AKT – ENT

Jackie Tran, aged 7, is brought in by his mother with a 2-day history of right ear pain and fever. He has been irritable and has difficulty sleeping. He had a cold last week which has mostly resolved. There is no vomiting or rash.

Past medical history includes mild asthma. No medications. Immunisations are up to date.

On examination, he has a temperature of 38.6°C. The right tympanic membrane is bulging, erythematous and has reduced mobility. The left ear is normal. His throat is mildly injected, but chest is clear.

What is the most appropriate management?

Sharon Wallace, aged 46, presents with a 3-month history of persistent hoarseness. She works as a schoolteacher and reports vocal fatigue by the end of the day. She has a 20-pack-year smoking history and consumes alcohol regularly.

No weight loss or dysphagia. No significant past medical history. No medications. Non-contributory family history.

Examination reveals a hoarse voice. Oral cavity, neck and thyroid examination are normal. No lymphadenopathy.

What is the most appropriate next step in management?

Brian Micallef, aged 72, presents with a sensation of fullness in the right ear and gradual hearing loss over the last 6 months. He denies pain, discharge or tinnitus. He has no history of recurrent infections or trauma.

Past history includes hypertension and hyperlipidaemia. Non-smoker. No regular medications affecting hearing.

On examination, the external auditory canal is clear. The right tympanic membrane is intact but retracted. Tuning fork tests show Weber lateralises to the right and Rinne is negative on the right.

What is the most likely diagnosis?

Grace Walker, aged 28, presents with left-sided facial pain, nasal congestion and purulent nasal discharge for 10 days. She reports frontal headache and a feeling of pressure over her cheeks. No visual symptoms or vomiting.

She has tried over-the-counter nasal decongestants without benefit. No significant medical history. Non-smoker. No recent dental procedures.

On examination, she is afebrile. Maxillary tenderness on the left and reduced transillumination. No periorbital swelling or signs of systemic illness.

What is the most appropriate next step in management?

Jason McNamara, aged 17, presents with a 2-day history of severe sore throat, fever, and difficulty swallowing. He denies cough or rhinorrhoea. He has been unable to eat due to pain and reports muffled voice.

No significant past medical history. No known allergies.

On examination, he has a temperature of 39.2°C and is drooling slightly. There is left-sided tonsillar swelling with uvular deviation to the right. Trismus is present. No stridor or respiratory distress.

What is the most appropriate management?

Naomi Vella, aged 34, presents with a 6-month history of episodic vertigo lasting several hours, often preceded by a sensation of ear fullness and associated with tinnitus. She denies hearing loss between episodes but reports that hearing is muffled during attacks. No history of recent infection or trauma.

On examination today, her ENT and neurological examination is normal. Weber lateralises to the left and Rinne is positive bilaterally.

What is the most likely diagnosis?

Abdul Qadir, aged 56, presents with intermittent epistaxis from the left nostril over the past 2 months. He reports no trauma and uses a CPAP machine for sleep apnoea. He has a history of hypertension and takes ramipril and aspirin.

On anterior rhinoscopy, there is crusting and telangiectasia on the anterior nasal septum. No active bleeding is seen. BP is 134/80 mmHg.

What is the most appropriate management?

Ella Nguyen, aged 5, presents with noisy breathing during sleep, frequent night waking, and daytime fatigue. Her parents also report mouth breathing and snoring. There is no history of asthma or recurrent infections.

On examination, she has enlarged tonsils and adenoids visible on nasopharyngeal inspection. No wheeze or nasal polyps. Growth and development are normal.

What is the most appropriate next step?

George Papas, aged 69, presents with a non-healing ulcer on the lateral border of his tongue that has been present for 6 weeks. He denies trauma or recent dental procedures. He is a smoker and consumes alcohol regularly. There is associated mild pain when chewing.

Examination reveals a 1.5 cm ulcer with indurated edges and no signs of healing. No cervical lymphadenopathy is noted.

What is the most appropriate next step?

Katherine Boyd, aged 42, presents with left-sided nasal obstruction and anosmia for the past 3 months. She also reports occasional headaches and a sensation of fullness on the left side of her face. No epistaxis or trauma. Past medical history includes allergic rhinitis.

On examination, there is a pale, polypoid mass visible in the left nasal cavity. No cervical lymphadenopathy. Oral cavity and neurological exams are normal.

What is the most appropriate next step?

Luke Hardy, aged 20, presents with a sudden onset of left ear pain and hearing loss after diving into a swimming pool. He also notes a small amount of bloody discharge. No vertigo or systemic symptoms. No previous ear problems.

On otoscopy, the left tympanic membrane appears perforated with some dried blood in the canal. No signs of infection or cholesteatoma.

What is the most appropriate initial management?

Margaret Donnelly, aged 81, presents with persistent bilateral hearing loss. She has no ear pain, discharge or vertigo. Her family have noticed she struggles to follow conversations. She is otherwise healthy, lives independently, and is on no ototoxic medications.

Otoscopy is unremarkable. Weber is midline and Rinne is positive bilaterally. Tympanometry is normal.

What is the most likely cause of her symptoms?

Claire Bennett, aged 29, presents with a 3-week history of nasal congestion, facial pressure and postnasal drip. She has a history of allergic rhinitis and recently returned from a trip to Melbourne. She denies fever but feels tired and congested.

On examination, her nasal mucosa is pale and boggy, and there is tenderness over the maxillary sinuses. No fever or purulent discharge is noted.

What is the most appropriate initial management?

Isaac Russell, aged 4, is brought in with his mother who reports that he inserted a small bead into his right nostril earlier today. He is not in distress but has had one episode of sneezing and some watery discharge from the nostril. No fever or cough.

On examination, a white plastic object is visible in the right nostril. There is no bleeding or purulent discharge.

What is the most appropriate next step?

Olivia Tan, aged 32, presents with odynophagia and a ‘lump in throat’ sensation for 4 days. She denies cough or coryza. She is afebrile. Past history includes seasonal allergic rhinitis. She reports recent stress and is in her first year of teaching.

On examination, her throat appears normal, with no tonsillar enlargement or erythema. No cervical lymphadenopathy. Voice is slightly strained.

What is the most likely diagnosis?

Emily Sorenson, aged 6, is brought in by her father with a 24-hour history of a painful, swollen area just anterior to her right ear. She has had a mild fever and reduced appetite. No known contacts with mumps. She is fully immunised and otherwise healthy.

On examination, the right parotid gland is tender and swollen. No pus seen at Stensen’s duct. No trismus or lymphadenopathy. Tympanic membranes are normal.

What is the most appropriate initial management?

James McCall, aged 47, presents with sudden severe vertigo, nausea and vomiting. He denies hearing loss or tinnitus. There is no history of trauma. Symptoms began this morning and he is unable to stand unaided.

On examination, horizontal nystagmus is noted. Head impulse test is positive. No focal neurological signs.

What is the most likely diagnosis?

Tommi Vu, aged 2, presents with irritability and tugging at his left ear. He has had a runny nose and low-grade fever for two days. No vomiting or rash. No significant medical history. Immunisations are up to date.

On examination, he is febrile at 38.2°C. The left tympanic membrane is red with loss of landmarks. No perforation. The right ear is normal.

What is the most appropriate management?

Sarah Karounis, aged 39, presents with a 4-month history of intermittent right-sided facial pain, triggered by cold wind or brushing her teeth. Pain is sharp and electric in nature, lasting seconds. No nasal or ocular symptoms. No focal neurological signs on examination.

She is otherwise well and takes no regular medications.

What is the most likely diagnosis?

Ben Taylor, aged 15, presents after being hit in the face with a basketball. He now has nasal pain and swelling. He is able to breathe through both nostrils but has mild bruising and deviation of the nasal bridge. No epistaxis at present.

On examination, there is tenderness over the nasal bones and slight rightward deviation of the bridge. No septal haematoma is noted. No other facial injuries.

What is the most appropriate management?

Anna Reid, aged 45, presents with persistent left-sided nasal obstruction and occasional blood-stained nasal discharge for the past 2 months. She is a non-smoker and has no recent URTI. She has tried over-the-counter nasal sprays with minimal relief.

On examination, a firm mass is noted in the left nasal passage. It does not transilluminate. No cervical lymphadenopathy.

What is the most appropriate next step?

Jacob Morrison, aged 9, presents with a sore throat, fever, and drooling. His mother reports he has been sitting upright and refusing to lie down. He has muffled speech and is visibly anxious. Immunisations are up to date.

On examination, he has a temperature of 39.8°C and a soft stridor. Neck movement is painful and restricted.

What is the most appropriate next step?

Linda Zhou, aged 33, presents with persistent foul taste in her mouth and halitosis. She reports intermittent discomfort in her throat and occasional white debris from her tonsils. No fever or systemic symptoms.

On examination, her tonsils have small crypts with visible white concretions. No lymphadenopathy or signs of infection.

What is the most likely diagnosis?

Mick Douglas, aged 62, presents with hearing loss and a sensation of fullness in the left ear. He recently recovered from a cold. No ear pain, discharge, or vertigo. He is otherwise well and takes antihypertensives.

On examination, the left tympanic membrane appears retracted with visible fluid level. Weber lateralises to the left; Rinne is negative on the left.

What is the most appropriate initial management?

Rachel Holmes, aged 37, presents with ear fullness and a crackling sensation when swallowing. She recently returned from a flight. No ear pain or discharge. No fever. Symptoms started during descent and have not resolved after 2 days.

Otoscopy shows a mildly retracted tympanic membrane. No effusion or redness noted.

What is the most appropriate initial management?

Sophie Mallard, aged 58, presents with a chronic sore tongue and altered taste sensation. She wears full upper and lower dentures. She also reports a burning sensation that worsens throughout the day. No recent dental work. Smoker, 10/day.

Examination reveals erythema of the tongue with no ulceration or exudate. No cervical lymphadenopathy.

What is the most likely diagnosis?

Adrian Cho, aged 16, presents with recurrent episodes of nosebleeds over the past month, typically from his right nostril. Each episode stops with pressure. He plays football and trains most days. No history of bleeding disorders.

On examination, there is a small visible vessel at Little’s area with crusting but no active bleeding.

What is the most appropriate next step?

Patricia Kline, aged 61, presents with a 3-week history of hoarseness. She is a teacher and has continued working despite a recent viral URTI. No pain, haemoptysis, or weight loss. She is a non-smoker and takes no regular medications.

On examination, her voice is breathy and strained. No neck masses or lymphadenopathy.

What is the most appropriate initial management?

Zoe Yi, aged 10, presents with a history of itchy, malodorous discharge from the left ear for 5 days. She recently swam in a local dam. On examination, the ear canal is erythematous and swollen with scant purulent debris. TM not visualised.

She has no fever and is systemically well. No mastoid tenderness or facial weakness.

What is the most appropriate management?

Isaac Levine, aged 50, presents with persistent unilateral hearing loss and occasional unsteadiness for the past 3 months. He denies tinnitus, ear pain or discharge. No relevant medical history. No noise exposure.

On examination, Weber lateralises to the right. Rinne is positive on the left and negative on the right. No cranial nerve deficits noted.

What is the most appropriate next step?

Natalie Benson, aged 4, is brought in with a history of snoring, restless sleep and frequent night-time awakenings. Her parents report she breathes through her mouth and often wakes up tired. She has no significant medical history. Immunisations are up to date.

On examination, she has visibly enlarged tonsils and adenoids. Growth parameters are normal.

What is the most appropriate management?

Leanne Harper, aged 52, presents with left ear pain and jaw discomfort that worsens with chewing. She denies hearing loss or discharge. No recent URTI or trauma.

On examination, ear canal and tympanic membrane are normal. There is tenderness over the left TMJ and clicking with opening.

What is the most likely diagnosis?

Daniel Petrou, aged 7, is brought in by his mother with a foul-smelling unilateral nasal discharge for the past 3 days. He has no fever or systemic symptoms. He is otherwise well and has no allergies.

On anterior rhinoscopy, there is purulent material in the right nasal cavity with a visible foreign object.

What is the most appropriate next step?

Yasmin El-Amin, aged 38, presents with 2-week history of sore throat, low-grade fever, and persistent hoarseness. She denies cough or rhinorrhoea. No history of smoking. She works as a call centre operator.

On examination, her voice is hoarse, throat is mildly erythematous, no exudates or lymphadenopathy. No systemic signs.

What is the most appropriate initial management?

Ethan Ward, aged 12, presents with left ear pain, fever, and reduced hearing. He was treated for acute otitis media 2 weeks ago with oral antibiotics. His mother now reports he has ongoing pain, and swelling behind the ear.

On examination, he is febrile (38.7°C). The pinna is displaced forward and there is tenderness over the mastoid process.

What is the most appropriate next step?

Trent Hobson, aged 42, presents with a unilateral sensation of ear fullness and crackling with swallowing that has been present for a week. He recently recovered from a cold. No otalgia or discharge. Hearing seems slightly reduced on the left.

Otoscopy shows a dull tympanic membrane on the left. Weber lateralises to the left, and Rinne is negative on the left.

What is the most likely diagnosis?

David Makris, aged 70, presents with a painless ulcer on the inner aspect of his cheek that has persisted for over 4 weeks. He has a 45-pack-year smoking history and drinks alcohol daily. No recent dental trauma.

On examination, the ulcer has raised, indurated edges and measures 1.5 cm. No cervical lymphadenopathy is detected.

What is the most appropriate next step?

Tina Pham, aged 31, presents with acute onset severe vertigo associated with nausea. She had an upper respiratory tract infection one week ago. No hearing loss or tinnitus. She has no past history of similar episodes.

On examination, she is unable to walk without support. There is horizontal nystagmus present. Neurological exam is otherwise normal.

What is the most appropriate management?

Kate Gillespie, aged 25, presents with sudden hearing loss in her right ear that started this morning. No pain or discharge. No recent illness. She denies vertigo. No previous ear problems.

On examination, Weber lateralises to the left and Rinne is positive bilaterally. TM appears normal bilaterally.

What is the most appropriate next step?

Lara Jenkins, aged 68, presents with a chronic dry cough, hoarseness and sensation of a lump in her throat. She is a lifelong non-smoker. Symptoms have been present for over 3 months. No weight loss or dysphagia.

Examination is unremarkable. No lymphadenopathy. Chest auscultation is clear. No oral lesions noted.

What is the most appropriate initial management?

Michael Zaatar, aged 11, presents with pain and swelling below the jaw on the right side, which worsens during meals. His temperature is 37.8°C. There is mild erythema over the submandibular area and tenderness on palpation. Oral exam shows purulent discharge from Wharton’s duct.

He has no history of dental issues or trauma.

What is the most appropriate management?

Alice Chan, aged 8, is brought in with a sore throat, fever, and difficulty swallowing. She also has a muffled voice and jaw stiffness. Symptoms have worsened over 3 days. Examination reveals unilateral tonsillar swelling with uvular deviation.

She is febrile (38.9°C) and has mild trismus. No airway compromise.

What is the most appropriate management?

Jonathan Pratt, aged 59, presents with progressive bilateral hearing loss over several years. He has trouble following conversations, especially in noisy environments. No vertigo or tinnitus. He has worked in a quiet office his whole life.

On examination, tympanic membranes are normal. Weber is midline. Rinne is positive bilaterally.

What is the most likely diagnosis?

Laura Singh, aged 36, presents with a sore throat, dry mouth, and gritty sensation in her eyes. She has had these symptoms for 3 months. No fevers or recent infections. Medical history includes mild asthma. No current medications.

On examination, dry buccal mucosa and bilateral parotid enlargement are noted.

What is the most likely diagnosis?

Felicity Browne, aged 3, is brought in with a 2-day history of fever and irritability. Her parents report she has been pulling at her right ear. No vomiting or rash. Immunisations are up to date.

On examination, she is febrile (38.5°C), and the right tympanic membrane is bulging and erythematous with no perforation. The left ear is normal.

What is the most appropriate management?

Anthony Miles, aged 65, presents with chronic cough and intermittent haemoptysis over the past 6 weeks. He also reports hoarseness and weight loss. He is a retired smoker (40 pack-years). No history of reflux or allergies.

On examination, voice is hoarse. No cervical lymphadenopathy. Chest is clear.

What is the most appropriate next step?

Emily Watson, aged 27, presents with intermittent nasal congestion and sneezing, worse in spring. She also experiences itchy eyes and occasional clear nasal discharge. No fever or systemic symptoms.

On examination, nasal mucosa appears pale and boggy. No polyps or masses.

What is the most appropriate first-line management?

Bruce Allen, aged 60, complains of a persistent feeling of a lump in the throat without pain, dysphagia, or weight loss. The sensation is worse when anxious. He denies smoking or alcohol use.

On examination, oral cavity and oropharynx are normal. No masses or lymphadenopathy. Flexible nasendoscopy (if done) is unremarkable.

What is the most likely diagnosis?

Naomi Jacobs, aged 14, presents with recurrent episodes of tonsillitis. She has had six documented episodes in the past year, missing school each time. She is otherwise well between episodes.

On examination today, her throat is normal and there is no lymphadenopathy. No peritonsillar signs.

What is the most appropriate management?

Clive Anderson, aged 72, presents with a 1-month history of right-sided facial weakness. He initially thought it was due to sleeping awkwardly. He denies ear pain or discharge but has noted reduced hearing on that side.

On examination, he has complete right-sided lower motor neuron facial palsy. Otoscopy reveals a small vesicular lesion in the right ear canal.

What is the most likely diagnosis?