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.

Q: Which of the following is a true differential cause of referred otalgia?

All of the above. **Explanation:** Referred otalgia occurs when pain is felt in the ear due to a shared nerve supply with a distant site of pathology. The ear receives sensory innervation from several cranial nerves (V, VII, IX, and X) and cervical nerves (C2, C3). Therefore, any lesion in the regions supplied by these nerves can present as ear pain. * **Carcinoma of the Larynx (Option A):** The larynx is supplied by the **Vagus nerve (CN X)** via the superior and recurrent laryngeal nerves. The ear is also supplied by the Vagus nerve via **Arnold’s nerve** (auricular branch). Malignancies of the supraglottis or hypopharynx frequently refer pain to the ear. * **Carcinoma of the Oral Cavity (Option B):** The anterior two-thirds of the tongue and the floor of the mouth are supplied by the **Mandibular nerve (V3)**. This shares a pathway with the **Auriculotemporal nerve**, which supplies the external auditory canal and TMJ. * **Carcinoma of the Tongue (Option C):** The posterior one-third of the tongue and the oropharynx are supplied by the **Glossopharyngeal nerve (CN IX)**. This nerve also provides sensation to the middle ear via **Jacobson’s nerve** (tympanic branch). This is a classic cause of referred otalgia in cases of tonsillitis or base-of-tongue tumors. **Clinical Pearls for NEET-PG:** * **The "Rule of 5":** Remember the nerves involved: CN V, VII, IX, X, and Cervical plexus (C2, C3). * **Trotter’s Triad:** Nasopharyngeal carcinoma can present with conductive hearing loss, palatal palsy, and referred otalgia (due to CN V involvement). * **High-Yield Fact:** In an elderly patient with a normal-looking ear exam complaining of otalgia, always perform a thorough fiberoptic laryngoscopy (FOL) to rule out an occult malignancy of the upper aerodigestive tract.

Q: Bleeding ear discharge is mostly due to which of the following conditions?

Glomus tumour. **Explanation:** **Glomus Tumour (Correct Answer):** Glomus tumours (Paragangliomas) are highly vascular, benign but locally invasive neoplasms arising from the glomus bodies in the middle ear (Glomus Tympanicum) or jugular bulb (Glomus Jugulare). Because these tumours are composed of a dense network of blood vessels, they are prone to spontaneous bleeding. **Bleeding ear discharge (otorrhagia)** is a classic presentation, often occurring after minor trauma or spontaneously as the tumour erodes the tympanic membrane. **Why the other options are incorrect:** * **Otosclerosis:** This is a metabolic bone disease of the otic capsule causing stapes fixation. It presents with progressive **painless conductive hearing loss** and a normal-looking tympanic membrane (except for the occasional Flamingo flush/Schwartz sign). There is no discharge or bleeding. * **Otitis Media with Effusion (OME):** This involves the accumulation of non-purulent fluid in the middle ear. It presents with hearing loss and a **retracted/dull tympanic membrane**. Discharge only occurs if the membrane ruptures, and even then, it is serous or mucoid, not primarily bloody. * **Acoustic Neuroma:** This is a benign tumour of the 8th cranial nerve (vestibular schwannoma). It is located in the internal auditory canal or cerebellopontine angle. It presents with **unilateral sensorineural hearing loss and tinnitus**, but never with ear discharge or bleeding as it is not located in the middle ear. **High-Yield Clinical Pearls for NEET-PG:** * **Pulsatile Tinnitus:** The most common early symptom of Glomus tumour ("hearing one's own heartbeat"). * **Brown’s Sign:** Pulsations seen on the tympanic membrane that blanch with positive pressure using a Siegle’s speculum (Pathognomonic for Glomus). * **Aquino’s Sign:** Blanching of the tympanic mass upon carotid artery compression. * **Rising Sun Appearance:** A red/blue fleshy mass seen behind an intact tympanic membrane.

Q: Which ossicle is most commonly involved in chronic suppurative otitis media (CSOM)?

Incus. **Explanation:** In Chronic Suppurative Otitis Media (CSOM), particularly the atticoantral type, the ossicular chain is frequently damaged due to bone-eroding mediators and pressure necrosis. **Why the Incus is the Correct Answer:** The **Incus** is the most commonly involved ossicle in CSOM. Specifically, the **long process of the incus** is the most vulnerable site. This susceptibility is due to its precarious blood supply (terminal branches of the anterior tympanic and deep auricular arteries) and its anatomical position, which makes it prone to ischemia when there is persistent inflammation or pressure from a cholesteatoma. **Analysis of Incorrect Options:** * **Malleus:** While the malleus is frequently involved, it is more resistant than the incus because it is firmly embedded within the layers of the tympanic membrane, providing it with a more robust collateral blood supply. The handle of the malleus is the second most common site of necrosis. * **Stapes:** The stapes is generally the most resistant ossicle. However, when it is involved, the suprastructure (crura) is usually destroyed first, while the footplate often remains intact, acting as a barrier to the inner ear. * **All the above:** While all ossicles *can* be affected, the question asks for the *most common*, making this option incorrect. **High-Yield Clinical Pearls for NEET-PG:** * **Most common ossicle affected:** Incus (Long process). * **Second most common ossicle affected:** Malleus (Handle). * **Most resistant ossicle:** Stapes (specifically the footplate). * **Mechanism of destruction:** Primarily due to osteoclast activation and collagenases triggered by chronic inflammation or cholesteatoma. * **Reconstruction:** If the incus is missing but the stapes is intact, a **Type II Tympanoplasty** (ossicular reconstruction) is often performed.

Q: Acute suppurative otitis media (ASOM) is treated using which of the following antimicrobial classes, except?

Streptomycin. **Explanation:** The primary goal in treating **Acute Suppurative Otitis Media (ASOM)** is to cover the most common causative organisms: *Streptococcus pneumoniae*, *Haemophilus influenzae*, and *Moraxella catarrhalis*. **Why Streptomycin is the Correct Answer:** Streptomycin is an **Aminoglycoside**. While effective against certain gram-negative bacteria, it is **not used** for ASOM for two critical reasons: 1. **Ototoxicity:** Streptomycin is highly vestibulotoxic and cochleotoxic. Using it to treat an ear infection poses a significant risk of permanent sensorineural hearing loss and equilibrium disruption. 2. **Spectrum:** It has poor activity against the typical respiratory pathogens that cause ASOM. **Analysis of Incorrect Options:** * **Penicillins (e.g., Amoxicillin):** This is the **drug of choice** for ASOM. Amoxicillin (often with Clavulanic acid) effectively targets *S. pneumoniae*. * **Cephalosporins (e.g., Cefuroxime, Ceftriaxone):** These are excellent second-line agents, especially in cases of penicillin resistance or treatment failure. * **Erythromycin (Macrolides):** Macrolides (including Azithromycin/Clarithromycin) are the preferred alternatives for patients with **penicillin allergies**. **NEET-PG High-Yield Pearls:** * **Drug of Choice (DOC):** Amoxicillin remains the first-line treatment for ASOM. * **Most Common Organism:** *Streptococcus pneumoniae* is the most frequent cause of ASOM across all age groups. * **Aminoglycoside Caution:** Never use aminoglycoside ear drops if a tympanic membrane perforation is suspected (due to risk of ototoxicity), and they are never the systemic choice for uncomplicated ASOM. * **Myringotomy Indication:** If the tympanic membrane is bulging and the patient has severe pain or high fever, a myringotomy (curvilinear incision in the posteroinferior quadrant) may be required.

Q: A 57-year-old patient has been diagnosed with a posterior superior retraction pocket cholesteatoma. All would constitute part of the management, except?

Myringoplasty. **Explanation:** The patient has a **posterior superior retraction pocket cholesteatoma**, which is a form of **Attico-antral (Unsafe) Chronic Suppurative Otitis Media (CSOM)**. This condition involves bone erosion and the presence of keratinizing squamous epithelium in the middle ear cleft, posing a risk of intracranial complications. **Why Myringoplasty is the correct answer (the "Except"):** Myringoplasty is defined as the surgical repair of a perforation in the tympanic membrane (pars tensa) without any middle ear exploration. It is indicated for **Tubotympanic (Safe) CSOM**. In the case of a retraction pocket cholesteatoma, the disease is not a simple perforation; it involves an invagination of the drum that often extends into the attic or mastoid. Simple closure of the drum (myringoplasty) would "trap" the cholesteatoma inside, leading to worsening bone destruction. **Analysis of other options:** * **Audiometry:** Essential pre-operative step to assess the degree of conductive hearing loss and check the cochlear reserve (bone conduction) before surgery. * **Mastoid Exploration (Canal Wall Down/Up Mastoidectomy):** The primary treatment for cholesteatoma is the surgical removal of the disease from the attic, antrum, and mastoid air cells to create a "safe" ear. * **Tympanoplasty:** This involves the eradication of disease from the middle ear cavity combined with the reconstruction of the hearing mechanism (ossiculoplasty and/or grafting). It is a standard part of the definitive management of unsafe CSOM. **Clinical Pearls for NEET-PG:** * **Cholesteatoma Theory:** The "Invagination Theory" (Wittmaack’s) explains posterior superior retraction pockets due to negative middle ear pressure. * **Surgery Goal:** The priority in cholesteatoma surgery is **Safety first**, followed by a dry ear, and lastly, hearing preservation. * **Prussak’s Space:** The most common site for the origin of a primary acquired cholesteatoma.

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

Question 6

Which of the following is a true differential cause of referred otalgia?

Accepted Answer

All of the above

Answer

Carcinoma of the larynx

Answer

Carcinoma of the oral cavity

Answer

Carcinoma of the tongue

Question 7

Bleeding ear discharge is mostly due to which of the following conditions?

Accepted Answer

Glomus tumour

Answer

Otosclerosis

Answer

Otitis media with effusion

Answer

Acoustic neuroma

Question 8

Which ossicle is most commonly involved in chronic suppurative otitis media (CSOM)?

Accepted Answer

Incus

Answer

Malleus

Answer

Stapes

Answer

All the above

Question 9

Acute suppurative otitis media (ASOM) is treated using which of the following antimicrobial classes, except?

Accepted Answer

Streptomycin

Answer

Erythromycin

Answer

Penicillin

Answer

Cephalosporin

Question 10

A 57-year-old patient has been diagnosed with a posterior superior retraction pocket cholesteatoma. All would constitute part of the management, except?

Accepted Answer

Myringoplasty

Answer

Audiometry

Answer

Mastoid exploration

Answer

Tympanoplasty

Diseases of the Ear — MCQs

Diseases of the Ear — MCQs

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