ORLHNS SSE

Purpose:

The purpose of the ORLHNS Speciality Surgical Sciences Examination (SSE) is to

ensure that all trainees have a minimally competent level of knowledge and
understanding of the basic sciences relevant to ORLHNS. These include Anatomy
(including embryology and developmental anatomy), Physiology and Pathology.
This knowledge is deemed to be essential to enable progression towards
achieving the minimal standards required to be considered a competent surgeon.

Timeframe:

The ORLHNS Speciality SSE must be successfully completed within the first 2
years of commencement on the ORLHNS training program and have 4
opportunities to sit.

Surgeon scientists who are undertaking a PhD over 3 years and trainees
successful in being granted an interruption of training can seek further
clarification of circumstance from the Board of ASOHNS.

Content and Format of the Exam:

The ORLHNS SSE is undertaken in a single sitting and delivered electronically.

The content of the exam is 50% Anatomy, 25% Pathology and 25% Physiology.
Questions are designed around the Syllabus as outlined below.

The exam format is a combination of multiple -choice questions and “Spot”

questions.

MCQs
The multiple-choice questions are a combination of Type A, Type B and Type X
questions:

Type A

These questions consist of a stem and require selection of the 'most appropriate'
response. Whilst all the distractors may be correct, one is 'better' than the rest.

There is only one correct answer and a correct answer is worth one mark.

Type B

These questions consist of a statement (S) and a reason (R) and the candidate is
required to determine the relationship between the two. Firstly, determine
 whether S and R are true or false; if S and R are both true, then you must
determine whether R explains S.

There is only one correct answer and a correct answer is worth one mark.

Mark the answer sheet according to the key:

A - S is true, R is true and is a valid explanation of S

B - S is true, R is true but is not a valid explanation of S
C - S is true and R is false
D - S is false and R is true
E - both S and R are false

Type X

These questions consist of a stem and four distractors. A candidate needs to

answer whether each distractor is true or false.

A correct answer to each distractor is worth one mark. Each type X question, as a
whole, is therefore worth up to four marks.

“Spot” Questions
These questions require short text answers and relate to an illustration. The
entire question is worth 8 marks. Marks are divided between the various
sections for each spot question with 4 marks related to anatomy, 2 marks related
to pathology and 2 marks related to physiology.
The exam will contain 6 Spot Questions, two (2) questions with a focus on
otology, two (2) questions with a focus on rhinology and two (2) questions with
a focus on head & neck / laryngology.

Otolaryngology, Head & Neck Surgery SSE Syllabus

The syllabus below covers the areas that are examinable in the ORLHNS SSE.
This syllabus builds on knowledge gained from undertaking the Generic Surgical
Sciences Examination and goes into much greater depth in areas relevant to this
surgical speciality.

Anatomy
Knowledge of applied gross and microscopic anatomy relevant to
Otolaryngology Head and Neck Surgery in the following areas:
• Skull and head
o Cranial nerves
o Face
• The neck
o Contents, Compartments and Triangles of the neck
• Otology
o External ear
o Middle ear
o Inner ear
• The upper aerodigestive tract
 o Nasopharynx
o Oropharynx
o Larynx
o Hypopharynx
o Oral cavity
o Oesophagus
o
• Rhinology
o Nasal cavity and sinuses
• Respiratory tract
o Trachea
• Endocrine system
o Thyroid
o Parathyroids

Physiology
Knowledge of applied physiology relevant to Otolaryngology Head and Neck
Surgery in the following areas:
• Skull and head
• Otology
o External ear
o Middle ear
o Inner ear
o Principles of hearing
o Vestibular and balance
• The upper aerodigestive tract
o Larynx and voice
o Swallowing
o Saliva
o Taste
• Rhinology
o Nasal cavity and sinuses
o Olfaction
• Respiratory tract
o Trachea
• Endocrine system
o Thyroid
o Parathyroids
o
• Sleep and its disorders relevant to Otolaryngology
• Lymphatics

Pathology
Knowledge of applied pathology relevant to Otolaryngology Head and Neck
Surgery in the following areas:
• Antibiotics
• Infectious diseases
• Neoplasia of the head and neck
 o Benign lesions
o Precancerous lesions
o Malignant lesions
o Genetics and molecular biology
o Epidemiology
o Salivary gland
o Thyroid
o Oral cavity lesions

• Genetics and Molecular Biology

• General pathology
o Acute and chronic inflammation
o Tissue response to injury
o Cell cycle
o Tissue repair

• Immunology
• Normal immune response
• Hypersensitivity
• Autoimmune diseases
• Immunodeficiency
o Congenital & Acquired
• Viral diseases and manifestations in the head and neck
• Lymphoid tissue of the head and neck
• Congenital head and neck lesions
• Rhinosinusitis and associated conditions
• Systemic diseases affecting the nose and paranasal sinuses

Suggested reference text(s):

Anatomy
th
Last’s anatomy regional and applied R.M.H McMinn 9 edition
th
Wheater’s Functional Histology a text and colour atlas 4 edition
th
Langman’s Medical Embryology 10 edition

Pathology
th
Robbins Pathologic Basis of Disease 7 edition

Physiology
th
Ganong’s Review of Medical physiology 24 edition

Specialty specific reference texts

Head and Neck Surgery – Otolaryngology by Byron J. Bailey and Jonas T. Johnson
th
(editors) 5 edition Volume 1 and 2

th
Cumming’s 5 edition Head and Neck Surgery – Otolaryngology by Byron J.
 th
Bailey and Jonas T. Johnson (editors) 6 edition Volume 1 and 2

Sample Questions

Sample questions are provided to assist candidates in preparing for the exam.
The expectation is that candidates sitting for the ORLHNS SSE examination are
adult learners and are able to synthesize information from a number of sources
rather than rote learning from a limited number of texts.

A sample of each type of MCQ is provided with an example of the rationale used
to write the questions and set the exam.

MCQ Type A question

Rationale: The anatomy of the tonsil is considered important as tonsillectomy is

a common procedure performed by otolaryngology head and neck surgery
trainees.

Type A question

The palatine tonsil is supplied by the

A. facial artery
B. occipital artery
C. superior thyroid artery
D. sternocleidomastoid artery
E. superior laryngeal artery

The correct answer is A. facial artery via the tonsillar branch providing the main
arterial supply with smaller contributions from the lingual, ascending
pharyngeal and ascending palatine vessels. Reference: Last’s anatomy 9th edition
page 490-491.

MCQ Type B question

Rationale: Laryngeal physiology and anatomy are considered important core

knowledge for assessment of the vocal folds and dysphonia by otolaryngology
head and neck surgery trainees.

Type B question

S. The lamina propria of the normal vocal fold aids phonation

Because
R. it allows the underlying muscle to restrict vocal fold vibration

The correct answer is C, S is true, R is false. The answer is referenced from

Bailey’s Otolaryngology Head and Neck Surgery 5th edition Chapter 61 page 874.
Normal laryngeal physiology describes the mucosa over the vocal fold as
allowing vibration and phonation. The lamina propria serves as a shock absorber
or impendance matcher, so that the epithelium can vibrate freely without
restriction by the underlying muscle. This explains why S (statement) is true and
R (reason) is false.
MCQ Type X question

Example of a question on pathology involving common otolaryngology

conditions seen by trainees, which includes microbiology and inflammation

Type X question

With regards to the palatine tonsils

A. Infections can be due to Haemophilus influenzae
B. Infections are not usually caused by group A beta-hemolytic streptococcus
C. Infections can be complicated with development of rheumatic fever
D. Is usually mild in children and infants

The correct answers are

A. True.
B. False. Up to 30% of bacterial tonsillitis is attributed to group A beta-
hemolytic streptococcus.
C. True. One of the potential complications of streptococcal tonsillitis is
rheumatic fever and glomerulonephritis.
D. False. Particularly severe forms of pharyngitis and tonsillitis are seen in
infants and children who have not developed any protective immunity to
such agents.

Referenced in Robbin’s pathologic basis of disease 7th edition page 750 section
on inflammations of the tonsil and Bailey’s Otolaryngology Head and Neck
Surgery Otolaryngology 5th edition Chapter 95. Adenotonsillar disease in
children page 1433.

Another example of a question regarding the physiology of hearing:

Sensorineural hearing loss is

A. Less likely with exposure to loud noise
B. Associated with outer hair cell loss
C. Associated with normal otoacoustic emissions
D. Less likely with use of aminoglycosides

The correct answers are

A. False. Sensorineural hearing loss is more likely associated with loud noise
exposure.
B. True. Pathology and physiology studies have shown that outer hair cell’s
are most susceptible to damage from excessive noise exposure.
C. False. Otoacoustic emissions are cannot be evoked with acoustic stimuli
when outer hair cells are structurally damaged.
D. False. Aminoglycoside’s are more likely associated with sensorineural
hearing loss especially if excessive doses are used.
The answers are referenced from Bailey’s Otolaryngology Head and Neck
Surgery Otolaryngology 5th edition page 2284, 2530, 2532, and 2533

Spot Questions

Below is a sample of a “Spot Question” and how this covers all three areas of
study: Anatomy, Physiology and Pathology

*Important
Answers to the spot questions should be unambiguous and ideally
abbreviations should be avoided. Any abbreviation that is not clearly
recognizable and widely accepted will not be marked.

Question 1

a. Name the structure indicated by the Arrow labelled ‘A’? (2 marks)

Answer: Epiglottis
This is an Anatomy question. Variations in spelling that cannot be
interpreted as meaning something else are generally given full marks. For
example, ‘epiglotis’ , ‘epiglotts’ would not be marked down. If spelling is
 very poor ie ‘epyglots’ half marks may be awarded. No marks would be
given for ‘glottis’.

b. The infective process causing gross swelling of the structure

indicated by the Arrow labelled ‘A’ is now rare due to childhood
immunization. What is the classic causative organism that has been
targeted by immunization? (2 marks)
Answer: Haemophilus Influenzae Type B
This is a Pathology question. Variations in spelling, such as ‘hemophilus’,
‘hemophilous’ or “influzena’ would not be marked down. If you skipped
the “Type” and wrote “haemophilus influenza B’ you would receive full
marks. If you did not put the “B” you would receive half marks. If you
answered ‘haem inf B’ or “HiB’ no marks would be given as these are
considered an abbreviation and an acronym. If you write many answers,
such as “Haemophilus Influenzae B, Haemophilus Influenzae A,
Streptococcus B’ you would automatically be given half marks. Do not
provide multiple answers unless specifically asked.

c. What movement does the structure (transected at its posterior end)

indicated by the Arrow labelled ‘D’ perform during the laryngeal
phase of swallow? (2 marks)
Answer: Adduction
This is a Physiology question. Variations in spelling will not necessary be
marked down ie’aduction’ If you wrote ‘adbuction’ this would score no
marks as this could be ‘abduction’ which would be incorrect. If you
answer “closes’, “moves to the centre’, half marks would be scored.

d. The movement, identified in Part ‘c’ of this question, occurs due to

innervation by which nerve?
Answer: Left recurrent laryngeal nerve
This is an Anatomy question. In this case, if Left was not stated, you would
still receive full marks as the question is asking about the movement of
adduction of the vocal cords. If you wrote “RLN” this would receive no
marks, as it is an acronym.