Mastering High-Yield ENT Scenarios for PLAB 2 OSCEs

Mastering High-Yield ENT Scenarios for PLAB 2 OSCEs

As a medical professional aiming for the PLAB 2 exam, you're acutely aware that the OSCE (Objective Structured Clinical Examination) demands not just theoretical knowledge but practical, patient-centered application. While a broad range of specialties can appear, Ear, Nose, and Throat (ENT) scenarios are consistently high-yield. They test your ability to take a focused history, perform relevant examinations, identify red flags, and formulate appropriate management plans, all while maintaining excellent communication.

Let's delve into some of the most frequently encountered ENT presentations in PLAB 2 and how to approach them effectively.

1. The Aching Ear: Otitis Media and Otitis Externa

Scenario: A patient presents with ear pain.

PLAB 2 Approach:

• History: Differentiate between Otitis Media (often follows a cold, fever, reduced hearing, more common in children) and Otitis Externa (swimmer's ear, pain on touching pinna, discharge, itchiness). Ask about recent swimming, ear cleaning habits, and general well-being.

• Examination: Gain consent to examine the ear. If appropriate and safe, use an otoscope (remember to brace your hand!). Look for a red, bulging tympanic membrane in otitis media or a swollen, red ear canal with discharge in otitis externa. Always check pre-auricular and post-auricular lymph nodes.

• Red Flags: Severe pain, swelling behind the ear (mastoiditis), facial weakness, persistent discharge, or recurrent infections in a child.

• Management:

  • Otitis Media: Analgesia (paracetamol/ibuprofen), safety-netting for worsening symptoms. Antibiotics are often not needed unless severe or prolonged. Advise against flying if ear is painful.

  • Otitis Externa: Topical antibiotic/steroid drops, analgesia. Advise to keep the ear dry.

• Communication: Explain the likely diagnosis clearly, advise on pain relief, and provide safety netting for when to return.

2. The Bleeding Nose: Epistaxis

Scenario: A patient presents with a nosebleed.

PLAB 2 Approach:

• Initial Management (if active): Reassure the patient. Instruct them to sit, lean forward, pinch the soft part of their nose (just above the nostrils) for 10-15 minutes, and breathe through their mouth. Apply a cold pack to the bridge of the nose/nape of the neck.

• History: Onset, duration, frequency, which nostril, amount of blood loss, any precipitating factors (nose picking, trauma, dry air), medication (especially anticoagulants like warfarin, DOACs, aspirin), history of hypertension, liver disease, or bleeding disorders. Assess for symptoms of significant blood loss (dizziness, faintness).

• Examination: Once bleeding controlled, a brief look in the nostrils (if safe and consent given) to identify the bleeding point (often Little's area). Check vital signs if concerned.

• Red Flags: Heavy, uncontrolled bleeding; involvement of both nostrils; signs of hypovolaemia; bleeding from posterior epistaxis (blood trickling down throat); patient on anticoagulants.

• Management:

  • If bleeding stops: Advise on avoiding nose picking, hot drinks, strenuous activity for 24-48 hours. Lubricating creams (e.g., Vaseline) for dry noses. Follow-up if recurrent.

  • If bleeding continues: Consider nasal packing (e.g., merocel, rapid rhino) or chemical cautery (if visualised and appropriate). Referral to ENT is crucial for persistent or severe cases.

• Communication: Provide clear instructions for initial management and follow-up advice.

3. The Sore Throat: Pharyngitis/Tonsillitis & Red Flags

Scenario: A patient presents with a sore throat.

PLAB 2 Approach:

• History: Onset, severity, difficulty swallowing (dysphagia), pain radiating to ear, fever, cough, runny nose, recent contact with sick individuals. Importantly, ask about red flags: difficulty breathing (stridor), drooling, muffled voice, neck stiffness, inability to open mouth fully (trismus).

• Examination: Look at the throat (tonsils for exudates, swelling), check for enlarged cervical lymph nodes. Observe for stridor or respiratory distress.

• Red Flags: Signs of epiglottitis (severe dysphagia, drooling, stridor, tripod position) or peritonsillar abscess (quinsy - severe unilateral pain, hot potato voice, trismus). These are medical emergencies.

• Management:

  • Viral: Most sore throats are viral. Advise on analgesia (paracetamol/ibuprofen), warm drinks, lozenges. Safety-netting for worsening symptoms.

  • Bacterial (e.g., Strep throat): Use Centor score (or similar clinical scoring) to assess likelihood. Antibiotics (e.g., penicillin V) may be indicated for high scores or severe cases.

  • Emergency: Refer immediately to A&E for suspected epiglottitis or quinsy.

• Communication: Explain the cause, self-care advice, and clear instructions on when to seek urgent medical attention.

4. The Spinning Room: Dizziness and Vertigo

Scenario: A patient reports feeling dizzy.

PLAB 2 Approach:

• History: This is critical! Differentiate true vertigo (spinning sensation) from lightheadedness or presyncope. Ask: When did it start? Is it constant or episodic? What makes it better/worse (head position changes)? Associated symptoms: hearing loss, tinnitus, ear fullness (Meniere's disease); nausea/vomiting (vestibular neuronitis); headaches (migrainous vertigo). Rule out orthostatic hypotension.

• Examination: Focused neurological exam (eye movements for nystagmus, Romberg's test). If suspicious of BPPV, and safe, consider Dix-Hallpike manoeuvre.

• Red Flags: New-onset headache, focal neurological deficits (weakness, numbness), double vision, speech difficulty, gait instability – these suggest central causes (stroke/tumour) and require urgent referral.

• Management:

  • BPPV: Epley manoeuvre (if trained and appropriate).

  • Meniere's: Dietary modifications (low salt), anti-emetics during acute attacks.

  • Vestibular Neuronitis: Symptomatic relief with anti-emetics, vestibular rehabilitation exercises.

  • Referral: To ENT or Neurology for specialist assessment, or emergency services for red flags.

• Communication: Explain the likely cause and management plan, including any exercises or lifestyle changes.

General PLAB 2 Tips for ENT Stations:

• Consent is Key: Always ask for consent before touching or examining a patient.

• Safety First: Be aware of urgent and emergency conditions (epiglottitis, quinsy, severe epistaxis, central vertigo signs) and act decisively to refer.

• Communication: Explain clearly, use simple language, reassure, and offer safety netting. Check for understanding.

• Practical Skills: While not always tested with a real patient, knowing the steps for otoscopy, anterior rhinoscopy, and oropharyngeal examination is crucial.

Practicing these high-yield ENT scenarios will not only boost your confidence but also ensure you’re well-prepared for a significant portion of the PLAB 2 clinical stations. Good luck!