FMGE 2025 Practice Questions

Q: A patient presents with a fish bone stuck in the pyriform sinus. During the removal procedure, there is accidental nerve injury. Which nerve is most likely to be damaged?

Internal branch of the superior laryngeal nerve. ***Internal branch of the superior laryngeal nerve***- This nerve branch runs immediately beneath the **mucosa** of the pyriform sinus before piercing the thyrohyoid membrane, making it highly susceptible to injury during instrumentation or foreign body manipulation in this area.- It is the principal **sensory nerve** supply to the laryngeal cavity above the vocal cords; injury would result in loss of sensation in this region, often leading to laryngeal incompetence and aspiration.*Recurrent laryngeal nerve*- This nerve is located more inferiorly within the **tracheoesophageal groove**, supplying motor innervation to nearly all intrinsic muscles of the larynx.- Injury to the recurrent laryngeal nerve would cause **vocal cord paralysis** and hoarseness, which is less likely given the specific location of minimal trauma in the high hypopharynx.*Glossopharyngeal nerve*- The glossopharyngeal nerve (**CN IX**) supplies sensation to the posterior third of the tongue, tonsils, and **oropharynx**, and is not directly related to the pyriform sinus mucosa.- Injury would primarily manifest as loss of the **gag reflex** and sensory deficits in the posterior pharynx, which is topographically distant from the immediate site of endoscopic manipulation in the hypopharynx.*External branch of the superior laryngeal nerve*- This nerve primarily provides **motor innervation** to the **cricothyroid muscle**, responsible for lengthening and tensing the vocal cords (pitch control).- Anatomically, it descends alongside the **superior thyroid artery** and is situated deeper and more anteriorly, placing it at less risk of superficial mucosal trauma than the internal branch.

Q: Human papillomavirus (HPV) infection is most strongly associated with which of the following head and neck cancers?

Oropharyngeal carcinoma. ***Oropharyngeal carcinoma***- HPV (high-risk types, especially **HPV-16**) is the primary etiologic agent for a distinct and increasing subtype of **oropharyngeal squamous cell carcinoma (OPSCC)**, mainly affecting the tonsils and base of the tongue.- HPV-positive OPCs are biologically distinct from those caused by tobacco and alcohol, typically present in younger patients, and have a significantly improved prognosis.*Nasopharyngeal carcinoma*- The strongest viral association with nasopharyngeal carcinoma (NPC) is the **Epstein-Barr virus (EBV)**, not HPV.- NPC is also strongly linked to dietary factors (salted fish) and genetic predisposition, often showing a different geographic distribution.*Hypopharyngeal carcinoma*- This cancer is predominantly caused by heavy use of tobacco and alcohol, placing it firmly in the category of traditional **squamous cell carcinoma** risk factors.- HPV positivity in hypopharyngeal cancers is rare and not considered a major causative factor.*Laryngeal carcinoma*- Laryngeal squamous cell carcinoma is overwhelmingly associated with **tobacco smoking** and, secondarily, alcohol use.- While HPV can cause laryngeal papillomatosis, its definitive causal role in invasive laryngeal *carcinoma* is weak and inconsistent compared to its strong association with the oropharynx.

Q: The image below shows a lateral view of the face with a highlighted region in front of the ear. Which type of abscess is most likely indicated in this area?

Luc's abscess. ***Luc's abscess*** - This is a **subperiosteal abscess** located in the **preauricular region**, on the external surface of the squamous part of the temporal bone, which corresponds to the highlighted area. - It is a rare complication of **acute otitis media** or **mastoiditis**, occurring when infection spreads through the tympanosquamous suture. *Citelli’s abscess* - This abscess is located at the **tip of the mastoid process** and extends into the **digastric triangle** of the neck, which is posterior and inferior to the area shown. - It is formed when pus from mastoiditis tracks along the posterior belly of the **digastric muscle**. *Bezold's abscess* - This is a **deep neck abscess** that forms when infection erodes through the medial aspect of the mastoid tip and spreads inferiorly into the neck. - The swelling is located deep to the **sternocleidomastoid muscle**, far from the preauricular location shown in the image. *Zygomatic abscess* - This abscess forms over the **zygomatic process** of the temporal bone, which is located superior and anterior to the external auditory canal. - It results from the spread of infection from mastoid air cells into the **root of the zygoma**, a location slightly more superior than what is highlighted.

Q: A patient presents with enophthalmos and periorbital ecchymosis after being hit by a ball. What is the most likely diagnosis?

Orbital blowout fracture. ***Orbital blowout fracture*** - The clinical presentation of **periorbital ecchymosis** (bruising around the eye) and **enophthalmos** (posterior displacement of the eyeball) following blunt trauma from an object like a ball is classic for an orbital blowout fracture. - This injury often involves the thin orbital floor, leading to herniation of orbital contents into the maxillary sinus and potential entrapment of the **inferior rectus muscle**, which can cause **diplopia** (double vision) on upward gaze. *Zygomatic fracture* - A zygomatic (cheekbone) fracture typically causes facial flattening, a palpable **step-off deformity** along the orbital rim, and numbness over the cheek due to **infraorbital nerve** injury. - While it can be associated with an orbital floor fracture, isolated **enophthalmos** is not its primary presenting sign; facial asymmetry is more prominent. *Nasal bone fracture* - This is the most common facial fracture and presents with localized pain, swelling, deformity of the nasal bridge, and **epistaxis** (nosebleed). - **Enophthalmos** is not a feature of an isolated nasal bone fracture, although periorbital ecchymosis can be present. *Le Fort I fracture* - This is a horizontal fracture of the maxilla, resulting in a **"floating palate"** where the entire upper dental arch is mobile. - It is characterized by **dental malocclusion** and does not typically cause the isolated orbital signs of **enophthalmos** seen in this case.

Q: A patient presents with a history of fall and is found to have bleeding from the ear on examination. What is the investigation of choice?

CT Temporal bone. ***CT Temporal bone***- This is the **investigation of choice** for suspected **temporal bone fractures**, which are strongly suggested by **otorrhagia** (bleeding from the ear) following trauma.- CT provides superior resolution for visualizing the intricate bony anatomy of the temporal bone, allowing for the precise identification of fracture line extension (e.g., *longitudinal* or *transverse*) and related complications like **ossicular chain integrity** or **hemotympanum**.*CBC*- Complete Blood Count (CBC) is part of the initial trauma workup to assess general systemic status (e.g., potential **blood loss** or baseline hemoglobin), but it is not a diagnostic tool for identifying the source of bleeding (the anatomical injury).- It provides no structural information necessary to localize the injury or determine the presence of a **skull fracture**.*MRI Brain*- **MRI** is optimized for visualizing **soft tissue injury** (e.g., brain contusions, nerve damage) and is poor for detailing acute bony fractures, especially the fine structures of the temporal bone.- It may be used if profound neurological deficits or specific **intracranial injury** (e.g., vascular dissection or brain parenchymal damage) are suspected, but not as the primary diagnostic imaging for bony trauma.*X-ray Skull*- **Plain X-rays** lack the sensitivity and detail required to reliably capture the subtle, complex fractures of the **temporal bone** or skull base.- This method is largely superseded by **CT scans** for trauma evaluation due to high rates of **false negatives** regarding skull base injuries.

Q: A 60-year-old man complains of gradual hearing loss over several years. He reports difficulty hearing conversations, especially in noisy environments, and has trouble perceiving high-pitched sounds. There are no episodes of vertigo, tinnitus, or ear fullness. What is the most likely diagnosis?

Presbycusis. ***Correct: Presbycusis*** - It is the most common cause of **gradual, bilateral sensorineural hearing loss** in the elderly, characterized by a protracted course over several years. - The defining feature is difficulty hearing **high-pitched sounds** (loss of high-frequency hearing) and **poor speech discrimination** in noisy environments, consistent with the clinical picture. - This is age-related cochlear degeneration, typically beginning after age 50-60. *Incorrect: Meniere's disease* - This condition is defined by the classic triad of **episodic vertigo**, **fluctuating (usually low-frequency) sensorineural hearing loss**, and **tinnitus** with aural fullness, none of which are present. - The hearing loss is typically episodic and unilateral, contrasting with the patient's chronic, gradual deterioration. *Incorrect: Otosclerosis* - This disorder causes **conductive hearing loss** (or mixed loss) due to abnormal bone growth around the **stapes footplate**, often presenting earlier in life (20s–30s). - Unlike the gradual, high-frequency loss seen here, otosclerosis causes reduced sound transmission to the inner ear, typically improving speech perception in noise (**paracusis Willisii**). *Incorrect: Acoustic neuroma* - Although it causes sensorineural hearing loss, it is typically **unilateral** and often asymmetrical, frequently accompanied by **unilateral tinnitus** and imbalance. - This diagnosis is less likely in a patient with **bilateral**, gradual hearing loss without unilateral symptoms or specific cranial nerve involvement.

Q: A diabetic male presents with facial pain and blackish discoloration in the nose. The CT image shows bone erosion and sinus involvement. What is the most likely diagnosis?

Rhino-orbital-cerebral mucormycosis. ***Rhino-orbital-cerebral mucormycosis*** - This diagnosis is strongly suggested by the clinical triad of an **immunocompromised state (diabetes)**, the presence of a **black necrotic eschar** in the nose, and imaging evidence of **bone erosion**. - Mucormycosis is an **angioinvasive** fungal infection that causes tissue infarction and necrosis, leading to the characteristic black discoloration and rapid spread through tissues. *Acute bacterial sinusitis* - While it causes facial pain and sinus inflammation, it typically presents with purulent discharge and does not cause a **black necrotic eschar**. - **Bone erosion** is a very rare complication and not a characteristic feature, unlike in invasive fungal disease. *Allergic fungal sinusitis* - This is a **non-invasive** hypersensitivity reaction to fungi and does not cause tissue destruction, necrosis, or bone erosion. - It is characterized by the presence of thick **allergic mucin** containing eosinophils and fungal hyphae within the sinuses, often in atopic individuals. *Nasal polyposis* - This condition involves benign mucosal growths that cause chronic nasal obstruction and anosmia, not acute facial pain or tissue necrosis. - Nasal polyps may remodel bone over time due to pressure, but they do not cause the rapid and destructive **bone erosion** seen in this invasive process.

Q: A tympanometry graph is shown below. An arrow indicates a shallow peak at pressure = 0 daPa. What is the most likely diagnosis based on the tympanometry result shown?

Type As. ***Type As*** - This tympanogram shows a peak pressure within the normal range (around 0 daPa) but with significantly reduced static compliance (a shallow or stiff peak), which is characteristic of a Type As curve. - This finding indicates a stiff middle ear system and is commonly associated with conditions like **otosclerosis**, **tympanosclerosis**, or **ossicular fixation**. *Type A* - A Type A tympanogram represents a **normal** middle ear system, characterized by a sharp peak at normal pressure (around 0 daPa) and normal static compliance (0.3-1.6 mmho). - The graph shown has abnormally **low compliance**, distinguishing it from a normal Type A curve. *Type B* - A Type B tympanogram is a **flat line** with no discernible peak, indicating very poor compliance of the tympanic membrane across all pressures. - This pattern is typically seen with **fluid in the middle ear** (otitis media with effusion) or a tympanic membrane perforation, which is inconsistent with the peaked curve shown. *Type Ad* - A Type Ad tympanogram shows a peak at normal pressure but with **abnormally high compliance** (a deep or hypermobile peak). - This suggests a flaccid tympanic membrane or a discontinuity in the ossicular chain (**ossicular disarticulation**), which is the opposite of the low compliance seen in the provided image.

Q: A patient presents with lung injury and tympanic membrane rupture following a blast exposure. These injuries are characteristic of which level of blast wave effect?

Level I. ***Level I*** - Level I, often equated with **primary blast injury**, results directly from the unique effects of the **blast overpressure wave** on the body. - Air-filled organs are most susceptible; **tympanic membrane rupture** is the most common primary injury, and significant **blast lung** (pulmonary contusion/hemorrhage) is the most lethal. *Level II* - Level II injuries, or **secondary blast injuries**, are caused by objects or fragments energized by the explosion impacting the victim. - These manifest as **penetrating injuries**, lacerations, or embedded foreign bodies, distinct from the pressure effects seen in the lung and ear. *Level III* - Level III injuries, or **tertiary blast injuries**, occur when the victim is displaced (thrown) by the blast wind and subsequently impacts a surface. - This mechanism typically causes blunt trauma, resulting in **closed and open fractures**, crush injuries, and significant blunt head trauma. *Level IV* - Level IV injuries, or **quaternary blast injuries**, encompass all other blast-related injuries not covered by the first three categories. - These include **burns** from flash fire, toxic inhalation exposure, exacerbation of chronic illnesses, and crush injuries from structural collapse.

Q: A professional singer presents with difficulty in raising the pitch of her voice following thyroid surgery. There is no hoarseness, but high-pitched voice production is impaired. Which nerve is most likely injured?

External branch of the superior laryngeal nerve (EBSLN). ***Correct: External branch of the superior laryngeal nerve (EBSLN)*** - The EBSLN innervates the **cricothyroid muscle**, which is responsible for increasing **vocal cord tension** - Injury results in inability to tense the vocal cords, causing **loss of high-pitched voice** production - Crucially, there is **NO hoarseness** because vocal cord adduction (brought together by other muscles) remains intact - Classic presentation: Professional singers or teachers notice difficulty hitting high notes after thyroid surgery *Incorrect: Recurrent laryngeal nerve (RLN)* - RLN innervates all intrinsic laryngeal muscles **except** the cricothyroid - Injury causes **hoarseness** due to impaired vocal cord adduction - This patient has no hoarseness, making RLN injury unlikely *Incorrect: Internal branch of the superior laryngeal nerve (IBSLN)* - IBSLN is purely **sensory** to the supraglottic larynx - Injury causes loss of sensation above the vocal cords, leading to **aspiration risk** - Does not affect voice pitch or motor function *Incorrect: Glossopharyngeal nerve* - Provides motor innervation to stylopharyngeus and sensory to pharynx/posterior tongue - **Not involved in laryngeal function** or voice production - Injury would cause dysphagia and loss of gag reflex, not voice changes

Question 1

A patient presents with a fish bone stuck in the pyriform sinus. During the removal procedure, there is accidental nerve injury. Which nerve is most likely to be damaged?

Accepted Answer

Internal branch of the superior laryngeal nerve

Answer

Recurrent laryngeal nerve

Answer

Glossopharyngeal nerve

Answer

External branch of the superior laryngeal nerve

Question 2

Human papillomavirus (HPV) infection is most strongly associated with which of the following head and neck cancers?

Accepted Answer

Oropharyngeal carcinoma

Answer

Laryngeal carcinoma

Answer

Hypopharyngeal carcinoma

Answer

Nasopharyngeal carcinoma

Question 3

The image below shows a lateral view of the face with a highlighted region in front of the ear. Which type of abscess is most likely indicated in this area?

Accepted Answer

Luc's abscess

Answer

Zygomatic abscess

Answer

Bezold's abscess

Answer

Citelli’s abscess

Question 4

A patient presents with enophthalmos and periorbital ecchymosis after being hit by a ball. What is the most likely diagnosis?

Accepted Answer

Orbital blowout fracture

Answer

Le Fort I fracture

Answer

Zygomatic fracture

Answer

Nasal bone fracture

Question 5

A patient presents with a history of fall and is found to have bleeding from the ear on examination. What is the investigation of choice?

Accepted Answer

CT Temporal bone

Answer

X-ray Skull

Answer

MRI Brain

Answer

CBC

Question 6

A 60-year-old man complains of gradual hearing loss over several years. He reports difficulty hearing conversations, especially in noisy environments, and has trouble perceiving high-pitched sounds. There are no episodes of vertigo, tinnitus, or ear fullness. What is the most likely diagnosis?

Accepted Answer

Presbycusis

Answer

Meniere’s disease

Answer

Otosclerosis

Answer

Acoustic neuroma

Question 7

A diabetic male presents with facial pain and blackish discoloration in the nose. The CT image shows bone erosion and sinus involvement. What is the most likely diagnosis?

Accepted Answer

Rhino-orbital-cerebral mucormycosis

Answer

Acute bacterial sinusitis

Answer

Allergic fungal sinusitis

Answer

Nasal polyposis

Question 8

A tympanometry graph is shown below. An arrow indicates a shallow peak at pressure = 0 daPa. What is the most likely diagnosis based on the tympanometry result shown?

Accepted Answer

Type As

Answer

Type A

Answer

Type B

Answer

Type Ad

Question 9

A patient presents with lung injury and tympanic membrane rupture following a blast exposure. These injuries are characteristic of which level of blast wave effect?

Accepted Answer

Level I

Answer

Level II

Answer

Level III

Answer

Level IV

Question 10

A professional singer presents with difficulty in raising the pitch of her voice following thyroid surgery. There is no hoarseness, but high-pitched voice production is impaired. Which nerve is most likely injured?

Accepted Answer

External branch of the superior laryngeal nerve (EBSLN)

Answer

Glossopharyngeal nerve

Answer

Internal branch of the superior laryngeal nerve (IBSLN)

Answer

Recurrent laryngeal nerve (RLN)

FMGE 2025

ENT

Forensic Medicine

Surgery