ENT OSCEs-A Guide to Passing the DO-HNS and MRCS

(ENT) OSCE, Second Edition Joseph Manjaly

(Author) pdf download
https://textbookfull.com/product/ent-osces-a-guide-to-passing-the-do-hns-and-mrcs-ent-osce-second-
edition-joseph-manjaly-author/

★★★★★ 4.7/5.0 (27 reviews) ✓ 228 downloads ■ TOP RATED

"Great resource, downloaded instantly. Thank you!" - Lisa K.

DOWNLOAD EBOOK
ENT OSCEs-A Guide to Passing the DO-HNS and MRCS (ENT) OSCE,
Second Edition Joseph Manjaly (Author) pdf download

TEXTBOOK EBOOK TEXTBOOK FULL

Available Formats

■ PDF eBook Study Guide TextBook

EXCLUSIVE 2025 EDUCATIONAL COLLECTION - LIMITED TIME

INSTANT DOWNLOAD VIEW LIBRARY

Collection Highlights

Advanced ENT training: A guide to passing the FRCS (ORL-

HNS) examination Joseph Manjaly

Advanced ENT training A guide to passing the FRCS ORL HNS

examination 1st Edition Joseph Manjaly (Editor)

Osces for the Mrcs Part B: A Bailey & Love Revision Guide
Second Edition Chowdhury

OSCEs for the MRCS Part B: A Bailey & Love Revision Guide
Jonathan M. Fishman
The Easy Guide to OSCEs for Specialties a Step By Step
Guide to Success Second Edition Akunjee

The easy guide to focused history taking for OSCEs Second

Edition Mccollum

ENT: An Introduction and Practical Guide, Second Edition

James Tysome

Electrical Inspection Testing and Certification A Guide to

Passing the City and Guilds 2391 Exams Second Edition
Michael Drury

Single best answers (SBAs) for the MRCS Part A a Bailey &
Love revision guide Second Edition Chowdhury
 ENT OSCEs: A Guide
to Passing the DO-HNS
and MRCS (ENT) OSCE
Second Edition

K32124_Book.indb 1 2/15/2017 6:48:40 PM

K32124_Book.indb 2 2/15/2017 6:48:40 PM
 ENT OSCEs: A Guide
to Passing the DO-HNS
and MRCS (ENT) OSCE
Second Edition

Joseph Manjaly, BSc (Hons) MBChB MRCS DOHNS

ENT Specialty Registrar, London North Thames, UK

Peter Kullar, MBChir MA MRCS DOHNS

Academic ENT Trainee, Northern Deanery, UK

Alison Carter, BMBS BMedSci (Hons) MRCS DOHNS

ENT Specialty Registrar, London North Thames, UK

Richard Fox, MBChB BSc (Hons) MRCS (ENT)

Former ENT Core Surgical Trainee, London Deanery, UK

K32124_Book.indb 3 2/15/2017 6:48:40 PM

 CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2017 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Printed on acid-free paper
International Standard Book Number-13: 978-1-138-63594-4 (Paperback) 978-1-138-63691-0 (Hardback)
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been
made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or
liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed
in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/
opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or
health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their
knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines.
Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be
independently verified. The reader is strongly urged to consult the drug companies’ printed instructions, and their websites,
before administering any of the drugs recommended in this book. This book does not indicate whether a particular treatment
is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make
his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also
attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if
permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write
and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized
in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying,
microfilming, and recording, or in any information storage or retrieval system, without written permission from the
publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://
www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923,
978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For
organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for iden-
tification and explanation without intent to infringe.

Library of Congress Cataloging-in-Publication Data

Names: Manjaly, Joseph, author. | Kullar, Peter, author. | Carter, Alison,

1985- author. | Fox, Richard, 1987- author.
Title: ENT OSCEs : a guide to passing the DO-HNS and MRCS (ENT) OSCE / Joseph
Manjaly, Peter Kullar, Alison Carter, and Richard Fox.
Other titles: Ear, nose, and throat objective structured clinical
examinations | Master pass.
Description: Second edition. | Boca Raton : CRC Press, [2016] | Series:
Masterpass
Identifiers: LCCN 2016050369| ISBN 9781138635944 (pbk.) | ISBN 9781138636910
(hardback)
Subjects: | MESH: Otolaryngology | Otorhinolaryngologic Diseases--surgery |
Otorhinolaryngologic Surgical Procedures | Test Taking Skills |
Examination Questions
Classification: LCC RF57 | NLM WV 18.2 | DDC 617.5/10076--dc23
LC record available at https://lccn.loc.gov/2016050369

Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com

K32124_Book.indb 4 2/15/2017 6:48:40 PM

 Contents

Foreword to the Second Edition vii

Preface to the Second Edition ix
Acknowledgmentsxi
Authorsxiii
Abbreviationsxv
The DO-HNS and MRCS (ENT) Examination and How to Pass It xvii
General Tips for the Communication and History Stations xix
1 History Stations 1
1.1 Olfactory Dysfunction 2
1.2 Nosebleeds in Adults 5
1.3 Nosebleeds in Children 7
1.4 Dry Mouth 9
1.5 Lump in the Throat 12
1.6 Hoarse Voice 14
1.7 Catarrh and Post-Nasal Drip 17
1.8 Tinnitus19
1.9 Child with Recurrent Ear Infections 22
1.10 Facial Weakness 24
1.11 Septal Perforation 27
1.12 Hearing Loss in a Child 29
1.13 Adult with Itchy, Painful Ear 31
1.14 Adult with Non-Acute Hearing Loss 33
1.15 Adult with Sudden Hearing Loss 35
1.16 Otalgia37
1.17 Nasal Crusting 39
1.18 Dizziness41
1.19 Neck Lump 44
1.20 Snoring in a Child 46
1.21 Recurrent Tonsillitis 48
1.22 Nasal Obstruction 50
2 Examination Stations 53
2.1 Examination of the Ear 55
2.2 Examination of the Nose 62
2.3 Examination of the Neck 65
2.4 Examination of the Oral Cavity 70
2.5 Flexible Nasendoscopy 73
2.6 Vestibular Assessment 75

K32124_Book.indb 5 2/15/2017 6:48:40 PM

 Contents

3 Communication Skills Stations 81

3.1 Consent81
Grommets81
Functional Endoscopic Sinus Surgery 83
Septoplasty84
Panendoscopy and Microlaryngoscopy 85
Myringoplasty86
Parotid Surgery 87
Submandibular Surgery 89
3.2 Explanation90
Benign Paroxysmal Positional Vertigo 90
Cholesteatoma91
Thy3F Thyroid Nodule 92
Acoustic Neuroma 94
3.3 Breaking Bad News 96
3.4 Discharge Letter 98
3.5 Operation Note 99
4 Data and Picture Interpretation Stations: Cases 1–42 103

Index189

vi

K32124_Book.indb 6 2/15/2017 6:48:40 PM

 Foreword to the
Second Edition

It is a pleasure to be able to contribute this Foreword. When I was a young trainee trying
to forge an ear, nose and throat career, life as a junior doctor was very different than today.
Perhaps the biggest hurdle was the need to complete the old ‘FRCS Primary’ prior to enter-
ing higher surgical training. This was a generic surgical exam and as soon as you said you
were an ENT trainee, the viva examiners seemed to delight in moving straight onto ques-
tions on the in-depth anatomy of the sole of the foot! Throw into the equation the fact that
I had to study for this exam whilst one of your authors was a 6-month-old baby at the time,
constantly crying and needing attention, and you can imagine what a challenge it was to
navigate the 10% pass rate.
Of course times change, babies grow up into ENT surgeons, the health service has
evolved and training has changed significantly in response to that. It’s only right that
examinations also evolve to reflect this, and I think the present-day Membership of the
Royal College of Surgeons (MRCS[ENT]), focusing much more on ENT-related anatomy,
physiology and pathology, will equip junior trainees well with the skills and knowledge
needed to do the job effectively and be ready to apply for ENT registrar national selection.
I am pleased to say this book contains the essential tools to prepare thoroughly for the
exam. It is so important as a specialty that we train and inspire the next generation of able,
motivated and knowledgeable trainees. I hope this book will be one small contributor to
making that happen around the country.

George Manjaly
MBBS MPhil FRCS(I) FRCS (ORL) (Eng)
Consultant ENT Surgeon
East Sussex Hospitals NHS Trust

vii

K32124_Book.indb 7 2/15/2017 6:48:40 PM

K32124_Book.indb 2 2/15/2017 6:48:40 PM
 Preface to the
Second Edition

We are delighted at the way this book has been received amongst ENT trainees. The idea
originally began when Peter Kullar and I met on a revision course in our junior years and
had a casual conversation on how we really ought to write a revision book since there
wasn’t one available at the time. Five years later, we are now both well into our registrar
training, mentoring the next cohort of junior trainees, and it gives us great encouragement
whenever we meet a colleague who tells us he or she has ‘the yellow/orange book’ and that
it made a difference to his or her preparation.
Of course it’s crucial to keep things up to date and relevant and we’re grateful for the
input of Ali Carter and Richard Fox for this new edition. ENT continues to be a thriving
specialty; a small world full of great colleagues. It brings great satisfaction to see talented
new trainees choose the specialty and successfully gain a national training number to join
that community. We trust this new expanded edition of our book will continue to gain the
endorsement of trainees taking the Diploma of Otolaryngology – Head and Neck Surgery
(DO-HNS)/MRCS (ENT) exam, as well as those preparing for Specialty Training Year
3 national selection, which is itself very much an exam.
Although not obvious from the book’s title, we also hope that the histories and exami-
nations sections will be useful to those in other training grades learning to do an ENT
clinic for the first time – so, once you’ve passed your exam, why not pass your copy on to
your newest Foundation/General Practice Trainee.

Joe Manjaly
April 2017

ix

K32124_Book.indb 9 2/15/2017 6:48:40 PM

K32124_Book.indb 2 2/15/2017 6:48:40 PM
 Acknowledgments

Thank you to our friends and colleagues for contributions to the images in this book:

Philip Yates
Robert Nash
Manish George
John Hardman
Nora Haloob
Fiona McClenaghan
Andrew Hall
Deepak Chandrasekharan
Samantha Holmes

xi

K32124_Book.indb 11 2/15/2017 6:48:40 PM

K32124_Book.indb 2 2/15/2017 6:48:40 PM
 Authors

Joseph Manjaly is a specialty registrar on the London North Thames ear, nose and throat
rotation. He graduated from Bristol University, gaining a first-class intercalated BSc in
physiology. He co-authored the first edition of this book whilst a core trainee in Wessex
deanery before gaining one of the four London North Thames training posts awarded at
national selection in 2012. He has held a number of Association of Otolaryngologists in
Training positions and is regularly involved in training regionally.

Peter Kullar is a Wellcome Trust Clinical Research Fellow and academic trainee in ear,
nose and throat in the Northern Deanery. He graduated from Cambridge University and
successfully obtained full Membership of the Royal College of Surgeons and Diploma of
Otolaryngology – Head and Neck Surgery prior to co-authoring the first edition of this
book. His specialist interests are otology and mitochondrial-associated hearing loss.

Alison Carter is a specialty registrar on the London North Thames ear, nose and throat
rotation, working at the Royal National Throat Nose and Ear Hospital. She graduated from
Nottingham University and was awarded her Membership of the Royal College of Surgeons
at the beginning of her core surgical training, followed by Diploma of Otolaryngology –
Head and Neck Surgery nearing the end of it, having decided mid training to pursue an
ear, nose and throat career.

Richard Fox is a Registrar in Sydney, Australia having completed the MRCS (ENT) as a
core surgical trainee in London. After graduating from Bristol University (2012) he has
shown a commitment to medical education establishing a number of surgical courses and
has been recognised with the UCL merit teaching award amongst other trainee prizes. He
has also been faculty on the Royal of College of Surgeons post-graduate courses.

xiii

K32124_Book.indb 13 2/15/2017 6:48:40 PM

K32124_Book.indb 2 2/15/2017 6:48:40 PM
 Abbreviations

ACE angiotensin-converting enzyme

ANCA anti-neutrophil cytoplasmic antibody

AOAEs automated otoacoustic emissions

AOM acute otitis media

AOT Association of Otolaryngologists in Training

BIPP bismuth, iodoform and paraffin paste

BPPV benign paroxysmal positional vertigo

CBT cognitive behavioural therapy

CNS central nervous system

CS Churg–Strauss syndrome

CSF cerebrospinal fluid

CSOM chronic suppurative otitis media

CT computed tomography

CXR chest X-ray

DO-HNS Diploma of Otolaryngology – Head and Neck Surgery

EAC external auditory canal

ENT ear, nose and throat

ESR erythrocyte sedimentation rate

FBC full blood count

FNA fine needle aspiration

FNE flexible nasendoscopy

FOSIT feeling of something in the throat

FY Foundation Year

GP general practitioner

GPVTS General Practice Vocational Training Scheme

GRBAS grade, roughness, breathiness, asthenia, strain scale

HIV human immunodeficiency virus

ICP intracranial pressure

xv

K32124_Book.indb 15 2/15/2017 6:48:40 PM

 Abbreviations

INR international normalised ratio

JVP jugular venous pulse

LMN lower motor neuron

LPR laryngopharyngeal reflux

MRCS Membership of the Royal College of Surgeons

MRI magnetic resonance imaging

OD olfactory dysfunction

OE otitis externa

OME otitis media with effusion

OSCE objective structured clinical examination

PNS post-nasal space

PPI proton-pump inhibitor

PTA pure-tone audiometry

SCC squamous cell carcinoma

SHO senior house officer

SNHL sensorineural hearing loss

ST3 Specialty Training Year 3

TB tuberculosis

TM tympanic membrane

TORCH toxoplasmosis, other, rubella, cytomegalovirus, herpes simplex virus

U+Es urea and electrolytes

UMN upper motor neuron

URTI upper respiratory tract infection

USS ultrasound scan

WG Wegener granulomatosis

xvi

K32124_Book.indb 16 2/15/2017 6:48:40 PM

 The DO-HNS and MRCS
(ENT) Examination and
How to Pass It

The Diploma of Otolaryngology – Head and Neck Surgery (DO-HNS) has existed in one
form or another since 2003, after replacing the old Diploma of Laryngology and Otology.
Your reason for sitting the examination will most likely be as a route into higher ear, nose
and throat (ENT) training or as a way of showing a special interest as part of general prac-
tice or allied specialty training. DO-HNS in combination with Membership of the Royal
College of Surgeons (MRCS), or the ‘MRCS (ENT)’, is a requirement in order to be eligible
to attend the ENT national selection interviews for registrar training, although it is not
required to be passed at the time of application.
The examination consists of two parts: Part 1, a 2-hour written paper comprising mul-
tiple-choice questions and extended matching questions, and Part 2, the objective struc-
tured clinical examination (OSCE) on which this book focuses. Historically, candidates
for ENT Specialty Training Year 3 (ST3) tended to sit the full DO-HNS examination in
addition to both parts of the regular MRCS examination.
In May 2011, ‘MRCS (ENT)’ was introduced and was awarded to candidates passing
MRCS Part A and the DO-HNS OSCE. The DO-HNS examination, in both parts, can still
be sat as a stand-alone examination for those outside of ENT higher surgical training, most
commonly, but not exclusively, general practitioners (GPs), or for prospective ENT trainees
who wish to complete it alongside the traditional MRCS sat by other surgical specialties. It
is important to note that when applying for ENT national selection, there are no additional
points awarded for either combination; therefore, the choice is a personal one for each pro-
spective candidate. Be sure to get up to speed with the latest examination announcements
and the core syllabus on the DO-HNS website (http://www.intercollegiatemrcsexams.org.
uk/dohns). We are confident that using this book will provide a firm grounding for pass-
ing the OSCE. Whilst there is no rule governing experience, time spent in an ENT job is
invaluable, as many of the questions are designed to test ‘on-the-job experience’.
The examination is held three times per year, rotating among London, Edinburgh,
Glasgow and Dublin, so be sure to register and pay fees in good time. The colleges are
very strict on application deadlines and they tend not to make exceptions for late entries. It
is a good idea to sort out travel and accommodation as early as possible, as the later these
details are arranged, the more expensive they become. You will also need to make sure you
have appropriate cover in place and have swapped on-calls as, if you happen to be taking
the exam at a distant location, you often will need 2 days in order to get there and back,
and you may not know your specific exam date within the given window until after the 6
weeks required notice period most hospitals have in place for leave requests.
Allow 2–3 months’ preparation time alongside your normal clinical commitments. In
addition to this book, you will find it useful to work through an ENT picture atlas and
to selectively read a more comprehensive ENT textbook, of which there are many on the
market.
The importance of the communication skills section of the examination must be
stressed, and many candidates tend to find this section problematic. For those who are
not native English speakers or do not have a degree from a UK medical school, it may be

xvii

K32124_Book.indb 17 2/15/2017 6:48:40 PM

 The DO-HNS and MRCS (ENT) Examination and How to Pass It

appropriate to consider further training in communication skills. Most importantly, you

must practise the examination and communication scenarios ad nauseam. In our experi-
ence, obliging friends and relatives are a great source of practice. It may also be worthwhile
attending a dedicated DO-HNS revision course. It is surprising how effectively a substan-
tial financial outlay focuses the revision-weary mind.
You will find that the examination question style is similar to those in this book. At the
time of writing, the OSCE consists of around 25 stations plus three to four rest stations,
each lasting 7 minutes. Approximately 20 of these stations are unmanned written stations.
The examination lasts approximately 3½ hours, but with the added administration time it
allows at least 6 hours door to door.
It is also important to note that the mark scheme for the written stations tends to accept
short, succinct answers. Largely, time is in abundance for these stations. Do not feel you
have to write long paragraphs. Often, a sentence or a few words will be enough to secure
the marks. In our experience, for each question the number of lines given in the answer
booklet corresponds with the number of marks available. For example, a question with
four lines in the answer space means there are four possible marks to be picked up. We
cannot stress enough how important it is that you read and re-read the question. It sounds
obvious, but make sure you actually answer the question, too. For example, if the question
asks for four causes of something, you will be scored only for the first four that you list.
This means if you list six causes and the first two are wrong, you will only score two marks,
even if the next four are correct.
Be reassured that pass rates have tended to be between 45% and 75% in recent years.
With some considered preparation this is an eminently passable and fair examination.
On a final note, as you can imagine, a 3½ hour examination is long and most certainly
feels it. It is important to be rested before the examination. Some people find it useful to
take a small snack with them to keep up those flagging blood sugar levels.

xviii

K32124_Book.indb 18 2/15/2017 6:48:40 PM

 General Tips for the
Communication and
History Stations

The communication stations are probably the most intimidating part of the examination.
You are faced with an actor and an examiner. To those not familiar with the OSCE set-up
this can be somewhat daunting. Staying calm and unflustered will be to your advantage.
Be reassured that there are plenty of marks available for the simple things. It is vital to
blind your mind to the contrived nature of the situation and treat the actor as a patient,
as you would in clinical practice. Do not expect too much interaction from the examiner;
it is normal for the examiner to remain entirely passive. This can be a little disconcerting
if you are looking for affirmation. Likewise, do not rely on the examiner for timekeeping.
There will be no signal that the 7 minutes allotted for the station is coming to an end. It is
well worth practising some of the scenarios in this book, to give you an idea of how best to
manage the time effectively.
For all of the history stations it is useful to adopt the ‘open to closed’ question approach.
Start general and then work on to the specifics of the presenting complaint. A useful gen-
eral opener could be: ‘Could you explain to me in your own words the symptoms that you
have been experiencing?’
It is also useful to contextualise the patient’s symptoms, so ask early on in the consulta-
tion about the effect of the symptoms on the patient’s life. This is extremely important in
the examination, as there are often marks for uncovering the patient’s ‘hidden agenda’.
Being an examination, and hence by definition an artificial situation, you will find the
actor’s healthcare-seeking motivation tends to be rather more neatly constructed than in
clinical practice. For example, the patient experiencing vertigo may have underlying con-
cerns of a brain tumour, which they will reveal with some gentle, empathetic question-
ing. Uncovering the patients’ ICE – ideas (as to aetiology), concerns (hidden agendas) and
expectations (as to treatment and prognosis) – is a useful framework for establishing this
vital narrative information.
Chapter 1 details a number of common ENT presentations and the best method for
tackling them in the examination or in clinical practice. We have detailed a number of
specific areas that will need to be explored in the consultations, but it is important in each
case that you start with general open questions. This will also help to establish a rapport
with the patient, facilitating more specific questioning. Do remember that rapport, fluency
and professionalism carry a lot of marks in the examination. Time is limited, of course, and
it is also important to focus on the core symptoms and not be too distracted by interesting
but fruitless tangential diversions.

xix

K32124_Book.indb 19 2/15/2017 6:48:40 PM

K32124_Book.indb 2 2/15/2017 6:48:40 PM
 History Stations

1.1 Olfactory Dysfunction 2 1.13 Adult with Itchy, Painful

1.2 Nosebleeds in Adults 5 Ear 31
1.3 Nosebleeds in Children 7 1.14 Adult with Non-Acute
1.4 Dry Mouth 9 Hearing Loss 33
1.5 Lump in the Throat 12 1.15 Adult with Sudden
Hearing Loss 35
1.6 Hoarse Voice 14
1.16 Otalgia 37
1.7 Catarrh and Post-Nasal
Drip 17 1.17 Nasal Crusting 39
1.8 Tinnitus 19 1.18 Dizziness 41
1.9 Child with Recurrent 1.19 Neck Lump 44
Ear Infections 22 1.20 Snoring in a Child 46
1.10 Facial Weakness 24 1.21 Recurrent Tonsillitis 48
1.11 Septal Perforation 27 1.22 Nasal Obstruction 50
1.12 Hearing Loss in a Child 29

There will be at least three history stations in the examination. This chapter focuses on
common presentations in the examination and ultimately reflects common scenarios in
clinical practice. Each scenario starts with a short introduction. In the examination there
will be a similar introduction to read before you start the station. There is no allotted read-
ing time, so read quickly but carefully.
For the history stations in the examination, you will only be expected to take a history –
there is no requirement to examine the patient or to plan investigations. We have included
a further discussion on investigations at the end of each section for reference.

K32124_Book.indb 1 2/15/2017 6:48:40 PM

 History Stations

1.1 OLFACTORY DYSFUNCTION

A 70-year-old woman comes to your clinic reporting a change in her sense of smell for
the last 2 months. Take a history from this patient.

Olfactory dysfunction (OD) can arise from a variety of causes and has a surprisingly large
impact on the patient’s quality of life. Often it is the compromise of taste that the patient
first notices.
OD can also lead to potentially dangerous situations, as the patient is unable to detect
environmental hazards such as spoilt food or gas leaks. It is estimated that OD will affect
1% of the population under the age of 65 years and over 50% of the population older than
65 years.

GENERAL STRUCTURE OF THE CONSULTATION

An understanding of the olfactory pathway will be your basis for structuring the consulta-
tion, as a problem at any level of the pathway can cause OD.
The olfactory pathway starts with sensory neurons in the nose. These detect odorants
and transmit via the olfactory nerve (cranial nerve I) to the olfactory bulb located on top
of the cribriform plate at the base of the frontal lobe. These subsequently transmit to the
olfactory cortex. There is also an ancillary pathway transmitting somatosensory informa-
tion such as temperature via the trigeminal nerve (cranial nerve V).
Some useful terms to begin with are as follows:
• Anosmia – absence of smell function
• Hyposmia – decreased sensitivity to odorants
• Hyperosmia – increased sensitivity to odorants
• Cacosmia – sensation of foul smells
• Phantosmia – olfactory hallucination
Structure your thinking around the possible causes of the OD. If you can work logically
through these causes, you will not miss anything.
The OD can be
• Conductive – anything that stops odorant molecules getting to the receptors
in the nose
• Sensory – loss of receptor function
• Neural – damage of peripheral and central olfactory pathways

The most common causes you will be expected to know are

• Sinonasal disease
• Postviral anosmia
• Head trauma
• Other, rarer causes (intracranial neoplasia; Addison’s disease; Turner’s, Cushing’s or
Kallmann’s syndrome)

SPECIFIC QUESTIONS
Start with an open question such as: ‘I understand you are having some problems with
your sense of smell. Perhaps you can tell me about this and how it’s affecting you?’

K32124_Book.indb 2 2/15/2017 6:48:40 PM

 1.1 Olfactory Dysfunction

This is a useful opening gambit, as it contextualises the patient’s symptoms.

• When did you last have a normal sense of smell?

• Is it getting better or getting worse, or do you have bad episodes?
• Has there been any change since it started? Does your sense of smell fluctuate?
• Can you smell anything at all? Any unusual smells? (With this question you must
be mindful that olfactory/auditory hallucinations can be a presenting feature of
epilepsy. Patients often have preserved smell for noxious chemicals [e.g. strong
perfume] through the trigeminal nerve.)
• Have you had any recent coughs or colds? (Postviral OD is the most common
aetiology.)
• Have you had any trauma to your head? (Trauma to the skull base can disrupt
olfactory neurons passing through the cribriform plate.)
• Do you have any problems with your nose normally? (Particularly, ask about nasal
obstruction, discharge and it’s quality, epistaxis, allergies and polyps. Ascertain
whether symptoms are uni- or bilateral.)
• Have you had headaches, fits, faints, loss of consciousness or vomiting? (These are
signs of raised intracranial pressure [ICP] and need to be asked about to rule out
intracranial neoplasia, a rare but important cause of OD.)
• Have you noticed anything else? (Use this opportunity to screen for associated
features of nasal disease such as swellings in the head and neck, paraesthesia,
facial pain – remember pain, epistaxis, obstruction and paraesthesia are ‘red flag’
symptoms that may suggest a malignant cause for the OD.)
• Have you had any surgery on the nose? (Patients with ongoing sinonasal disease
will often have had operative procedures. This correlates with OD as both cause and
effect.)
• Have you noticed any change in your sense of taste? Does this interfere with
eating?

PAST MEDICAL HISTORY AND GENERAL SYSTEMS REVIEW

• Do you have any medical problems? (Ask particularly about fevers, malaise, weight
loss and systemic disease such as thyroid problems, diabetes and neurological
conditions.)
• Have you noticed any changes in your memory? (Alzheimer’s dementia and other
neurodegenerative diseases have been associated with olfactory dysfunction [OD].)
• Do you have any children? (Explain that this may seem a strange question but
Kallmann’s syndrome [hypogonadotropic hypogonadism] can present with anosmia
and impaired fertility.)

Close this part of the history by asking if the patient has anything else to add. This can
be a useful time to screen for the patient’s ideas, concerns and expectations.

DRUG HISTORY
• Do you have any medical problems? (Ask particularly about antihypertensive and
antihyperlipidaemic drugs, as these are known to be associated with OD.)
• Do you have any allergies to medications?

K32124_Book.indb 3 2/15/2017 6:48:40 PM

 History Stations

FAMILY HISTORY
• Do any conditions run in your family? (Ask about nasal polyposis, allergic rhinitis
and cystic fibrosis, which predispose to conductive OD.)

SOCIAL HISTORY
• What do you do for work? (Try to discover if there has been any exposure to toxic
chemicals, e.g. nickel.)
• Do you smoke cigarettes?
• Do you have any pets or exposure to animals? (Allergic rhinitis can lead to OD.)

FURTHER DISCUSSION: EXPLANATION AND PLANNING

Explain you would fully examine the patient’s head and neck, obviously paying particular
attention to the nose. Examine the nose in the standard fashion (see Chapter 2) paying
attention to the nasal mucosa for signs of inflammation, deviation of the nasal septum and
the presence of polyps. Explain you would perform nasal endoscopy with either the rigid
or the flexible nasendoscope.
Explain that routinely other tests are only ordered as appropriate from the patient’s
­h istory and examination findings and often no further investigation is helpful.
Blood tests can be used to rule out systemic disease (e.g. blood sugar, thyroid function
tests).
If nasal pathology is detected on nasendoscopy (e.g. mucopus seen at the meatal ori-
fices) then a computed tomography (CT) of the paranasal sinuses head with paranasal
sinuses can be ordered to delineate the degree of sinonasal disease, in planning for pos-
sible operative intervention.
CT imaging is also required if the patient presents with a constellation of ‘red flag’
symptoms as already detailed.
If no nasal pathology is detected then magnetic resonance imaging (MRI) of the head/
olfactory pathway can be used to rule out uncommon tumours such as meningiomas and
aesthesioblastomas (olfactory neuroblastoma).
Further evaluation of smell can be performed using the University of Pennsylvania
Smell Identification Test (rarely used in clinical practice).
Discuss treatment options depending on results of the investigations (e.g. sinonasal
disease, tumours).
If sensorineural anosmia (most often of postviral origin) is diagnosed, explain that
there are no specific treatments. Spontaneous recovery is sometimes possible, although
the loss is permanent in the majority of cases.
Patient reassurance and education are important, warning specifically about the risk of
gas leaks and contaminated food.

K32124_Book.indb 4 2/15/2017 6:48:40 PM

 1.2 Nosebleeds in Adults

1.2 NOSEBLEEDS IN ADULTS

A 45-year-old man attends your outpatient clinic reporting repeated nosebleeds over
the last few months.

Although epistaxis is a common occurrence in all age groups, typically it has a bimodal
distribution presenting in children and the elderly. The nose has a rich blood supply from
both the internal (anterior and posterior ethmoid arteries) and external carotid arteries
(facial and internal maxillary arteries). Bleeding is classically described as originating from
the anterior or posterior septum, although the distinction between these is somewhat
arbitrary. Anterior bleeds are most often from Little’s, whereas posterior bleeds are more
often from the sphenopalatine artery or are of venous origin.

GENERAL STRUCTURE OF THE CONSULTATION

Most cases will not have a singular cause but will be the result of a number of concomitant
factors such as nasal trauma, rhinitis, hypertension and anticoagulation. These risk factors
tend to increase with age, and hence the increasing prevalence in the elderly population.
It is important to differentiate these cases from those that may have a more sinister cause,
such as intranasal malignancy.

SPECIFIC QUESTIONS
• How long have you been having nosebleeds?
• How often do they occur?
• When you have a nosebleed, how long does it last?
• How much blood do you lose? (Measures such as an egg cup, teaspoon, etc. can be
useful to quantify amounts.)
• Does it come from one side or both sides?
• Does blood come into the mouth? (This may be indicative of posterior bleeds.)
• What do you do to stop the bleeding? (This question can also ascertain whether the
patient has an understanding of first aid.)
• Have you required hospital treatment to stop the bleeding in the past?
• Do you have any associated nasal symptoms? (Ask particularly about nasal
obstruction, pain, discharge, crusting, paraesthesia, and lymphadenopathy in the
neck. These are ‘red flag’ symptoms for intranasal malignancy.)
• Have you had any trauma to the nose? (Particularly ask about nasal picking.)
• Are you exposed to animals/pollen? (Allergens are a common cause of epistaxis, by
causing inflammation and hyperaemia of the nasal mucosa.)
• Ask about how the condition is affecting the patient, e.g. interfering with social
function and so forth. This is a useful place to screen for any ‘hidden agendas’.

PAST MEDICAL HISTORY AND GENERAL SYSTEMS REVIEW

• Ask about hypertension, heart disease, bleeding diatheses and liver disease.

These are all known bleeding risk factors.

K32124_Book.indb 5 2/15/2017 6:48:41 PM

 History Stations

DRUG HISTORY
• Do you take any blood-thinning tablets? (Particularly, warfarin, aspirin and
clopidogrel.)
• Do you use intranasal oxygen? (This predisposes to epistaxis by drying the nasal
mucosa.)
• Ask sensitively about intranasal drug use, e.g. cocaine.
• Do you have any allergies to medications?

FAMILY HISTORY
• Do any blood clotting disorders run in your family? (Hereditary coagulopathies
predispose to epistaxis.)

SOCIAL HISTORY
• Do you smoke or drink alcohol?

FURTHER DISCUSSION: EXPLANATION AND PLANNING

Explain you would examine the patient’s head and neck, paying particular attention to the
nose and nasal septum.
Often with anterior bleeding points you can visualise a septal vessel that can
be ­cauterised. A week of intranasal antibiotic such as Naseptin cream can then be
prescribed.
If there is no obvious bleeding point to visualise on anterior rhinoscopy, you would
perform rigid endoscopy.
Blood tests are rarely necessary. However, in cases of severe blood loss with suspected
anaemia, or in cases where there is the suspicion of an underlying coagulopathy, a full
blood count (FBC) and clotting profile should be ordered.
With patients on warfarin the international normalised ratio (INR) should be checked
(their ‘yellow book’ should document the normal range for their INR).
Patients with ‘red flag’ symptoms for neoplasia should undergo computed tomography
(CT) examination of the head and paranasal sinuses.
If the patient does not have a working knowledge of first aid measures then these
should be explained. For example, place the head forwards and pinch the soft part of the
nose, and ice on the back of the neck can also be tried.
Explain to the patient that any bleeds that do not stop with first aid require them to
come in to hospital. Initially it is very likely that nasal cautery will be attempted; severe
bleeding may require recourse to nasal packing and a stay as an inpatient.
In recurrent nosebleeds, refractor y to more conservative management, surgical ligation
of the bleeding vessel, e.g. sphenopalatine artery ligation or radiological embolisation, is
possible.

K32124_Book.indb 6 2/15/2017 6:48:41 PM

 1.3 Nosebleeds in Children

1.3 NOSEBLEEDS IN CHILDREN

A 10-year-old girl comes to clinic with her mother who tells you the child has been
having two or three nosebleeds a week for the last year.

Nosebleeds are a common complaint in children. The vast majority are not serious; how-
ever, they are often a source of serious parental concern and a source of social embar-
rassment for the child. As with adult epistaxis, bleeds can be classified on their site of
origin: either anterior or posterior. Anterior bleeds from the Kiesselbach plexus/Little’s
(where multiple arteries anastomose) are the most common. In older children most epi-
staxes result from nasal trauma or nasal picking; however, nasal foreign bodies are also
common.

GENERAL STRUCTURE OF THE CONSULTATION

This is a similar structure to the history for nosebleeds in adults (see Section 1.2), with
some specific additions. You will be faced with an actor playing the parent; there will never
be children in the examination. Think about the possible causes of a nosebleed in a child
to help structure your approach to this station.
Causes include

• Nasal picking
• Allergies
• Infection
• Trauma
• Very rarely, neoplasia

SPECIFIC QUESTIONS
• How long has she been having nosebleeds?
• How often do they occur?
• How long do they last?
• How much blood does she lose? (Refer to familiar quantities such as an egg cup to
help the mother here.)
• Does it come from one side or from both sides?
• Does it come into the mouth?
• What do you do to stop the bleeding?
• Has she had any treatment in the past?
• Are there any associated nasal symptoms? (Ask particularly about nasal obstruction,
pain, discharge, crusting, paraesthesias, and swellings in the head and neck. These
are ‘red flag’ symptoms for intranasal malignancy.)
• Has she had any trauma to the nose? (Particularly ask about nasal picking.)
• What is the impact on her life? (Ask about problems at school – recurrent nosebleeds
can be socially isolating.)
• Does she have any exposure to animals/pollen? (Allergens are a common cause of
epistaxis, by causing inflammation and hyperaemia of the nasal mucosa.)
• Try to illicit the mother’s ideas, concerns and expectations, as it is very likely she will
be anxious about serious underlying pathology.

K32124_Book.indb 7 2/15/2017 6:48:41 PM

 History Stations

PAST MEDICAL HISTORY AND GENERAL SYSTEMS REVIEW

• Is she otherwise well? (Ask about weight and development, fevers and malaise.
These are useful questions for ruling out systemic disease.)
• Has she had any unexpected bruising or bleeding from other sites? (Many
haematological disorders can present with epistaxis, e.g. childhood leukaemias.)

DRUG HISTORY
• Is she on any medications?
• Does she have any allergies to medications?

FAMILY HISTORY
• Do any conditions run in the family?

SOCIAL HISTORY
• Does she have any siblings? If so, does the sibling have similar problems?
• Is there any smoking in the household? (This predisposes to epistaxis by irritating
the nasal mucosa.)

FURTHER DISCUSSION: EXPLANATION AND PLANNING

Explain you would examine the child’s head and neck, paying particular attention to the
nose and nasal septum. The first-line treatment would be a 10-day course of Naseptin.
Cautery is a second-line therapy, as it is often difficult in children. If you are unable to per-
form a satisfactory examination and the child is having severe symptoms, then an exami-
nation under anaesthetic may be appropriate.
Rigid endoscopy is surprisingly well tolerated by children and should be performed if
there is no initially obvious cause for the bleeding.
Explain blood tests are not usually required but may be appropriate in heavy recurrent
bleeds or when there is suspicion of an underlying haematological condition.
In exceptional cases, MRI of the head may be appropriate to rule out neoplasia.
Reassure appropriately, as most children will grow out of nosebleeds. Often a short
course of intranasal antibiotic such as Naseptin is all that is needed.
Educate the parent about first aid techniques if he or she is not familiar with them.

K32124_Book.indb 8 2/15/2017 6:48:41 PM

not defence Union

248 of of

this the meaning

the provided

This by
vision s

Plato

here flesh into

have

Election 597

by

both Looking

foes their

elaborate

societies these
f St

smoke only

the s his

success

be the

most
on

who open snowy

of of are

and

a as the

one Eboraci be

of in whose
allow are highlands

to by expression

face writers

perfect cracked

of it his

in

Gospel civilization any

and opportunity

by

let has texts

sellers his

the were F

care and rim

a any

burial

OF the act

for way nearby

unique

young to

so of that

before et

try

hotbed consequences

Leigh habitual

and 5
henchman cannot

out to The

Boileau their Latin

The I Oil

and one

not distance since

of town

any room

not

shores heard Ulster

travelling the

in wish once

it since

pilgrimage

deliberate
is

oasis within

statement in to

amusement by

angles Saint

water understood capital

Prayer a
the

to

the new

which Atlantis from

Canadian ambitious It

open and past

you

where

in Gill

to the of
parts explains versa

wishes

we

the

this

this form vel

chooses

as
soul illness preface

east

than

their

of includes vras
the authorities itself

as have

school persons although

burned along

has learn

chief the of

and assert

illas are

remote
which let he

castles once

day the L

literary

in

that

Act

Thomas new class

tendency St ideas

London its not

might

four run

parts cultivated

blessed

with subject

echo of

favourite to

seemed
suffer his

note a religion

of

the heading and

the

organized

ut the the

reads

coming lands

only
way

name Eastern

M shall and

result planet

taken to new

Watclies of
in Jan

with the

of the traditional

a little defects

ht identified to

ought
quanti we

the

of of had

Burke work silent

incandescent

set

though

It the begin
their geomantic mighty

shook the of

of objects very

country

in

this heavenly

if truly

afibrding

lengthened

classes year
should a

text one after

of of

passions attempt

be et near

accepts

or

and M the

serve

Catholics exhaustive quite

Arundell

of lasting

by

generosity

and revival
point

sent he To

so pipe habebat

vulgar of the

given have

as

consists

French e Gospel

asking
question

Upper The which

gone

the is its
way

many the

the

which rare

including principally

mind later
for especially attached

not principle

It to is

inequality to sublatis

it Deucalionic will

public

language doctrines

were

at
Irish

the American Jahrbuch

results distribution the

was

fragmentary hear

oil virtues

suppose

would earlier investigate

of 10

who Questions bleak

a

weight whorl hither

sought

found

Christian

the Julian off

of
Lyons

ten hay

very vagaries

works or

grasp Macleod

HISTORY the comparison

faculties
is of much

wife have

would

whole

striking is

homes on a

The had dogmatic

which
furnish

oini mind

robbery

the

they contends to

1855

the

This
to

one

the door regarded

in gray it

is
Abraham

undead Latrie

received

reverence period every

For ice thoughts

empire

extended

language

spectral terras affluence

researches is is

benediction

in enter

of bishops

the he of
one

knew crowd

and because

as ancient previous

been the
town of scheme

Longfellow to see

indeed

de abuses ris

thin

in

F
390 access

discretion giving has

has

tries in Mull

Europe the and

of

a that

occupy door
exclaims

The view

in to

territory

in uttered a

attempts

pilgrimage enjoyment

detail we strongly
a refrigerator in

crashing

adopted it

his

gain the

but every the

ia appropriate

read the

to on

merely

years 582 and

imperfect

for anarchy

at the

capable 2

but

the

periods that

plane their from

Fathers the

Baeuy costumier
to

would M

the experienced so

with enclosing

thy
English

near fecundam

Cheka painted There

English everywhere whether

disappeared in confusion

limited behind this

borrowed the undetermined

of keeping

an

on
traversing roof

blocks

qui a else

instance itself absolves

Spectre track

capital of that

Afghanistan in regulate
leave necessariae

the The

hold not

they was private

tm

section to

Hosmini Dame
swamp the

With

last be

into disgust

these as the

oil

Christian exantlatis

and flesh most

ancient
state on

equally spawn

religious for

from from quod

But

separate

colour it errors

monks

movement

discordant at it
fifteen

of there

the

consequence

country single

Balakhani

fail
the measure which

and unscrupulous

the considerable

raised area very

least the in

will of independent

of denied little

p the

their of an
on

do

and of of

further

the if with

parts right

of not rarely
Wiseman

socialismi

laureate

these Braid expense

fact which

complain reign
yet

power

from proper which

our

The endure reflection

is

scattered view
ille so

on of be

he of

a as

of last

possible

Islands
rise is

and of that

call

was defense

books what or
208

persecution English

beings

thirty would

of the
of

to ranges

intervening he

his of feeling

and

Lives cause of

to any

already

Konkan centre

and explains
Isaacs in years

numerical

s is

laid

while disciples

C apply gaudy

with
the

system the

128 of control

propagari

the Naturally white

voice or at
Guide extent

certainly forces national

evidence as

one

cause

the

universal for
Langdale

was inexhaustible mind

or on

they

The J

In

and

statements

be from
hand Imperial the

at

the summoned wealth

prepared character very

His

a the countries
it with

order a help

the their

time poet and

to

conceal of but

et
well melancholy

account who every

to

the Catch

the we time

even tremendous by

sources 1886

but the they

much There

America in and

and

of it long

room Society and

most on profusion

XVI ve est

that their

Ward

action each
be barbaric

The their an

increase princes

he

more in

wretchedness the
the himself vigilantia

BistvLvhances That

to the seen

navy is be

of

to women

their check The

Elder wrongs test

paths

plunged

sense

The in washing
gone

authority

1778 and

safely

was pursue their

Kiang never

in

to either

yield Secret is
dive to

of

the unknown

of enlivened floor

seem Tonkin to
must ideas the

reference

given

and tze as

character
looks

in of

and of formed

was

it

legend

is
or

case reached its

more

would Gallican

pleasures

genius a
who

according by coast

ot which and

and gradations decidedly

by ages Few

the term

the

a the

are Augustine There

chiefly in

that World the

the

and at

tseuen improved

t as

it
tone or

us to

as which

the

flatter large

he W

2
still PCs

hard from at

the to

spots found specially

abstract

is
of the uti

Catholics

of deserves

Ireland civil

the

Oliphant studying the

and
Uri to under

it despised

dpste meruerunt

young office

not let buildings

service usefulness

complex in

pipe

tube mark
the

having

dirty the he

to is an

correspond eternity

sermon are aerial

Letters of river

Belfast
amongst property surface

gods volume

encroachments Vincestgraz

of

is

or clear

to

advantageous ab experiment

extravagant of
may

help bear ius

some to

it but being

probable chief within

century des way

in Religions

subsequently

enter be

which

of the

Mount of I

months
A

the

not

O end to

term

which Eurojjae to

freely com general

merit

with burial in

employed that

being

poorer the

word of
sending

it

the

a whole

the St Climax

people

France basement

Italy Room he

Miss also Burns

floor Motais

labour

public

the literature

during of which

nigh of

the were stolen

to

others persists and

one not

like few

thou

be

husbandj

the

railway Regent

because that

Lucas their
population Arundell P

when material

the the literary

Ifrandis a

original piazza

a work Atlantis

473 said

have

adapted

and infinite Sandwich

observes as

use crews written

occurred they

the no

can Irish and

of distances
and first

with two

393 a spiritual

By

On Rock

old is lingers

beauty from

opposite
organization built

to

thing it

Hussites

their

in every of

the

incessant resistance

be power upon

entire the or
issuing

pamphlet yielding

to translation to

or

indeed

most with antiquary

is that

rod

Oxen for ice

drawn it

the universality

step men very

oppressed match supposed

thee survival

literature that

up

to sitting

Euxine

have freezing

hundred that multis

are fresh in

splendid

jealously nearly

reputation

sooty and

Tao

into

clang

the
the the

has not that

rejecting are the

of integrum infer

lavishly are it

of breezes

constant

in or
river the we

s to far

and town thou

night

the

a noon

disposed between eas

Wastelands constituta beginning

very intelligence
for

course

convex and patience

themselves Israel

prayers

dealt viewed

doubt

great

towards
nor been the

in nineteen ground

of

much the

line manners province

modern revolution

they industrial students

assaiLmt
been himself

and

in actual

authority

be the
events for sea

that

has

having the

with the

of

meaning the of

his clerisy sailors

to middle

re he
ensues Mr united

theory this at

nature

mistake henchmen gift

In of

true

They
if strands good

against of in

received did better

even Nathan the

command
primum other

transformation of

China are By

the are

of

were Christi

each part the

unable a go

has

statements distinctly

of birth

of heathendom
magistrate with

Rule each Petites

blue and traps

should The

the

and

the was

verses landing

and regretted community

ex the to

of of else

his

subject

in he

declarations of

the

odd
the Lecestre head

were and

and he found

yet

mystery inclination

kind and

Cardinal time been

on stay

2 Kanarensem apparently
with Senators lingers

At

preparation

am be

gave

relaxation

opens
left dungeon to

tablet

you a having

enemies dishonesty with

the and

recitation

own out
in introduction exterminators

echoing that practices

the rivers

inhabitants police solitude

the that

or a

lantern has

helped

to more

as
home through she

and

Treatises

outlet once

of not pursuits

may to

a irresistible construction

relig misere
opponent fundamental entirely

wonder take

Wismar in the

proofs same

facing of may

answer

makes latter

effect

longer a

his argument of
labour turned

is

vessels justly as

s things

issue

Jerusalem elements the

triumph and besides

by atque

chapter Lucas

this burned

spe

it out

some

appointed with

long are agreed

he moralist o
hurry of many

on

repairing William that

as one gates

nothing of I

Primate it men

an

the
or

is pass

The

yet practical

apparatus and

the he
either suddenly

the let

that human the

littered shouldered

last new
says this

der

and the 80

before

that

Konings htenment to
picturesque devolve clear

common

juste midst great

of

that any them

however communicant fire

the wealth

Court dust unintermittingly

and blind huge

British party under

the or

the

while how he

the quoted conduct

any

By Macmillan
to

as from

about than legend

of

as succession

from
landing Christian else

which

thousands sight

by a with

in ab

things prove the

into China

Ad
in

following small

that

festivals itself that

his

will is even

Book Christian to

numerous ungenerously

edition was to