DOHNS

 Part  II  OSCE,  Glasgow,  May  9th  2013  

32  stations  in  total:  23  written  stations,  5  stations  with  actors,  2  prep  stations,  2  rest  stations  

Exam  Centre  Layout:  

Written  stations  were  laid  out  in  one  room.  Clinical  stations  in  another  room.  There  was  a  rest  
station  immediately  prior  to  entering  each  room.  You  rotate  from  station  to  station  immediately  
after  finishing  the  previous  one,  in  order.  There  is  7  minutes  per  station,  with  a  bell  at  the  end.  There  
is  no  extra  time  for  reading  instructions,  except  for  the  2  actor  stations  which  had  a  prep  station  
beforehand.  At  these  you  have  7  minutes  to  sit  and  read  the  instruction  sheet.  The  written  stations  
consisted  of  one  or  more  image/picture/audiogram/specimens  to  interpret  and  answer  questions  
on.  I  personally  found  time  to  be  quite  tight  at  these  and  was  often  just  finishing  the  last  question  
when  the  bell  went  (I  have  always  tended  to  write  too  much  though!).  

Clinical  Stations:  

1. Flexible  Nasendoscopy  for  investigation  of  hoarseness  (preceded  by  prep  station)  

a. Explain  procedure  to  patient  

b. Perform  procedure  on  mannequin  

c. Photo  of  larynx  with  tumour  on  vocal  cord  –  asked  to  draw  your  own  diagram  and  
label  

2. Mother  of  14  year  old  boy  attending  for  myringoplasty  with  subtotal  central  TM  
perforation,  keen  swimmer,  mildly  reduced  hearing  (preceded  by  prep  station)  

a. Explain  the  nature  of  the  problem  

b. Detail  the  procedure  

3. 26  year  old  woman  referred  by  GP  for  consideration  for  tonsillectomy  due  to  recurrent  
tonsillitis  

a. Take  her  history  (on  direct  questioning  she  reported  a  history  of  bleeding  post  
dental  extraction)  

b. Discuss  tonsillectomy  and  associated  risks  

4. Examine  a  man’s  ears  &  facial  nerve  (not  balance  system).  Actor  feigned  a  left  conductive  
hearing  loss  

5. Speak  to  the  daughter  of  a  75  year  old  man  with  dementia  who  was  admitted  through  
A&E  with  severe  epistaxis.  She  knew  very  little  of  her  father’s  medical  history.  

a. Discuss  possible  causes  of  epistaxis  (she  did  not  know  any  of  his  medical  history)  

b. Discuss  management  and  different  possible  surgical  approaches  

1. Audiology  –  draw  various  audiological  symbols  (right  air  conduction,  masked  right  bone  
conduction,  unmasked  bone  conduction,  left  air  conduction  with  patient  unable  to  hear  
lowest  frequency  tested).  Several  audiograms  to  interpret,  but  not  simply  give  diagnosis,  
asked  to  predict  if  Rinne  test  in  the  persons  left  ear  would  be  positive,  negative,  or  unable  to  
say.  

2. Questions  about  tracheostomy  

a. Label  instruments/  state  use:  Different  types  of  tracheostomy  tube,  tracheal  dilator,  
another  instrument  which  in  retrospect  was  probably  some  form  of  skin  hook!  

b. 3  Indications  for  tracheostomy  other  than  airway  obstruction,  etc  

3. Attic  Cholesteatoma  –  describe  image,  presenting  symptoms,  type  of  hearing  loss,  
management,  risks  of  surgery  

4. Causes  of  dizziness  –  images  with  some  questions  following  each.  Tricky.  First  was  sagittal  
MRI  brain  with  atypical  multiple  sclerosis  picture  I  think.  Second  was  cholesteatoma  and  ?  
perilymph  fistula  on  CT.  Third  was  Tullio  phenomenon  based  on  the  follow-­‐on  question  but  
no  idea  of  pathology  on  coronal  CT,  massive  cystic  dilatation  of  temporal  bone  surrounding  
cochlea    

5. Facial  trauma  –  pictures  with  questions  regarding  further  management.  Septal  

6. Ear  trauma  –  perichondrial  haematoma,  battles  sign,  management  

7. Oral  pathology  –  bifid  uvula:  embryology,  what  operation  contraindicated  in  this  setting.  
CT  of  opacified  maxillary  sinus,  patient  post  upper  molar  extraction  with  probable  impacted  
dental  root.  Asking  about  the  exact  pathology  and  principles  of  surgical  management.  

8. Pharyngeal  pouch  –  identify  structures  on  really  poor  quality  lateral  neck  xray.  Name  
pathology,  4  presenting  symptoms,  photos  of  endoscopic  stapling/myotomy  –  name  
operation,  5  immediate  post-­‐operative  risks  

9. Watch  battery  in  a  jar  –what  is  it,  usual  ENT  use,  2  consequences  each  of  placing  it  in  nose  
and  ear.  Young  man  with  special  needs  seen  by  carer  to  swallow  it,  what  imaging  do  you  
request,  immediate  management,  risks  if  management  delayed  by  2  hours  

10. Laryngomalacia  -­‐  2  x  images  of  childs  larynx  on  direct  laryngoscopy,  on  inspiration  and  
expiration.  Diagnosis,  presenting  symptoms  x  3,  3  characteristics  of  the  stridor,  ?  abnormal  
cry  or  not,  ?  3  features  of  the  larynx  on  laryngoscopy  in  this  condition,  management,  
prognosis  

11. Direct  laryngoscopy  images  of  larynx  –  name  various    structures.  Right  pyriform  fossa  
tumour  –  likely  pathology,  histology,  symptoms,  management  
12. Submandibular  Sialogram  –  stone  in  right  duct.  Pathology,  location  of  pathology,  
presenting  symptoms,  4  management  options,  3  nerves  that  can  be  injured  in  open  surgery  

13. Acute  left  submandibular  mass,  told  us  the  provisional  dx  is  branchial  cyst  -­‐  ?  which  
triangle,  3  differential  diagnoses,  if  FNE  normal,  whats  your  next  investigation  you  would  do  
in  clinic,  and  if  the  lesion  is  cystic,  what  three  specific  findings  might  you  see  on  the  
investigation  you  chose  to  do  (not  sure  what  they  were  looking  for  here,  I  bluffed  and  said  
aspirate  the  cyst).  2  steps  in  further  management.  

14. 4  Lateral  neck  xrays  with  brief  clinical  history  –  what  would  you  write  on  request  card  if  
you  wanted  this  imaging  performed.  What  are  the  findings,  immediate  
concerns/management.  Epiglottitis,  subcutaneous    emphysema  post  rigid  oesophagoscopy,  
retropharyngeal  abscess,  radio-­‐opaque  foreign  body  at  cricopharyngeus.  

15. Man  post  frontal  head  trauma  with  clear  rhonorrhea  –  axial  CT  brain,  whats  the  pathology  
(Fairly  subtle  fracture  of  frontal  bone  through  frontal  sinus  with  partial  opacification  of  the  
sinus).  What  concerns  you  about  the  fluid,  what  test(s)  would  you  do  on  it  if  you  could  get  a  
sample.  Principles  of  management  

16. Photo  of  child  with  orbital  cellulitis.  Very  difficult  questions,  quite  similar  to  eachother.  
Diagnosis.  What  4  symptoms/  signs  would  make  you  worry  about  serious  pathology.  What  4  
criteria  would  make  you  order  an  urgent  out  of  hours  CT.  What  3  criteria  would  make  you  
intervene  surgically  urgently.  Management  options.  

17. Real  temporal  bone  on  table,  asked  to  name  various  parts,  5  structures  passing  through  
internal  auditory  meatus,  stylomastoid  foramen  

18. Write  Op-­‐note  for  patient  post  adenoidectomy  and  grommet  insertion  

19. Photo  of  man  with  large  diffuse  goitre,  normal  TFT  results.  Diagnosis,  3  investigations  you  
would  perform,  management  options,  risks  of  surgery,  emergency  management  of  post-­‐
operative  hypocalcaemia  

20. 6  Audiograms,  6  tympanograms.    4  patient  scenarios  and  asked  to  put  the  most  likely  
audio  &  tympanogram  result  with  each  –  40year  old  woman  with  nasopharyngeal  carcinoma  
on  right  side,  6  year  old  child  with  right  glue  ear  and  left  patient  grommet  in  situ  (trick  
question,  2  tymps  fit,  had  to  be  sure  to  check  the  canal  volumes),  man  with  menieres,  right  
handed  man  with  longstanding  history  of  rifle  use  

21. Images  of  middle  ear  post-­‐mastoidectomy  –  label  the  parts.  Man  returned  4  years  post  
mastoidectomy  for  routine  follow-­‐up  –  asymptomatic  mass  noted  in  ear,  picture  not  very  
clear,  looked  like  osteoma  ?  what  is  the  lesion,  how  would  you  manage  it  

22. 3  hearing  aids  –  (A)behind  the  ear,  (B)bone  conduction  aid  on  headband,  (C)BAHA.  Name  
them,  state  disadvantages  of  each,  in  what  setting  would  B&C  be  superior  to  A,  principles  of  
bone  conduction,  which  cochlea  receives  signal  the  strongest  from  a  right  BAHA.  
 23. Audio  with  bilateral  SNHL,  superimposed  conductive  of  right  –  describe  audio.  MRI  brain  
with  bilateral  CP  angle  tumours  –  likely  pathology(bilateral  acoustic  neuroma),  what  
condition  does  this  occur  in  (NF2),  what  is  the  mode  of  inheritance.  Goes  on  to  state  that  
patient  had  surgery  and  developed  a  post-­‐op  complication  which  required  further  surgery  –  
what  is  the  imaging  and  what  was  the  surgery  -­‐    axial  CT  of  brain  with  what  looks  like  
ventricular  shunt/extraventricular  drain  in  situ  

And  that  was  it!  The  exam  goes  very  quickly  once  you  are  in  there.  With  regards  preparation,    clinical  
experience  working  in  ENT  is  invaluable.  I  had  9  months  SHO  experience  myself  and  this  is  probably  
the  biggest  factor  in  passing.  Books  wise,  I  would  thoroughly  recommend  ENT  OSCEs:  A  Guide  to  
Passing  the  DO-­‐HNS  and  MRCS  (ENT)  OSCE  (published  by  MasterPass).  I  got  it  for  about  40euro  on  
amazon  and  I  would  use  this  as  the  focus  of  your  revision.  Some  of  the  questions  in  the  exam  were  
directly  from  this  book,  although  they  threw  in  some  trickier  final  questions  in  the  actual  exam.  
 

 
I  would  supplement  this  with  Total  Revision  –  Ear,  Nose  and  Throat  (published  by  Pastest).  This  
Pastest  book  is  also  what  I  would  recommend  for  part  1  revision;  I  read  it  well  and  did  the  practice  
questions,  along  with  the  practice  questions  in  Masterpass:  MCQs  and  EMQs  for  the  Diploma  in  
Otolaryngology,  Head  and  Neck  Surgery.  With  these  2  books  pretty  much  alone,  I  got  over  90%  in  my  
first  attempt  at  part  1.  For  part  2  also  you  will  need  an  anatomy  text/google  images  for  looking  at  
inner  ear/thyroid  histology,  temporal  bone  anatomy  anything  else  you  think  seems  important.  
Judging  by  the  material  in  the  May  exam,  I  think  that  Total  Revision  &  Masterpass,  with  a  bit  of  
online  supplementation,  should  be  more  than  enough  to  cover  the  relevant  material,  other  than  the  
occasional  question  they  throw  in  from  left  field.  Everyone  is  different,  but  for  me,  these  2  books  
were  adequate  to  cover  the  exam  topics  and  I  passed  the  OSCE  on  my  first  attempt  at  this  sitting  
above.  Best  of  luck  to  anyone  reading  this  and  try  not  to  get  too  stressed  about  it!  I’d  be  happy  to  
respond  to  any  e-­‐mail  queries  looking  for  advice  on  the  email  below.  

Brendan  O’Connor  

Basic  Surgical  Trainee,  Ireland  

Email:  boc123@gmail.com