Free Otolaryngology (ENT) mock test

Otolaryngology (ENT) sample questions with answers

10 more original exam-style Otolaryngology (ENT) questions, worked in full. They are not real or recalled exam questions, and none of them is in the mock above or on the bank page, so sit the mock first if you have not.

1. Question 1 · Rhinology, Sinonasal Disorders & Allergy

   An obese 47-year-old woman with headaches and pulsatile tinnitus has spontaneous CSF rhinorrhoea from a lateral sphenoid recess defect, with an empty sella on MRI. After successful endoscopic multilayer repair, which additional measure most reduces the risk of recurrence?

   1. ALong-term prophylactic antibiotics
   2. BLifelong nasal saline irrigation
   3. CAssessment and treatment of raised intracranial pressure, including acetazolamide, weight loss and consideration of CSF diversion or venous sinus stenting
   4. DRoutine annual repeat endoscopic repair
   Show answer and explanation

   Correct answer: C. Assessment and treatment of raised intracranial pressure, including acetazolamide, weight loss and consideration of CSF diversion or venous sinus stenting

   Spontaneous CSF rhinorrhoea in this demographic is strongly associated with idiopathic intracranial hypertension, and failure to address the elevated pressure is a leading cause of repair failure and of new leaks at other sites. Postoperative measurement of opening pressure with medical therapy, weight reduction and, in selected patients, shunting or venous sinus stenting is therefore recommended. Prophylactic antibiotics, irrigation and planned repeat surgery do not address the underlying hydrodynamic cause.

   Reference: Cummings Otolaryngology - Head and Neck Surgery, 7th edition (2021), CSF rhinorrhoea; Woodworth BA et al., spontaneous CSF leak and intracranial hypertension literature

2. Question 2 · Laryngology, Voice, Swallowing & Airway

   A 50-year-old woman with suspected laryngopharyngeal reflux has completed three months of twice-daily proton pump inhibitor therapy taken 30 minutes before meals, alginate at night, and full dietary and lifestyle modification. Her Reflux Symptom Index remains high and laryngoscopy findings are unchanged. What is the most appropriate next step?

   1. AProceed directly to laparoscopic fundoplication
   2. BIncrease the proton pump inhibitor to four times daily indefinitely
   3. CPerform 24-hour pharyngeal pH-impedance monitoring
   4. DGive empirical Helicobacter pylori eradication therapy
   Show answer and explanation

   Correct answer: C. Perform 24-hour pharyngeal pH-impedance monitoring

   When an adequate empirical trial fails, objective testing with 24-hour multichannel intraluminal pH-impedance monitoring is required, both to confirm or refute pathological proximal reflux and to detect non-acid or weakly acidic reflux that a proton pump inhibitor will not control. Escalating acid suppression indefinitely without proof of reflux exposes the patient to long-term risk with no evidence of benefit. Antireflux surgery should never be offered without objective confirmation, and Helicobacter pylori eradication has no established role in laryngopharyngeal reflux.

   Reference: Lechien JR et al., Clinical Practice Guidelines for the Diagnosis and Management of Laryngopharyngeal Reflux (2019/2022 updates); Cummings Otolaryngology, 7th edition (2021)

3. Question 3 · ENT Emergencies, Trauma & Critical Airway

   A recreational diver performs a forceful Valsalva manoeuvre during a difficult descent. On surfacing he has severe rotatory vertigo, tinnitus and a marked sensorineural hearing loss in one ear, with an intact tympanic membrane and no features of decompression sickness. Which is the most appropriate initial management?

   1. AImmediate recompression in a hyperbaric chamber
   2. BIntravenous heparin and urgent CT angiography of the posterior circulation
   3. CStrict bed rest with head elevation, avoidance of straining, nose-blowing and further diving, with surgical exploration for a perilymph fistula if symptoms progress or fail to improve
   4. DEpley canalith repositioning manoeuvre and discharge
   Show answer and explanation

   Correct answer: C. Strict bed rest with head elevation, avoidance of straining, nose-blowing and further diving, with surgical exploration for a perilymph fistula if symptoms progress or fail to improve

   This is inner ear barotrauma, in which a forceful Valsalva against a blocked eustachian tube produces implosive or explosive pressure transfer with possible round or oval window rupture; management is conservative with bed rest, head elevation, avoidance of any Valsalva-type straining and no further diving, with exploration and window sealing if hearing or vertigo worsens or does not recover. Recompression is the treatment for inner ear decompression sickness, which typically follows deeper dives with other decompression symptoms and can be worsened by delay in distinguishing the two; anticoagulation is not indicated, and the Epley manoeuvre treats BPPV, which does not cause acute sensorineural hearing loss.

   Reference: Undersea and Hyperbaric Medical Society guidance on inner ear barotrauma; Scott-Brown's Otorhinolaryngology, Head and Neck Surgery, 8th ed. (2018)

4. Question 4 · Thyroid, Parathyroid & Salivary Glands

   During a right hemithyroidectomy the surgeon encounters a prominent posterolateral projection of thyroid tissue adjacent to the tracheo-oesophageal groove, corresponding to the tubercle of Zuckerkandl. What is the usual relationship of the recurrent laryngeal nerve to this landmark?

   1. AThe nerve runs superficial (lateral) to the tubercle in the majority of patients
   2. BThe tubercle indicates that the nerve is non-recurrent on that side
   3. CThe nerve passes deep (medial) to the tubercle as it ascends towards the cricothyroid joint
   4. DThe nerve consistently pierces the substance of the tubercle
   Show answer and explanation

   Correct answer: C. The nerve passes deep (medial) to the tubercle as it ascends towards the cricothyroid joint

   In the large majority of glands the recurrent laryngeal nerve lies deep and medial to the tubercle of Zuckerkandl, so the tubercle can be retracted anteromedially to expose the nerve just before it passes beneath Berry's ligament. It is not a marker of a non-recurrent nerve, which is a right-sided anomaly associated with an aberrant subclavian artery and is best predicted by preoperative imaging. The nerve does not normally run lateral to or through the tubercle, and assuming so risks transection.

   Reference: Scott-Brown's Otorhinolaryngology, Head and Neck Surgery, 8th ed (2018); Pelizzo et al., anatomical studies of the tubercle of Zuckerkandl, World Journal of Surgery

5. Question 5 · Facial Plastic & Reconstructive Surgery

   Six hours after upper and lower lid blepharoplasty, a 55-year-old woman develops severe deep orbital pain, marked proptosis, a tense orbit, a relative afferent pupillary defect and reduced visual acuity. What is the immediate management?

   1. AUrgent CT of the orbits before any intervention
   2. BIntravenous mannitol and acetazolamide alone with hourly observation
   3. CImmediate lateral canthotomy and inferior cantholysis
   4. DReturn to the operating theatre on the next available list
   Show answer and explanation

   Correct answer: C. Immediate lateral canthotomy and inferior cantholysis

   This is retrobulbar haemorrhage causing orbital compartment syndrome, a sight-threatening emergency in which retinal ischaemia can become irreversible within 60-120 minutes; immediate bedside lateral canthotomy and inferior cantholysis decompresses the orbit and must not wait for imaging or theatre. Medical measures such as mannitol, acetazolamide and steroids are adjuncts only, and formal exploration with evacuation of the haematoma follows the decompression.

   Reference: American Academy of Ophthalmology, Preferred Practice Pattern - Orbital compartment syndrome; Papel ID (ed.), Facial Plastic and Reconstructive Surgery, 4th ed., 2016

6. Question 6 · Professionalism, Ethics, Communication & Patient Safety

   A 68-year-old woman with recurrent laryngeal carcinoma after chemoradiotherapy asks, 'How long do I have, doctor?'. The MDT estimates a median survival of about 9 months with best supportive care. Which response best balances honesty and hope?

   1. A'It is impossible to say anything useful about time; let us not focus on that.'
   2. B'You have about nine months.'
   3. C'Some people in your situation live many years, so try to stay positive.'
   4. D'Averages suggest months rather than years, though individuals vary considerably; may I ask what you are most hoping to be able to do in that time?'
   Show answer and explanation

   Correct answer: D. 'Averages suggest months rather than years, though individuals vary considerably; may I ask what you are most hoping to be able to do in that time?'

   Best practice is to give honest information framed in ranges with acknowledged uncertainty, then pivot to the patient's values and goals, which sustains realistic hope and enables planning. Refusing to discuss prognosis denies information the patient has explicitly requested; a single precise figure conveys false certainty and is often experienced as a sentence; false reassurance about many years misrepresents the evidence and undermines trust when deterioration occurs.

   Reference: Back AL, Arnold RM, Tulsky JA, Mastering Communication with Seriously Ill Patients (Cambridge, 2009); NCCN Guidelines for Palliative Care

7. Question 7 · General Otology & Otoneurology

   A 35-year-old has an 8 mm purely intracanalicular vestibular schwannoma with serviceable hearing (pure tone average 25 dB, word recognition 90 percent) and, after counselling about observation and radiosurgery, opts for microsurgical removal with an attempt at hearing preservation. Which approach is most appropriate?

   1. ATranslabyrinthine approach
   2. BMiddle cranial fossa approach
   3. CTransotic approach
   4. DInfratemporal fossa type A approach
   Show answer and explanation

   Correct answer: B. Middle cranial fossa approach

   The middle cranial fossa approach gives excellent exposure of the lateral internal auditory canal while preserving the labyrinth and cochlea, and is the preferred hearing-preservation route for small intracanalicular tumours (the retrosigmoid approach is the alternative but has limited access to the most lateral canal). The translabyrinthine and transotic approaches sacrifice the labyrinth and therefore all residual hearing. The infratemporal fossa type A approach is designed for jugular foramen paragangliomas, not for intracanalicular schwannomas.

   Reference: Cummings Otolaryngology - Head and Neck Surgery, 7th edition (2021), surgical approaches to the cerebellopontine angle and vestibular schwannoma

8. Question 8 · Head & Neck Oncology and Reconstruction

   A 60-year-old man has a level II node whose fine-needle aspiration cytology shows p16-positive squamous cell carcinoma. Clinical examination, flexible endoscopy, contrast-enhanced CT of the neck and whole-body PET-CT show no primary tumour. What is the most appropriate next step?

   1. AProceed directly to neck dissection followed by bilateral neck and total mucosal irradiation
   2. BExamination under anaesthesia with bilateral tonsillectomy and tongue base mucosectomy (lingual tonsillectomy)
   3. CRepeat the PET-CT in three months and observe in the interim
   4. DGive empirical chemoradiotherapy directed at the nasopharynx alone
   Show answer and explanation

   Correct answer: B. Examination under anaesthesia with bilateral tonsillectomy and tongue base mucosectomy (lingual tonsillectomy)

   A p16-positive nodal metastasis points strongly to an occult oropharyngeal primary in the tonsillar or lingual tonsillar crypts, and diagnostic bilateral tonsillectomy with tongue base mucosectomy (often transoral robotic) identifies the primary in a substantial proportion of cases, permitting targeted treatment and smaller radiotherapy volumes. Committing to total mucosal irradiation without seeking the primary causes avoidable toxicity, repeating imaging delays treatment, and nasopharynx-directed therapy is inappropriate for p16-positive disease.

   Reference: NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers - Occult Primary, 2023; Cummings Otolaryngology - Head and Neck Surgery, 7th edition, 2021

9. Question 9 · Pediatric Otolaryngology

   In the Jahrsdoerfer grading system used to select candidates for atresiaplasty, which feature carries the greatest weighting?

   1. APresence of a normal stapes
   2. BAppearance of the external ear
   3. CCourse of the facial nerve
   4. DAeration of the mastoid
   Show answer and explanation

   Correct answer: A. Presence of a normal stapes

   The Jahrsdoerfer 10-point CT-based scale awards 2 points for a present stapes and 1 point each for the other parameters, including the malleus-incus complex, incudostapedial connection, oval and round windows, middle ear space, facial nerve course, mastoid pneumatisation and external ear appearance. A score of 7 or more predicts a reasonable chance of closing the air-bone gap to within 30 dB, and 8 or more is generally preferred. External ear appearance, facial nerve course and mastoid aeration each contribute only a single point.

   Reference: Jahrsdoerfer RA et al., Grading system for the selection of patients with congenital aural atresia, American Journal of Otology (1992)

10. Question 10 · Audiology, Vestibular Assessment & Speech-Language Pathology

    A 70-year-old man treated with prolonged intravenous gentamicin now has oscillopsia when walking and marked unsteadiness in the dark. Video head impulse testing shows bilaterally reduced gains with overt saccades, and caloric responses are absent bilaterally. Which rehabilitation strategy is most appropriate?

    1. AA supervised programme emphasising substitution strategies (visual and somatosensory cues, saccadic and cervico-ocular substitution) with gaze-stability and balance training
    2. BRepeated Epley manoeuvres to both sides
    3. CLong-term vestibular suppressant medication to reduce the oscillopsia
    4. DUnilateral vestibular deafferentation surgery on the more affected side
    Show answer and explanation

    Correct answer: A. A supervised programme emphasising substitution strategies (visual and somatosensory cues, saccadic and cervico-ocular substitution) with gaze-stability and balance training

    In bilateral vestibular hypofunction there is no residual asymmetry to adapt to, so rehabilitation relies on substitution: training compensatory saccades, potentiating visual and somatosensory input, and progressive balance and gait work, together with falls-risk reduction and counselling about walking in the dark or on uneven ground. Repositioning manoeuvres treat canalithiasis, which is not the problem here. Chronic vestibular suppressants impair central compensation and increase falls in the elderly, and ablative surgery would only worsen an already absent vestibular function.

    Reference: Clinical Practice Guideline: Vestibular Rehabilitation for Peripheral Vestibular Hypofunction (2nd edition), Journal of Neurologic Physical Therapy (2022); Barany Society criteria for bilateral vestibulopathy (2017)