tympanic membranes bilaterally with reduced mobility on pneumatic otoscopy. No signs of acute infection.

What are the most appropriate next steps in management? Select three (3) from the following list:

Anthony Russo, aged 48, presents with a sudden onset of left-sided facial weakness that developed overnight. He is unable to close his left eye fully, has difficulty smiling on that side, and food tends to fall out of the left side of his mouth. He denies headache, limb weakness, or speech disturbance. He had a mild upper respiratory tract infection a few days ago.

Medications: Nil

Allergies: Nil known

Past history: Hypertension, controlled

Examination findings: Blood pressure 135/85 mmHg. Left lower motor neuron facial nerve palsy with complete involvement of the forehead and lower face. No vesicular rash or hearing loss. No other cranial nerve involvement. Limb strength and coordination normal. No signs of stroke.

What are the most appropriate next steps in management? Select three (3) from the following list:

Samantha Leigh, aged 31, presents with a 5-day history of a sore throat and odynophagia. She also reports low-grade fever and malaise. She is a schoolteacher and has had several students recently with colds. She denies cough or nasal congestion. On examination, her temperature is 38.2°C, she has bilateral tonsillar enlargement with white exudates, tender anterior cervical lymphadenopathy, and no rash or hepatosplenomegaly.

Medications: Nil

Allergies: Penicillin (rash)

Past history: Nil significant

What are the most appropriate next steps in management? Select three (3) from the following list:

Rajiv Balan, aged 40, presents with recurrent episodes of nasal blockage, anosmia, and postnasal drip over the past year. He describes a persistent pressure sensation over his forehead and around his eyes but denies purulent discharge or fever. He has a history of adult-onset asthma and has been hospitalised twice in the past year for exacerbations.

Medications: Salbutamol and inhaled budesonide/formoterol

Allergies: Nil known

Past history: Asthma, allergic rhinitis

Examination findings: Nasal examination reveals bilateral pale, edematous masses consistent with nasal polyps. No facial tenderness or purulent discharge. Lungs clear on auscultation.

What are the most appropriate next steps in management? Select three (3) from the following list:

Angela Li, aged 26, presents with a sudden onset of severe vertigo, nausea, and vomiting that began 12 hours ago. She reports difficulty walking due to imbalance but denies hearing loss, tinnitus, or ear pain. The symptoms are constant and worsened by head movement. She had a mild viral upper respiratory infection one week ago but is otherwise healthy.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Afebrile. BP 120/75 mmHg. Horizontal nystagmus beating to the right, worsened with left gaze. Positive head impulse test to the left. No limb ataxia. No dysarthria. Romberg positive with eyes closed. No hearing loss on bedside testing.

What are the most appropriate next steps in management? Select three (3) from the following list:

Fatima Noor, aged 58, presents with a 6-month history of persistent dry mouth. She finds it difficult to chew and swallow dry foods and frequently sips water throughout the day. She also reports dry eyes and occasional joint stiffness in the morning. She is not on any new medications and denies recent illness, radiation exposure, or chemotherapy.

Medications: Atorvastatin

Allergies: Nil known

Past history: Hyperlipidaemia

Examination findings: Oral mucosa appears dry, tongue is fissured and lacks normal coating. Dental caries present on several molars. No parotid swelling. Schirmer’s test performed in-clinic shows decreased tear production. No rash, no synovitis. Vitals stable.

What are the most appropriate next steps in management? Select three (3) from the following list:

Nick Foster, aged 34, presents with intermittent dizziness and a sensation that the room is spinning when he turns over in bed or looks up quickly. The episodes last less than one minute, resolve spontaneously, and are not associated with hearing loss, tinnitus, or headache. He is otherwise healthy and takes no regular medications.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Vitals normal. Dix–Hallpike manoeuvre on the right side reproduces vertigo and elicits a brief burst of upbeat, torsional nystagmus. Neurological examination normal. No gait or limb abnormalities. Hearing intact.

What are the most appropriate next steps in management? Select three (3) from the following list:

Claire Boswell, aged 73, presents with a 2-week history of left-sided ear pain, worsening hearing, and foul-smelling otorrhoea. She reports a feeling of fullness and some dizziness but denies fevers. She is a type 2 diabetic and notes poor glycaemic control recently.

Medications: Metformin, gliclazide

Allergies: Nil known

Past history: Type 2 diabetes mellitus, hypertension

Examination findings: Temperature 37.8°C. Tragal tenderness and canal oedema with granulation tissue visible on otoscopy. The tympanic membrane is obscured. Mild left-sided facial weakness noted. No mastoid tenderness. Blood glucose today 16.2 mmol/L.

What are the most appropriate next steps in management? Select three (3) from the following list:

Zara Nasser, aged 4, is brought in by her mother after she began complaining of a sore nose and persistent foul-smelling discharge from the right nostril over the past 3 days. There is no fever, facial swelling, or trauma. Zara is otherwise well and has no significant medical history. Her mother recalls Zara was playing with beads unsupervised earlier in the week.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Right nasal discharge is thick, green, and malodorous. Mild tenderness on palpation of the nasal bridge. Left nostril and oropharynx are clear. No systemic symptoms. Afebrile. Child is cooperative but anxious during nasal examination.

What are the most appropriate next steps in management? Select two (2) from the following list:

George Lin, aged 62, presents with a 3-month history of progressive hoarseness. He describes his voice as raspy and tiring quickly when he speaks. He denies sore throat, cough, dysphagia, or haemoptysis. He is a retired public speaker and reports a 40-pack-year smoking history. He drinks alcohol socially and has not seen a doctor in several years.

Medications: Nil

Allergies: Nil known

Past history: Hypertension (untreated)

Examination findings: Vitals within normal limits. Neck exam shows no palpable masses or lymphadenopathy. Oropharynx appears normal. Chest clear on auscultation.

What are the most appropriate next steps in management? Select three (3) from the following list:

Hannah Christie, aged 29, presents with ongoing nasal congestion, facial pressure, and clear rhinorrhoea that has persisted for over 12 weeks. She reports frequent sneezing, postnasal drip, and anosmia. Symptoms are worse in spring and when cleaning the house. She has a personal history of eczema and asthma.

Medications: Salbutamol as needed

Allergies: Dust mites (confirmed)

Past history: Atopic triad (asthma, eczema, allergic rhinitis)

Examination findings: Pale, boggy nasal mucosa on anterior rhinoscopy. No septal deviation or purulent discharge. Lungs clear. No facial tenderness or swelling. No polyps seen.

What are the most appropriate next steps in management? Select three (3) from the following list:

Benjamin Kerr, aged 55, presents with a painful left ear and reduced hearing that began two days ago after cleaning his ears with a cotton bud. He reports a sensation of blockage and hearing his own voice loudly in that ear (autophony). There is no fever or dizziness. He has a long history of earwax build-up.

Medications: None

Allergies: Nil known

Past history: Recurrent cerumen impaction

Examination findings: Otoscopy shows a completely occluded external auditory canal with dark impacted cerumen. No view of the tympanic membrane. No canal swelling or discharge. The right ear is normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Sarah Ibrahim, aged 47, presents with a 2-day history of severe right-sided throat pain and difficulty swallowing. She is unable to eat solids and has developed a muffled voice. She denies cough or rhinorrhoea but reports some fevers. She has no known allergies and has had multiple episodes of tonsillitis over the past year.

Medications: Nil

Allergies: Nil known

Past history: Recurrent tonsillitis (6 episodes in past 12 months)

Examination findings: Temperature 38.4°C. Right tonsil enlarged and displaced medially, uvula deviated to the left. Mild trismus noted. No neck stiffness. Tender cervical lymphadenopathy on the right. No stridor or respiratory distress.

What are the most appropriate next steps in management? Select three (3) from the following list:

David Chen, aged 60, presents with a persistent non-healing ulcer on the lateral aspect of his tongue for the past 6 weeks. He describes some mild discomfort when eating spicy foods but no significant pain. He denies weight loss, dysphagia, or systemic symptoms. He is a long-term smoker and consumes alcohol daily.

Medications: Atorvastatin

Allergies: Nil known

Past history: Hyperlipidaemia, no previous oral lesions

Examination findings: A 1 cm ulcer with indurated edges is noted on the left lateral tongue. It is non-tender and has not improved with topical treatments. No cervical lymphadenopathy. Oral hygiene is moderate. No other lesions identified in the oral cavity.

What are the most appropriate next steps in management? Select three (3) from the following list:

Alexis Morgan, aged 15, presents with sudden onset of left-sided ear pain and blood-stained discharge following a loud popping sensation while diving into a swimming pool. She reports decreased hearing in the affected ear but denies vertigo, fever, or systemic symptoms. She is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: No recurrent ear infections or ear surgery

Examination findings: Mild tenderness on palpation of the left ear. Otoscopy reveals a small central perforation of the tympanic membrane with minimal bleeding. The canal is otherwise clean. Weber test lateralises to the left; Rinne negative on the left and positive on the right.

What are the most appropriate next steps in management? Select three (3) from the following list:

Peter Wallace, aged 52, presents with a 2-week history of persistent right-sided nasal obstruction and mild epistaxis. He reports a blocked sensation and occasional blood-tinged discharge from the right nostril, especially in the mornings. He denies sinus pain, fever, or facial swelling. He has a 30-pack-year smoking history and works in woodwork and furniture manufacturing.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Right nasal cavity shows a friable lesion obstructing the nasal passage on anterior rhinoscopy. Left nostril is clear. No cervical lymphadenopathy. No facial tenderness or cranial nerve abnormalities.

What are the most appropriate next steps in management? Select three (3) from the following list:

Oliver Green, aged 10, presents with a 3-day history of right ear pain and fever. His mother reports that he has been irritable and not sleeping well. He had a recent upper respiratory tract infection. He has no previous history of ear problems and is otherwise healthy.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Temperature 38.5°C. Otoscopy reveals a red, bulging right tympanic membrane with loss of light reflex. Left ear is normal. No mastoid tenderness or discharge. Cervical lymph nodes slightly enlarged.

What are the most appropriate next steps in management? Select three (3) from the following list:

Isabelle Dubois, aged 42, presents with a 6-month history of intermittent sore tongue, dry mouth, and a burning sensation that worsens throughout the day. She denies ulcers, trauma, or recent dental procedures. She reports mild anxiety but no other systemic symptoms. She brushes twice daily and uses alcohol-containing mouthwash regularly.

Medications: Escitalopram

Allergies: Nil known

Past history: Generalised anxiety disorder

Examination findings: Oral mucosa appears normal with no ulcers, white plaques, or signs of infection. Tongue is mildly erythematous but without fissures or coating. Dentition is intact. Saliva flow appears normal. No cervical lymphadenopathy.

What are the most appropriate next steps in management? Select three (3) from the following list:

Matthew Haines, aged 35, presents with persistent right-sided facial pain and pressure, worsened when leaning forward, along with nasal congestion and purulent nasal discharge for the past 12 days. He describes the pain as dull and localised over the cheek and reports a blocked nose and postnasal drip. He has tried over-the-counter decongestants and paracetamol with little relief.

Medications: Nil

Allergies: Nil known

Past history: Seasonal allergic rhinitis

Examination findings: Tenderness over the right maxillary sinus. Purulent discharge visible in the right nasal passage. No periorbital swelling or fever. Oral examination unremarkable. No dental tenderness.

What are the most appropriate next steps in management? Select three (3) from the following list:

Emily Tan, aged 5, is brought in by her parents with concerns about persistent mouth breathing and snoring. They report that she snores most nights, sleeps restlessly, and occasionally pauses in her breathing. She also has difficulty breathing through her nose during the day. There is no history of asthma or allergies. She had multiple upper respiratory tract infections in early childhood but is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Frequent URTIs in infancy

Examination findings: Height and weight on 50th percentile. Mild adenoidal facies with open mouth posture. Enlarged tonsils (Grade 3+), no exudate. No nasal discharge or tenderness. Chest clear. ENT findings otherwise unremarkable.

What are the most appropriate next steps in management? Select three (3) from the following list:

Jessica Rayner, aged 26, presents with a 3-week history of a persistent non-healing ulcer on the inside of her lower lip. She describes occasional mild discomfort but no bleeding, trauma, or systemic symptoms. She is a non-smoker and has no personal or family history of autoimmune disease. She has had similar but shorter-lived ulcers in the past during periods of stress.

Medications: Combined oral contraceptive pill

Allergies: Nil known

Past history: Nil significant

Examination findings: A 0.5 cm shallow ulcer with a yellow base and erythematous halo is seen on the inner aspect of the lower lip. No induration. No lymphadenopathy. Oral hygiene is good. No other oral or skin lesions noted.

What are the most appropriate next steps in management? Select three (3) from the following list:

Mohammed Farah, aged 67, presents with a 4-month history of progressive difficulty swallowing solids, a sensation of food sticking in his throat, and recent unintentional weight loss of 5 kg. He denies odynophagia, hoarseness, or reflux symptoms. He quit smoking 10 years ago after a 25-pack-year history and drinks 2–3 glasses of wine daily. He has not seen a doctor in several years.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Normal vital signs. No cervical lymphadenopathy. Oral cavity inspection unremarkable. Mild weight loss apparent. ENT and neurological examination normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Tommy Ngu, aged 2, is brought in by his parents due to concerns about frequent ear infections. He has had five episodes of acute otitis media in the past six months, each treated with antibiotics. His parents report that he sometimes does not respond to his name and seems to be saying fewer words than other children his age. There are no other health concerns, and he attends childcare three days a week.

Medications: Nil

Allergies: Nil known

Past history: Recurrent acute otitis media

Examination findings: Otoscopy today shows dull, retracted tympanic membranes bilaterally with no signs of acute infection. No discharge. Tympanic membranes are intact. Mild nasal congestion. General development otherwise within normal limits.

What are the most appropriate next steps in management? Select three (3) from the following list:

Linda Matthews, aged 70, presents with a sensation of a lump in her throat for the past 2 months. She denies pain, dysphagia, odynophagia, or weight loss. The sensation is worse when she is anxious and not associated with eating. She has no significant past medical history and takes no regular medications. She is a non-smoker and does not drink alcohol.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: No visible or palpable neck masses. Oropharyngeal and thyroid examination normal. Flexible nasendoscopy performed in-clinic by ENT (already arranged by GP) was normal. No lymphadenopathy. No red flag features.

What are the most appropriate next steps in management? Select three (3) from the following list:

Ruby Watson, aged 14, presents with recurrent episodes of spontaneous nosebleeds from the right nostril over the past 2 months. They typically occur at night or during dry weather and last around 5 minutes before stopping with pressure. She denies trauma, systemic symptoms, or bleeding from other sites. She has no history of easy bruising or prolonged bleeding.

Medications: Nil

Allergies: Nil known

Past history: Unremarkable

Examination findings: Vital signs stable. Anterior rhinoscopy reveals dry nasal mucosa and a small visible vessel in Little’s area (Kiesselbach’s plexus) on the right. No active bleeding. Oral exam and skin normal. No hepatosplenomegaly or lymphadenopathy.

What are the most appropriate next steps in management? Select three (3) from the following list:

Michael Rogers, aged 61, presents with a 2-month history of progressive hoarseness and a sensation of throat clearing. He denies pain, haemoptysis, dysphagia, or weight loss. He has a 35-pack-year smoking history and consumes 3–4 alcoholic drinks daily. He works as a taxi driver and frequently eats late at night. He has not previously had similar symptoms.

Medications: Nil

Allergies: Nil known

Past history: Hypertension, managed with diet and exercise

Examination findings: Vitals normal. Oral examination and neck palpation unremarkable. ENT review arranged by GP reveals mild laryngeal erythema and oedema with no mass lesion. No vocal cord paralysis or suspicious lesions were noted. Flexible nasendoscopy otherwise normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Angela De Vries, aged 45, presents with intermittent episodes of dizziness described as a spinning sensation triggered when she turns her head quickly, especially when lying down or getting out of bed. The episodes last less than a minute and are not associated with hearing loss, tinnitus, or neurological symptoms. She has no cardiovascular risk factors and is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Vitals normal. Dix–Hallpike manoeuvre on the right elicits vertigo and torsional upbeat nystagmus lasting 10 seconds. Neurological examination including cranial nerves, cerebellar signs, and gait is normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Harriet Lowe, aged 48, presents with left-sided facial weakness that began suddenly this morning. She woke up with difficulty closing her left eye and noticed drooping of the mouth on that side. She is otherwise well and denies limb weakness, headache, speech disturbance, or visual changes. No trauma, rash, or ear pain. She had a mild cold last week.

Medications: Nil

Allergies: Nil known

Past history: Hypertension (well controlled)

Examination findings: Left-sided lower motor neuron facial nerve palsy affecting the forehead and lower face. She is unable to fully close the left eye. No other cranial nerve abnormalities. Neurological examination is otherwise normal. Otoscopy and oropharyngeal exam unremarkable. No vesicles or rash.

What are the most appropriate next steps in management? Select three (3) from the following list:

James Holloway, aged 36, presents with left-sided ear pain and discharge that started 3 days ago. He reports swimming in a freshwater lake shortly before symptoms began. The pain is severe and worsens when touching the outer ear. He has no hearing loss, fever, or systemic symptoms.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: The external auditory canal is erythematous, swollen, and tender to touch. Purulent discharge is present. The tympanic membrane is not visible. Tragus and pinna are tender. No mastoid tenderness or lymphadenopathy. Vital signs are normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Simon Bailey, aged 64, presents with a 4-month history of intermittent ear fullness, mild hearing loss on the left side, and occasional tinnitus. He denies vertigo, otalgia, or systemic symptoms. He has no history of recurrent ear infections, trauma, or noise exposure. Examination reveals normal external ears and tympanic membranes bilaterally.

Medications: Amlodipine

Allergies: Nil known

Past history: Hypertension

Examination findings: Weber test lateralises to the left ear. Rinne test is negative on the left (bone conduction > air conduction) and positive on the right. Tympanic membranes intact and mobile. No neurological signs. No masses or tenderness.

What are the most appropriate next steps in management? Select three (3) from the following list:

Sienna Cooper, aged 9, is brought in by her mother due to concerns about bad breath and snoring. Sienna has also been frequently mouth breathing and has a persistent nasal voice. Her mother reports that she has had recurrent colds and is always congested. There is no history of asthma, allergies, or sinus infections. Sienna has missed some school recently due to tiredness.

Medications: Nil

Allergies: Nil known

Past history: Recurrent upper respiratory tract infections in early childhood

Examination findings: Adenoidal facies with open-mouth posture, dry lips, and nasal speech. Anterior rhinoscopy shows congested nasal mucosa but no discharge. Tonsils are mildly enlarged. No cervical lymphadenopathy. No wheeze or stridor. Vitals normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Joshua Bell, aged 50, presents with a 2-week history of unilateral right-sided pulsatile tinnitus. He describes it as a rhythmic whooshing sound that coincides with his heartbeat and is worse at night when lying down. He has no hearing loss, vertigo, otalgia, or recent infections. He is a non-smoker and has no cardiovascular or neurological history.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Vitals stable and BP 130/85. Otoscopy normal. No bruits heard over the neck or skull. Tuning fork tests normal. Cranial nerve and neurological examination unremarkable. No masses or lymphadenopathy.

What are the most appropriate next steps in management? Select three (3) from the following list:

Katie McLean, aged 31, presents with a sore throat, hoarseness, and a dry cough that began two days ago after attending a concert. She denies fever, dysphagia, or systemic symptoms. She reports frequent use of her voice at work as a schoolteacher and feels her voice tires easily. She has no history of allergies or recent upper respiratory tract infection.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Mild erythema of the oropharynx. No tonsillar enlargement or exudate. Cervical lymph nodes not enlarged. Voice is hoarse but breathing is normal. No stridor. No sinus tenderness or nasal congestion.

What are the most appropriate next steps in management? Select three (3) from the following list:

Alex Novak, aged 58, presents with chronic nasal congestion and intermittent anosmia for the past 6 months. He reports no facial pain, but describes a constant blocked sensation in both nostrils. He uses over-the-counter nasal decongestants daily. He denies sneezing, itching, or watery rhinorrhoea. He is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Anterior rhinoscopy reveals bilateral pale, boggy masses consistent with nasal polyps. No purulence. Tympanic membranes normal. Lungs clear. No facial tenderness or lymphadenopathy.

What are the most appropriate next steps in management? Select three (3) from the following list:

Olivia Tran, aged 40, presents with sudden-onset left-sided sensorineural hearing loss that began this morning. She reports a blocked sensation and reduced hearing but no pain or discharge. She denies vertigo, recent infections, or trauma. She is otherwise healthy and has no significant past medical history.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Otoscopy is normal. Weber test lateralises to the right ear. Rinne test is positive bilaterally. No neurological deficits. Tympanic membranes intact and unremarkable. Cranial nerves intact.

What are the most appropriate next steps in management? Select three (3) from the following list:

Deborah Lang, aged 62, presents with a chronic dry mouth that has worsened over the past 6 months. She finds it difficult to swallow dry foods and often needs to sip water while eating. She also reports dry eyes, occasional joint stiffness, and a gritty sensation in her eyes. She denies mouth ulcers, fever, or weight loss.

Medications: Amlodipine, paracetamol as needed

Allergies: Nil known

Past history: Osteoarthritis

Examination findings: Oral mucosa appears dry with evidence of dental caries and fissuring of the tongue. No oral ulcers. No lymphadenopathy. Schirmer’s test is reduced bilaterally. No parotid enlargement.

What are the most appropriate next steps in management? Select three (3) from the following list:

Matthew Rowe, aged 5, is brought in by his parents due to persistent snoring, mouth breathing, and occasional pauses in breathing during sleep. His parents describe restless sleep and daytime fatigue. He has no history of asthma or allergies. His teacher has noted difficulty with attention and behaviour at school.

Medications: Nil

Allergies: Nil known

Past history: Recurrent tonsillitis (4 episodes in the past year)

Examination findings: Height and weight appropriate for age. Large tonsils (grade 3+), adenoidal facies, open-mouth posture. No nasal discharge or wheeze. ENT otherwise unremarkable. No lymphadenopathy.

What are the most appropriate next steps in management? Select three (3) from the following list:

Clara Bianchi, aged 38, presents with a 1-week history of pain and swelling in the left submandibular region, particularly around mealtimes. She reports a dry mouth but no fevers or systemic symptoms. The pain is described as a dull ache that worsens with chewing. She has no history of similar episodes or recent dental procedures.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Tender, firm swelling beneath the left jaw, worse with palpation. No erythema or fluctuance. Oral cavity examination reveals clear saliva expression from the right submandibular duct but minimal flow from the left. No pus or ulceration seen. No fever. Cranial nerves intact.

What are the most appropriate next steps in management? Select three (3) from the following list:

Helen Zhou, aged 73, presents with a 3-week history of progressive hoarseness and mild throat discomfort. She denies dysphagia, weight loss, or systemic symptoms. She is a retired teacher and a lifelong non-smoker. She reports no recent upper respiratory infections and no history of reflux symptoms.

Medications: Atorvastatin

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Examination findings: Voice is breathy and hoarse. No cervical lymphadenopathy. Oral cavity and neck examination unremarkable. Otoscopy and cranial nerve exam normal. Flexible nasendoscopy reveals left vocal cord immobility in the paramedian position; no mucosal lesion seen. Right vocal cord appears normal.

What are the most appropriate next steps in management? Select three (3) from the following list: