Diseases of the Ear Practice Questions

Q: A 40 year old presented with bilateral hearing loss. Audiogram shows a dip at 2000 Hz. What is the most appropriate investigation?

Impedance audiometry. ### ***Impedance audiometry*** - In a patient with **otosclerosis**, the characteristic **Carhart's notch** (a dip at 2000 Hz on bone conduction audiometry) is a hallmark finding due to stapes fixation. - **Impedance audiometry** (specifically **tympanometry**) will demonstrate a **Type As tympanogram**, indicating reduced compliance of the tympanic membrane due to increased stiffness of the ossicular chain. ### *BERA* - **Brainstem Evoked Response Audiometry** (BERA) is primarily used for **retro-cochlear pathology** like **vestibular schwannomas** or in pediatric audiology screening. - While it can assess hearing thresholds, it is not the standard next diagnostic step for evaluating **conductive hearing loss** caused by stapes fixation. ### *Otoacoustic emissions* - **Otoacoustic emissions** (OAEs) are used to assess **outer hair cell function** in the cochlea, largely for neonatal hearing screening. - They do not provide diagnostic utility for middle ear pathologies like otosclerosis, as the sound energy cannot effectively enter or exit the middle ear. ### *Pure tone audiometry* - While **pure tone audiometry** is essential for establishing the diagnosis and identifying the **Carhart's notch**, it has already been performed in this scenario. - The clinical question asks for the *most appropriate investigation* to confirm the specific pathology (middle ear conduction system stiffness) implied by the audiogram findings.

Q: A factory worker presents with bilateral hearing difficulty. Audiometry is as shown in the image. This pattern is characteristic of:

Noise-induced hearing loss. ***Noise-induced hearing loss*** - Audiometry typically reveals a **classic 'notch' at 4000 Hz** (4 kHz), which is the hallmark diagnostic finding for occupational exposure to loud noise. - This condition results from damage to the **outer hair cells in the organ of Corti**, primarily in the basal turn of the cochlea, leading to high-frequency hearing loss. *Presbycusis* - Characterized by **bilateral symmetric progressive high-frequency sensorineural hearing loss** that typically begins above 2000 Hz, unlike the specific 4 kHz notch. - This is primarily due to **age-related degeneration** of the cochlea and neural pathways, not occupational trauma. *Meniere’s disease* - Often presents with **low-frequency sensorineural hearing loss**, which is the inverse of the high-frequency loss seen in noise trauma. - Associated with a **triad of symptoms**: episodic vertigo, fluctuating hearing loss, and aural fullness. *Sudden sensorineural hearing loss* - Defined as a rapid reduction in hearing (usually >30 dB in at least three contiguous frequencies) occurring within **72 hours**. - It is generally **unilateral** and idiopathic, whereas noise-induced hearing loss is typically bilateral and chronic.

Q: A 35-year-old patient presents with hearing loss. Clinical examination reveals a Rinne test where Air Conduction is greater than Bone Conduction in both ears. The Weber test lateralizes to the left ear. What is the most likely diagnosis?

Sensorineural hearing loss in the right ear. ***Sensorineural hearing loss in the right ear*** - A **positive Rinne test** (AC > BC) in both ears indicates that the inner ear function is compromised, suggesting **sensorineural hearing loss** (SNHL) rather than conductive pathology. - In SNHL, the **Weber test lateralizes to the better hearing ear** (the side without the pathology), meaning the left ear is the better hearing ear, confirming SNHL in the right ear. *Conductive hearing loss in the left ear* - In **conductive hearing loss**, the Rinne test would be negative (BC > AC) on the affected side, which contradicts the finding of AC > BC in both ears. - Furthermore, a conductive deficit would cause the **Weber test to lateralize to the affected side** (left), but the Rinne test results do not support a conductive etiology. *Conductive hearing loss in the right ear* - If the right ear had **conductive hearing loss**, the Rinne test would show BC > AC in that ear, failing to match the clinical finding of a positive Rinne. - The **Weber test lateralizing to the left ear** indicates the left ear is either normal or has better conduction, ruling out right-sided conductive pathology. *Sensorineural hearing loss in the left ear* - If the SNHL were in the left ear, the **Weber test** would typically lateralize to the right ear (the healthy side). - Since the Weber test lateralizes to the left, this implies the left ear is actually the one with better sensory function, making right-sided SNHL the correct diagnosis.

Q: A patient develops acute-onset severe unilateral hearing loss with no identifiable cause. Audiometry confirms sensorineural hearing loss. Which of the following pharmacological regimens is considered the first-line treatment for this condition?

Oral prednisolone (systemic corticosteroids). ***Oral prednisolone (systemic corticosteroids)*** - Systemic corticosteroids are the **first-line standard of care** for idiopathic sudden sensorineural hearing loss (SSNHL), typically initiated as soon as possible after diagnosis. - The goal is to reduce **inner ear inflammation** and edema, which is thought to be a primary pathophysiological mechanism for the condition. *Intratympanic steroid injections* - These are typically reserved as a **salvage therapy** for patients who fail to respond to initial systemic corticosteroid treatment. - While effective, they are generally not used as a first-line monotherapy due to the invasive nature and the proven efficacy of oral regimens. *Topical steroid ear drops* - These are ineffective for treating inner ear pathology because they are **unable to cross the tympanic membrane** into the middle and inner ear. - Topical therapy is primarily indicated for **otitis externa** and is irrelevant for sensorineural hearing loss conditions. *Gentamicin combined with systemic steroids* - Gentamicin is an **ototoxic aminoglycoside** that is toxic to the hair cells of the cochlea, which would potentially worsen, not treat, hearing loss. - This combination is contraindicated in the treatment of SSNHL and is actually used in a completely different context, such as chemical labyrinthectomy for Meniere's disease to ablate vestibular function.

Q: A 45-year-old man presents with a 6-month history of foul-smelling unilateral ear discharge and progressive right-sided hearing loss. He denies pain or vertigo. On examination, the ear canal contains scanty whitish debris. His otoscopic image is shown (Image 2). Which of the following complications is most classically associated with this attic cholesteatoma?

A. Lateral semicircular canal fistula with perilymph leak. ***A. Lateral semicircular canal fistula with perilymph leak*** - Attic cholesteatoma expands by eroding the **scutum** and the **aditus ad antrum**, making the **lateral semicircular canal** the most common site for a labyrinthine fistula. - Persistent erosion can lead to a **perilymph leak**, presenting clinically as episodic **vertigo** or sensorineural hearing loss when pressure is applied to the ear canal. *B. Perforation of the pars tensa with central conductive hearing loss* - This finding is characteristic of **tubotympanic type** (safe) chronic suppurative otitis media, rather than atttic cholesteatoma. - Cholesteatoma typically involves the **pars flaccida** (attic) or the posterior-superior quadrant, rather than causing a simple **central perforation**. *C. Eustachian tube dysfunction causing retraction of the posterior superior quadrant* - While **Eustachian tube dysfunction** is an underlying pathophysiological mechanism for forming a **retraction pocket**, it is considered a precursor rather than a complication of an established cholesteatoma. - The case describes a patient who already has **active disease** with debris, moving beyond the stage of simple retraction. *D. Otitis media with effusion causing a type B tympanogram* - **Otitis media with effusion** is characterized by fluid behind an intact tympanic membrane, typically presenting with a **Type B (flat) tympanogram** and no foul-smelling discharge. - A **type B tympanogram** in the presence of a cholesteatoma suggests middle ear congestion, but it does not represent the severe **erosive complications** associated with attic disease.

Question 1

A 40 year old presented with bilateral hearing loss. Audiogram shows a dip at 2000 Hz. What is the most appropriate investigation?

Accepted Answer

Impedance audiometry

Answer

BERA

Answer

Otoacoustic emissions

Answer

Pure tone audiometry

Question 2

A factory worker presents with bilateral hearing difficulty. Audiometry is as shown in the image. This pattern is characteristic of:

Accepted Answer

Noise-induced hearing loss

Answer

Presbycusis

Answer

Meniere’s disease

Answer

Sudden sensorineural hearing loss

Question 3

A 35-year-old patient presents with hearing loss. Clinical examination reveals a Rinne test where Air Conduction is greater than Bone Conduction in both ears. The Weber test lateralizes to the left ear. What is the most likely diagnosis?

Accepted Answer

Sensorineural hearing loss in the right ear

Answer

Conductive hearing loss in the left ear

Answer

Conductive hearing loss in the right ear

Answer

Sensorineural hearing loss in the left ear

Question 4

A patient develops acute-onset severe unilateral hearing loss with no identifiable cause.
Audiometry confirms sensorineural hearing loss. Which of the following pharmacological regimens
is considered the first-line treatment for this condition?

Accepted Answer

Oral prednisolone (systemic corticosteroids)

Answer

Intratympanic steroid injections

Answer

Topical steroid ear drops

Answer

Gentamicin combined with systemic steroids

Question 5

A 45-year-old man presents with a 6-month history of foul-smelling unilateral ear discharge and progressive right-sided hearing loss. He denies pain or vertigo. On examination, the ear canal contains scanty whitish debris. His otoscopic image is shown (Image 2). Which of the following complications is most classically associated with this attic cholesteatoma?

Accepted Answer

A. Lateral semicircular canal fistula with perilymph leak

Answer

B. Perforation of the pars tensa with central conductive hearing loss

Answer

C. Eustachian tube dysfunction causing retraction of the posterior superior quadrant

Answer

D. Otitis media with effusion causing a type B tympanogram

Diseases of the Ear — MCQs

Diseases of the Ear — MCQs

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