Question 1-3 of 10

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Theme: Deafness
A. Acute suppurative otitis media
B. Presbycusis
C. Meniere's disease
D. Drug ototoxicity
E. Otitis externa
F. Congenital rubella infection
G. Acoustic neuroma
H. Glue ear
I. Otosclerosis
J. Cholesteatoma

For each one of the following scenarios please select the most likely diagnosis:
1. A 36-year-old man presents with recurrent episodes of right-sided tinnitus, hearing loss and vertigo. These episodes typically last between 10-30 minutes. He
also describes a 'full' sensation in his right ear. Otoscopy is unremarkable and the cranial nerve examination is normal.

Meniere's disease

Symptoms with an acoustic neuroma tend to be more progressive rather than episodic.
2. A 31-year-old man presents with bilateral hearing loss and tinnitus. There is a family history of similar problems. Examination of the tympanic membranes is
unremarkable. Audiometry shows bilateral conductive hearing loss.

Otosclerosis
3. A 2-year-old boy is brought in by his mother due to concerns about his hearing and delayed speech. She has noticed problems for the past three months. You can
see from the notes that he has had frequent courses of amoxicillin for otitis media in the past. There is no evidence of excessive ear wax on examination.

You answered Acute suppurative otitis media

The correct answer is Glue ear
Next question

Deafness


The most common causes of hearing loss are ear wax, otitis media and otitis externa. The table below details some of the characteristic features of
other causes:
Presbycusis Presbycusis describes age-related sensorineural hearing loss. Patients may describe difficulty following
conversations

Audiometry shows bilateral high-frequency hearing loss
Otosclerosis Autosomal dominant, replacement of normal bone by vascular spongy bone. Onset is usually at 20-40 years -
features include:
conductive deafness
tinnitus
tympanic membrane - 10% of patients may have a 'flamingo tinge', caused by hyperaemia
positive family history
Glue ear Also known as otitis media with effusion
peaks at 2 years of age
hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive
hearing loss and elective surgery in childhood)
secondary problems such as speech and language delay, behavioural or balance problems may also
be seen
Meniere's disease More common in middle-aged adults
recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the
prominent symptom
a sensation of aural fullness or pressure is now recognised as being common
other features include nystagmus and a positive Romberg test
episodes last minutes to hours
Drug ototoxicity Examples include aminoglycosides (e.g. Gentamicin), furosemide, aspirin and a number of cytotoxic agents
Noise damage Workers in heavy industry are particularly at risk

Hearing loss is bilateral and typically is worse at frequencies of 3000-6000 Hz
Acoustic neuroma (more correctly called vestibular schwannomas) Features can be predicted by the affected cranial nerves
cranial nerve VIII: hearing loss, vertigo, tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy

Bilateral acoustic neuromas are seen in neurofibromatosis type 2
Question 8 of 10

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Which one of the following products is 'blacklisted' under Part XVIIIA of the Drug Tariff and hence cannot be dispensed on the NHS?


A. Juvela gluten-free bread


B. Clozapine


C. Farley's Soya Formula


D. EpiPen


E. Topical minoxidil
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Part XVIIIA of the Drug Tariff - The Blacklist

Theoretically any food, drug, toiletry or cosmetic may be prescribed on an NHS prescription unless the product is listed in Part XVIIIA of the Drug Tariff
('the blacklist').

Medical devices (appliances) can only be prescribed on NHS prescriptions if the product is listed in Part IX of the Drug Tariff.

If a proprietary product is listed in 'the blacklist', it cannot be dispensed on the NHS. The only exception to this is if the prescription is issued using a
generic name and the generic name is not itself included in the blacklist.

Some examples of 'blacklisted' products:
Propecia (finasteride for male-pattern alopecia)
Regaine (topical minoxidil for male-pattern alopecia)
Calpol (see above, paracetamol suspension may be prescribed)

The Selected List

Part XVIIIB of the Drug Tariff lists items that may only be prescribed for the patient groups and for the purpose listed in the Drug Tariff. Prescribers
must endorse prescriptions for these products 'SLS'. This section covers the prescription of phosphodiesterase type-5 inhibitors.

For example:
Niferex Elixir 30ml Paediatric Dropper Bottle - infants born prematurely - prophylaxis in treatment of iron deficiency
sildenafil - only if treated prior to September 1998 or if has one of the following conditions: diabetes mellitus, Parkinson's disease,
poliomyelitis, multiple sclerosis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida, spinal cord injury, renal
failure treated with dialysis or transplant, prostatectomy or radical pelvic surgery

Question 10 of 10
You are reviewing a new study on the benefit of omega-3 fish oils in patients with established ischaemic heart disease. What does the power of the
study equate to?


A. = 1 / p value


B. = standard deviation / square root of sample size


C. = 1 - probability of making a type II error


D. = 1 - probability of making a type I error


E. = 1 / probability of making a type I error
Power = 1 - the probability of a type II
error


Significance tests

A null hypothesis (H0) states that two treatments are equally effective (and is hence negatively phrased). A significance test uses the sample data to
assess how likely the null hypothesis is to be correct.

For example:
'there is no difference in the prevalence of colorectal cancer in patients taking low-dose aspirin compared to those who are not'

The alternative hypothesis (H1) is the opposite of the null hypothesis, i.e. There is a difference between the two treatments

The p value is the probability of obtaining a result by chance at least as extreme as the one that was actually observed, assuming that the null
hypothesis is true. It is therefore equal to the chance of making a type I error (see below).

Two types of errors may occur when testing the null hypothesis
type I: the null hypothesis is rejected when it is true - i.e. Showing a difference between two groups when it doesn't exist, a false positive.
This is determined against a preset significance level (termed alpha). As the significance level is determined in advance the chance of
making a type I error is not affected by sample size. It is however increased if the number of end-points are increased. For example if a
study has 20 end-points it is likely one of these will be reached, just by chance.
type II: the null hypothesis is accepted when it is false - i.e. Failing to spot a difference when one really exists, a false negative. The
probability of making a type II error is termed beta. It is determined by both sample size and alpha

Study accepts H0 Study rejects H0
Reality H0 Type 1 error (alpha)
Reality H1 Type 2 error (beta) Power (1 - beta)

The power of a study is the probability of (correctly) rejecting the null hypothesis when it is false, i.e. the probability of detecting a statistically significant
difference
power = 1 - the probability of a type II error
power can be increased by increasing the sample size