Master ENT (Otorhinolaryngology)
for PLAB 1

What the PLAB 1 Tests in ENT (Otorhinolaryngology)

PLAB 1 ENT focuses on common presentations: hearing loss (conductive vs sensorineural), otitis media (acute, chronic, glue ear), tonsillitis/Quinsy, epistaxis management, and neck lumps (branchial cyst, thyroglossal duct cyst, lymphadenopathy). Candidates must know red flags (e.g., stridor, unilateral nasal polyps in adults), first-line antibiotics (amoxicillin for acute otitis media, co-amoxiclav for sinusitis), and when to refer urgently (suspected malignancy, peritonsillar abscess, acute epiglottitis). Diagnostic tests (Rinne and Weber tuning fork tests, audiometry) and criteria for tonsillectomy (e.g., 7 episodes in 1 year, 5 per year for 2 years, 3 per year for 3 years) are frequently tested. Drug doses and routes (e.g., adrenaline nebulised for croup) are expected.

High-Yield Concepts

• Rinne & Weber Tuning Fork Tests: Rinne: normal = AC > BC (positive). Conductive loss = BC > AC (negative). Sensorineural loss = AC > BC but both reduced. Weber: lateralises to better ear in sensorineural loss, to worse ear in conductive loss.
• Acute Otitis Media (AOM) Management: First-line: amoxicillin 500 mg TDS for 5 days (or clarithromycin if penicillin allergic). Analgesia (paracetamol/ibuprofen). No decongestants or antihistamines. Refer if mastoiditis (post-auricular swelling, fever, ear protrusion) or intracranial complication suspected.
• Glue Ear (Otitis Media with Effusion): Common in children aged 2-5. Diagnosis: type B tympanogram. Watchful waiting for 3 months; if persistent with hearing loss >25 dB, consider grommet insertion. Adenoidectomy if coexistent adenoid hypertrophy.
• Tonsillectomy Indications (Paradise Criteria): ≥7 episodes of acute tonsillitis in 1 year, or ≥5 per year for 2 years, or ≥3 per year for 3 years. Each episode must be documented with sore throat, fever ≥38.3°C, cervical lymphadenopathy, tonsillar exudate, or GAS culture positive.
• Epistaxis Management: First aid: sit forward, pinch soft part of nose for 10-15 minutes. If persistent: topical lidocaine with phenylephrine (co-phenylcaine), then silver nitrate cautery or anterior nasal packing (e.g., Merocel). Posterior epistaxis: Foley catheter or balloon packing, refer to ENT.
• Acute Epiglottitis (Red Flag): Presents with stridor, drooling, dysphagia, fever, and tripod position. Do NOT examine throat. Immediate senior ENT and anaesthetic review. IV ceftriaxone (or cefotaxime) plus dexamethasone. Prepare for intubation in theatre.
• Neck Lumps: Congenital vs Malignant: Branchial cleft cyst: along anterior border of sternocleidomastoid, presents in young adults. Thyroglossal duct cyst: midline, moves with tongue protrusion. Lymphadenopathy: if >2 cm, firm, fixed, or in supraclavicular area, suspect malignancy (refer for USS and FNA).
• Croup (Laryngotracheobronchitis): Barking cough, stridor, hoarseness. Mild: single dose dexamethasone 0.15 mg/kg oral. Moderate-severe: nebulised adrenaline (5 mL of 1:1000) plus dexamethasone. If no response, refer to paediatrics for possible intubation.

Common Traps in ENT (Otorhinolaryngology) Questions

• Confusing conductive and sensorineural hearing loss: remember Rinne negative = conductive loss, not sensorineural.
• Giving antibiotics for viral pharyngitis or otitis media without confirming bacterial cause (e.g., Centor criteria for GAS tonsillitis).
• Forgetting that unilateral nasal polyps in adults are suspicious for inverted papilloma or malignancy, not simple polyps.
• Using ototoxic ear drops (e.g., gentamicin) in a patient with a perforated tympanic membrane; only non-ototoxic drops like ciprofloxacin are safe.
• Missing acute epiglottitis because you attempted throat examination without airway support.
• Assuming all stridor in children is croup; consider foreign body inhalation if sudden onset with no prodrome.

How to Revise ENT (Otorhinolaryngology) for the PLAB 1

Prioritise tuning fork test interpretation, antibiotic choice for common infections (AOM, sinusitis, tonsillitis), and red flag symptoms (stridor, unilateral nasal symptoms, neck lump characteristics). Questions often present a clinical scenario asking for next step (e.g., 'What is the most appropriate management?') or diagnosis. Practise distinguishing conductive vs sensorineural hearing loss using audiometry and tuning forks. Memorise tonsillectomy criteria and epistaxis first-line treatments. Focus on NICE and SIGN guidelines for acute sore throat and otitis media. Review congenital neck lump anatomy and when to suspect malignancy. Use past PLAB 1 questions to identify pattern of recurrent themes like croup management and peritonsillar abscess drainage.

Practise it: MedLumen has 50 ENT (Otorhinolaryngology) questions for the PLAB 1, each with a full explanation and references.