FRACS ENT (OHNS) Examinations 2026 Study Guide: What You Actually Need to Know

A practical guide for Otolaryngology Head and Neck Surgery SET trainees sitting the RACS basic-science SSE or the Fellowship Examination in the next twelve months. PRIMEX started in 2025 when an anaesthetic trainee at a regional NSW hospital built study tools for the ANZCA Primary. It now covers more than twenty Australasian specialty exams because trainees from each specialty asked us to build for them. The FRACS ENT (OHNS) curriculum on PRIMEX is mapped against the published RACS Otolaryngology Head and Neck Surgery syllabus, with topic mapping reviewed for accuracy.

The exam at a glance

Otolaryngology Head and Neck Surgery is examined by the Royal Australasian College of Surgeons in two distinct stages, and a candidate sits them at different points in SET (Surgical Education and Training). The first is the Specialty-Specific Examination (SSE), a basic-science gateway sat earlier in training. The second is the Fellowship Examination (FEX), the clinical exit examination that stands between trainee and Fellow. PRIMEX models both stages under one OHNS track, with the surfaces split by stage. Pass the Fellowship Examination and you finish training; fail it and most candidates re-sit at the next available sitting, which typically adds months to the path to Fellowship.

Format: the SSE (basic-science gateway)

• 100 multiple-choice questions covering applied anatomy, pathology and physiology, weighted roughly 50 per cent applied anatomy, 25 per cent pathology and microbiology and immunology, and 25 per cent physiology
• Question types include Type A (single best answer), Type B (statement and reason) and Type X (a stem with four true or false distractors, each worth one mark)
• Six spot questions worth eight marks each, distributed across anatomy, pathology and physiology and themed around otology, rhinology and head and neck or laryngology
• Delivered electronically across Australian and New Zealand cities. For OHNS candidates the SSE is offered in October and February, not June
• The SSE is the applied-anatomy filter: temporal bone, skull base, neck spaces and the relations of the cranial nerves are where the marks are won and lost

Format: the Fellowship Examination (clinical exit)

• Two written papers of 130 minutes each. Each paper has two extended-response questions (30 minutes each, in two equal parts) plus four short-response questions over 60 minutes; the second paper includes one generic non-technical-competencies question themed across all specialties
• Clinical Scenarios: a 60-minute segment of five clinical protocols with no patients present. The candidate takes a history from the examiners, describes the examination, requests and interprets investigations, gives a differential and discusses treatment
• Clinical Cases: a 40-minute segment with eight patients at five minutes each, examining specified regions, eliciting signs and interpreting investigations including imaging and audiograms
• Surgical Anatomy: a 30-minute anatomy-lab segment using wet specimens, dry bones and skulls, temporal-bone dissections and CT and MRI imaging
• Surgical Pathology: a 30-minute segment using images of pathology specimens, histological slides and clinical photographs
• Operative Surgery: a 30-minute segment on pre-operative decision-making and workup, operative technique and strategy, and the management of operative and post-operative complications
• The written component is delivered about a month before the clinical and viva segments. The clinical and viva day is held in Melbourne for Sitting 1 and Sydney for Sitting 2

Sittings and timing in 2026

• SSE: 7 October 2026 (applications close 4 August 2026) and 10 February 2027 (applications close 1 December 2026)
• Fellowship Examination Sitting 1: written paper on 9 April 2026, with the clinical and viva day in Melbourne around 30 to 31 May 2026 (applications close 28 January 2026)
• Fellowship Examination Sitting 2: written paper on 6 August 2026, with the clinical and viva day in Sydney around 19 to 20 September 2026 (applications close 25 June 2026)
• Always confirm the current sitting dates, venues and eligibility directly on the RACS website before locking in your study plan; dates beyond the February 2027 SSE were not yet published at the time of writing

Pass marks and standardisation

RACS does not publish a fixed numerical pass mark or a headline pass rate for the Otolaryngology Head and Neck Surgery examinations. The SSE is criterion-referenced. The Fellowship Examination is marked on the Expanded Close Marking System against the standard of a consultant in the first year of independent practice, with all seven segments carrying equal weight. From 2026 the written component is uncoupled: failing both written segments fails the sitting before the clinical and viva. A candidate who passes all seven segments passes; a candidate who reaches the clinical and viva and fails three or more segments fails; a candidate passing six is reviewed by the Specialty Court in Otolaryngology Head and Neck Surgery. Aggregate pass-rate data by specialty appears only in the RACS annual Activities Reports, so treat any quoted percentage as unverified.

Fees in 2026

• Fellowship Examination, full (written plus clinical and viva): A$10,465 excluding GST, or NZ$12,875 including GST
• Each component sat alone (written, or clinical and viva): A$5,232.50; from August 2025 the clinical and viva component can be sat alone with a written exemption
• SSE fee: RACS publishes specialty-specific examination fees per sitting, but a discrete 2026 OHNS SSE figure was not published as a single amount at the time of verification. Confirm the current amount on the official SSE fees page

What the college actually tests

The PRIMEX FRACS ENT (OHNS) curriculum holds 121 mapped learning objectives across 49 topics and 10 sections, drawn from the RACS Otolaryngology Head and Neck Surgery syllabus. The SSE sections are applied anatomy, applied physiology, and applied pathology, microbiology and immunology. The Fellowship Examination sections are otology and neurotology, rhinology and anterior skull base, laryngology and voice and airway, head and neck oncology and endocrine and salivary, paediatric ENT, facial plastics and reconstruction and trauma, and the generic and non-technical competencies. The breadth is the point. The examination is engineered to test that the candidate can reason as a safe consultant otolaryngologist across the full scope of the specialty, not as a subspecialist in any one region.

The highest-yield areas to anchor your study

Otology and the temporal bone

• Chronic otitis media with and without cholesteatoma, the natural history of an attic retraction, and the indications and technique trade-offs of canal-wall-up versus canal-wall-down mastoidectomy, with the management of intracranial and intratemporal complications
• Conductive versus sensorineural hearing loss worked from the history, tuning-fork tests, pure-tone and tympanometry, with otosclerosis, ossicular discontinuity and the indications for stapedotomy versus hearing aid
• The dizzy patient, separating benign paroxysmal positional vertigo, vestibular neuritis, Meniere disease and a central cause, with the Dix-Hallpike and head-impulse findings that discriminate them
• Facial nerve palsy graded on the House-Brackmann scale, the distinction of Bell palsy from a surgical or neoplastic cause, and the intratemporal course and surgical landmarks of the nerve
• Temporal-bone trauma, the longitudinal versus transverse pattern, facial-nerve and hearing implications, and the lateral skull base

Rhinology and the anterior skull base

• Chronic rhinosinusitis with and without nasal polyps, the role of CT of the paranasal sinuses, medical optimisation and the principles and complications of functional endoscopic sinus surgery
• Epistaxis from first principles, the sphenopalatine and anterior ethmoidal arterial supply, a stepwise approach from cautery and packing to sphenopalatine artery ligation, and the management of the anticoagulated patient
• Fungal and granulomatous sinonasal disease, separating invasive fungal sinusitis in the immunocompromised patient from allergic fungal disease and the systemic vasculitides
• Sinonasal and anterior skull base tumours, the cross-sectional imaging that drives the decision, and the principles of endoscopic versus open resection of the skull base
• Nasal obstruction and the assessment of the septum, turbinates and nasal valve, with olfactory dysfunction worked systematically

Head and neck oncology, endocrine and salivary

• Head and neck squamous cell carcinoma staged under AJCC eighth edition, with separate handling of HPV-associated oropharyngeal cancer by p16 status, and the systematic workup of the neck mass
• The neck levels and the principles of selective versus comprehensive neck dissection, the structures at risk, and the role of sentinel-node and elective neck treatment
• Differentiated thyroid cancer and the thyroid nodule worked through ultrasound and the Bethesda cytology system, total thyroidectomy with recurrent laryngeal nerve and parathyroid preservation, and the named complications
• Primary hyperparathyroidism, localisation with sestamibi and ultrasound, focused versus four-gland exploration, and intra-operative parathyroid hormone monitoring
• Salivary gland disease and the parotid lump, the facial-nerve-preserving principles of parotidectomy, and the management of pleomorphic adenoma and malignant disease

Laryngology, voice and the airway

• The hoarse voice worked systematically, benign vocal-fold lesions, the role of stroboscopy, and the red-flag features that mandate examination of the larynx to exclude malignancy
• The threatened and obstructed adult airway, laryngotracheal stenosis, the decision points around tracheostomy, and the safe management of the shared airway with the anaesthetist
• Laryngopharyngeal reflux and recurrent respiratory papillomatosis, and the management of laryngeal trauma and stridor
• Swallowing and aspiration, the assessment of dysphagia and the principles of airway protection

Paediatric ENT

• Adenotonsillar disease and the indications for adenotonsillectomy, the assessment of paediatric obstructive sleep-disordered breathing, and post-tonsillectomy haemorrhage
• The paediatric airway, the stridulous child, laryngomalacia, subglottic stenosis and the inhaled foreign body
• Paediatric otology and hearing, otitis media with effusion, the indications for grommets and the management of congenital and acquired hearing loss
• Congenital neck lesions, the branchial and thyroglossal anomalies and their embryological basis, and choanal atresia

Common pitfalls that fail candidates

• Treating the SSE as a recall test. The basic-science exam is weighted to applied anatomy of the temporal bone, skull base and neck spaces, where spatial relationships and clinical application earn the marks, not lists of structures
• Vague anatomy in the viva. Examiners do not accept "the facial nerve"; they want the named segments of its intratemporal course, the second genu, the relations at the stylomastoid foramen, and the landmarks you use to find it in parotid surgery
• Unstructured written answers. The short-response and extended-response questions reward a prioritised, structured approach to history, examination, investigation and management, not unstructured prose that buries the marking points
• Quoting outdated staging. AJCC eighth edition is the working standard for head and neck cancer, with HPV-associated oropharyngeal carcinoma staged separately by p16 status; older single-framework staging should not be the primary reference
• Talking around complications instead of through them. A post-thyroidectomy airway haematoma, a cerebrospinal fluid leak after sinus surgery, or a facial-nerve injury in parotid surgery is a clinical entity with a mechanism, a recognition pattern, a decision tree and a time window, not a line item
• Defaulting to a metropolitan tertiary answer when the stem is regional or rural. Examiners write rural scenarios deliberately and reward candidates who adjust transfer timing, retrieval logistics and consultant escalation accordingly
• Neglecting Operative Surgery and Surgical Pathology. These segments test pre-operative decision-making, technique and specimen interpretation rather than textbook recall, and they reliably catch candidates who studied only for the written paper

Realistic study timelines

The right run-up depends on how much operative time you have already accumulated, how strong your subspecialty rotations have been, and how heavy your on-call roster is during the study window. The plans below assume a working SET trainee on a normal full-time roster, not a study-only year. Adjust honestly. If your week genuinely contains no protected hours, the four-month plan is not for you.

Nine-month plan, around 8 to 10 hours per week

• Months 1 to 3: read across the curriculum at a topic-a-day pace, building a one-page summary for every PRIMEX study note. Anchor each summary on a current RACS, ASOHNS or international society guideline rather than a single textbook chapter
• Months 4 to 5: start untimed short-response answers from the structured question library, one per night plus a longer block on weekends. Write in a clinical-framework format from the first answer: history, examination, investigation, differential, management, complications
• Months 6 to 7: shift to timed written practice at exam pace, alternating short-response and extended-response questions. Begin viva practice at one segment per week, rotating Clinical Scenarios, Clinical Cases, Surgical Anatomy, Surgical Pathology and Operative Surgery
• Months 8 to 9: full mock written papers plus a clinical and viva day per fortnight at full segment length. Re-loop on the otology, rhinology, laryngology and head and neck domains where your operative exposure has been thin
• Last two weeks: light retrieval practice using flashcards on temporal-bone anatomy, neck levels, AJCC staging and named operative steps. No new content. Sleep hygiene

Six-month plan, around 12 to 15 hours per week

• Months 1 to 2: rapid pass through the 121 learning objectives, reading the PRIMEX study note for each and tagging the topics where your operative exposure has been thin. Be honest about the subspecialties you avoided as a junior registrar
• Months 3 to 4: untimed written answers each weeknight, structured to your weakest tag list first; weekend blocks for guideline reading on head and neck cancer, chronic rhinosinusitis, the dizzy patient and the threatened airway
• Month 5: timed written practice at exam pace, alternated with viva practice in voice mode for the Clinical Scenarios and Operative Surgery segments. Begin spot and image-identification drills using anatomy and pathology images
• Month 6: two full mock written papers and two full clinical and viva days under examination conditions, with focused remediation on the bottom-three domains

Four-month plan, around 18 to 22 hours per week

• Month 1: triage your weakest five clinical areas, read the relevant study notes, and start writing two structured short-response answers per night without timing. Begin daily spot-style image identification, ten images a session
• Month 2: timed written practice every weeknight, weekend mock blocks at exam pace; introduce viva practice three times a week across otology, rhinology, laryngology and head and neck cases
• Month 3: two full mock written papers and a full mock clinical and viva day, with a second loop on weak areas using operative scenarios at exam pace
• Month 4: maintenance only. Light flashcards on temporal-bone anatomy, neck levels and AJCC staging, sleep, and a final read-through of high-yield RACS and ASOHNS guidance

The single biggest mistake people make

The pattern that breaks competent candidates is treating the viva as a knowledge test rather than a decision-making test. You spend month one through month four reading and watching operative videos, you build pages of beautifully organised notes, and you tell yourself that knowing the operation cold will be enough. It is not. The clinical and viva segments are engineered to find the moment between two steps where the candidate has to commit to a decision under time pressure, and most candidates have never rehearsed the talking part of the operation before they walk in. You can name the steps of a parotidectomy perfectly and still struggle in Operative Surgery, because the examiner asks what you do when the facial nerve is encased in tumour, when the frozen section comes back malignant, when the patient bleeds in recovery after a thyroidectomy. The candidates who pass cleanly are the ones who practised speaking through cases out loud, with a partner who pushed back on every vague answer, from month one. Start saying the operation. Rough, hesitant talk-throughs are fine in week one. The point is to make the verbal sequence reflexive, so that on the day the medicine and the anatomy are the only things you have to think about, not the words.

How PRIMEX helps

• SAQ grader: write a Fellowship-format short-response or extended-response answer and get a marking-point-by-marking-point breakdown with model answers at examiner standard, calibrated to the RACS written expectations. Available inside the app and on the public SAQ grader for unauthenticated trial use.
• MCQ practice for the SSE: single-best-answer questions across the applied anatomy, pathology and physiology axes, with discriminating explanations for each option.
• OHNS viva simulator with voice mode: timed clinical-reasoning practice across the otology, rhinology, laryngology and head and neck domains, with a structured debrief after each session. Speak your answers out loud and have an AI examiner probe further. Available through the FRACS ENT study tools.
• Curriculum tracker: all 121 mapped learning objectives are visible on the FRACS ENT app page with progress tracking by topic, so you can see at a glance which sections have been studied and which need attention.
• Ask PRIMEX: a question-and-answer interface that returns guideline-aligned answers across RACS, ASOHNS and current international ENT guidance, useful when you want a quick sanity check on a management plan you are drafting.

Worked topic deep-dives

Three high-yield topics drawn straight from the PRIMEX FRACS ENT study notes. Each one is a teaser; the full note carries the complete operative principles and viva framing.

Head and neck SCC staging and the neck mass

The neck mass in an adult is a malignancy until proven otherwise, and the Fellowship viva expects a structured framework that integrates history, examination, imaging and staging before any mention of treatment.

• Work the neck mass systematically by site and node level, with the index of suspicion driven by age, smoking and alcohol history, and HPV exposure.
• Head and neck squamous cell carcinoma is staged under AJCC eighth edition, with HPV-associated oropharyngeal carcinoma staged separately by p16 status because its prognosis and nodal behaviour differ.
• The decision turns on accurate staging and multidisciplinary planning across surgery, radiation and systemic therapy rather than on a single modality.

How it is examined: the viva probes a structured approach to the neck mass and the imaging and staging that drive the decision. Common pitfall: jumping to a treatment plan before completing the workup and staging.

Read the full note →

Chronic and acute otitis media

Otitis media spans a spectrum from the self-limiting acute infection to chronic disease with cholesteatoma, and the viva expects you to recognise the natural history and the indications for surgery.

• Acute otitis media is largely a clinical diagnosis in the child, with antibiotic decisions guided by age, severity and bilaterality, and a watchful eye for the suppurative complications.
• Chronic disease divides into the mucosal and the squamous (cholesteatoma) pattern; cholesteatoma is a surgical disease because of its erosive natural history toward the ossicles, labyrinth, facial nerve and intracranial compartment.
• The operative decision balances disease clearance against hearing, weighing canal-wall-up against canal-wall-down mastoidectomy and the place of a planned second-look.

How it is examined: the viva tests the recognition of cholesteatoma and the principles of safe mastoid surgery and complication management. Common pitfall: underestimating the erosive natural history of an attic retraction.

Read the full note →

Thyroid and parathyroid surgery

Thyroid and parathyroid surgery is a recurring viva theme because it integrates endocrine workup, surgical anatomy and the named complications that define safe practice.

• The thyroid nodule is worked through ultrasound and the Bethesda cytology system, with the operative decision driven by cytology, size and patient factors.
• Total thyroidectomy turns on the preservation of the recurrent and external laryngeal nerves and the parathyroid glands, with intra-operative nerve monitoring a useful adjunct rather than a substitute for anatomical knowledge.
• Primary hyperparathyroidism is localised with sestamibi and ultrasound, and the choice of focused versus four-gland exploration is supported by intra-operative parathyroid hormone monitoring.

How it is examined: the viva probes the named complications, post-operative airway haematoma and hypocalcaemia, and the anatomy of the nerves at risk. Common pitfall: describing the operation without committing to the recognition and management of an early airway haematoma.

Read the full note →

Frequently asked questions

Related study guides

• FRACS General Surgery 2026 Study Guide
• RACS GSSE 2026 Study Guide