Diseases of the Ear Practice Questions

Q: A boy with acute suppurative otitis media (ASOM) is undergoing treatment with penicillin therapy for 7 days. He now presents with subsidence of pain and persistence of deafness. What is the most likely diagnosis?

Secretory otitis media. **Explanation:** The scenario describes a classic case of **"Masked Mastoiditis"** or **Resolution of ASOM into Secretory Otitis Media (SOM)** due to inadequate or incomplete antibiotic therapy. **Why Secretory Otitis Media is correct:** In ASOM, penicillin effectively treats the acute bacterial infection, leading to the subsidence of pain (otalgia) and fever. However, if the underlying Eustachian tube dysfunction persists or if the infection is only partially resolved, sterile fluid remains trapped in the middle ear cleft. This transition from an acute suppurative stage to a chronic non-suppurative stage results in persistent **conductive hearing loss** (deafness) despite the disappearance of acute symptoms. **Why the other options are incorrect:** * **Ototoxicity:** Penicillin is not ototoxic. Ototoxicity (usually caused by aminoglycosides) typically presents with sensorineural hearing loss and vertigo, not as a sequel to treated ASOM. * **Adhesive Otitis Media:** This is a late-stage complication where the tympanic membrane becomes retracted and "plastered" onto the promontory due to long-standing negative pressure. It does not occur acutely within 7 days. * **Tympanosclerosis:** This refers to hyalinization and calcification of the tympanic membrane (chalky white patches). It is a sequela of chronic inflammation, not an immediate post-treatment finding of ASOM. **NEET-PG High-Yield Pearls:** * **Masked Mastoiditis:** Often caused by inadequate antibiotic dose/duration. The classic triad is: *subsidence of pain, persistent deafness, and a thickened/dull tympanic membrane.* * **Treatment of choice for SOM:** Initially medical (decongestants); if persistent, **Myringotomy with Grommet insertion**. * **Hearing Loss Type:** ASOM and SOM both cause **Conductive Hearing Loss**. If a patient develops vertigo or SNHL, suspect labyrinthitis.

Q: A 3-year-old girl ruptured her eardrum when she inserted a pencil into her ear. Her mother took her to the emergency department after noticing that the child was crying and complaining of pain in her ear with a few drops of blood in the external auditory meatus. The attending doctor examined the child for possible injury to a nerve that runs across the eardrum. Which is the MOST likely nerve to be injured?

Chorda tympani. **Explanation:** **1. Why Chorda Tympani is Correct:** The **chorda tympani** is a branch of the facial nerve (CN VII) that carries taste sensation from the anterior two-thirds of the tongue and parasympathetic fibers to the submandibular and sublingual glands. Anatomically, it enters the middle ear through the posterior canaliculus and runs across the medial surface of the **upper part of the tympanic membrane (pars tensa)**, passing between the handle of the malleus and the long process of the incus. Due to its superficial position directly medial to the eardrum, it is the nerve most vulnerable to injury during traumatic tympanic membrane perforations (like pencil injuries) or middle ear surgeries (like stapedectomy). **2. Why Other Options are Incorrect:** * **Auricular branch of the vagus (Arnold’s nerve):** This nerve supplies the skin of the external auditory canal and the lateral surface of the tympanic membrane. While it mediates the "ear-cough reflex," it does not run *across* the drum; it is sensory to the outer surface. * **Glossopharyngeal nerve (CN IX):** It contributes to the **tympanic plexus** located on the promontory (medial wall of the middle ear), which is deeper and less likely to be injured by a superficial penetration compared to the chorda tympani. * **Lesser petrosal nerve:** This is a continuation of the tympanic plexus carrying preganglionic parasympathetic fibers to the otic ganglion. It exits the middle ear through the tegmen tympani and is not in direct contact with the tympanic membrane. **Clinical Pearls for NEET-PG:** * **Clinical sign of injury:** Damage to the chorda tympani results in a **metallic taste** or loss of taste on the ipsilateral anterior 2/3rd of the tongue. * **Anatomical Landmark:** It passes through the **Iter chordae anterius** (canal of Huguier) to exit the middle ear. * **Trauma:** In cases of longitudinal temporal bone fractures, the chorda tympani is frequently involved.

Q: What is the investigation of choice for cholesteatoma?

HRCT temporal bone. **Explanation:** **Cholesteatoma** is a destructive, non-neoplastic lesion characterized by the presence of keratinizing squamous epithelium within the middle ear or mastoid. **Why HRCT Temporal Bone is the Investigation of Choice:** High-Resolution Computed Tomography (HRCT) of the temporal bone is the gold standard for evaluating cholesteatoma. It provides superior bone detail, allowing for the precise assessment of: * **Bony Erosion:** Specifically of the scutum (often the earliest sign), ossicular chain, and mastoid air cells. * **Extent of Disease:** It maps the involvement of the attic, antrum, and middle ear cleft. * **Complications:** It identifies dehiscence of the fallopian canal (facial nerve), tegmen tympani (risk of intracranial spread), and the lateral semicircular canal (fistula). **Analysis of Incorrect Options:** * **A & C (X-rays):** Conventional radiography (Schuller’s or Lateral views) has been largely replaced by CT. While they can show mastoid pneumatization or large areas of destruction, they lack the sensitivity to detect early cholesteatoma or soft tissue extensions. * **B (Otoscopy):** While otoscopy is the **initial clinical step** and may show a retraction pocket or pearly white mass, it cannot determine the depth of the lesion or the extent of bony destruction behind the tympanic membrane. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest Bony Change:** Erosion of the **scutum** (outer attic wall). * **MRI (Non-EPI Diffusion Weighted):** This is the investigation of choice for detecting **recurrent or residual** cholesteatoma post-surgery, as it can differentiate between fibrous tissue/granulation and keratin. * **Clinical Sign:** A "marginal perforation" or "attic perforation" with foul-smelling discharge is classically associated with cholesteatoma.

Q: Medical treatment is not effective in which type of otitis media?

Secretory otitis media. **Explanation:** The correct answer is **Secretory Otitis Media (SOM)**, also known as Otitis Media with Effusion (OME). **Why Secretory Otitis Media?** The primary pathophysiology of SOM is **Eustachian tube dysfunction**, leading to negative middle ear pressure and the accumulation of sterile, non-purulent fluid. Unlike bacterial infections, SOM is **not an active inflammatory or infectious process** that responds to antibiotics. Medical management (decongestants, antihistamines, or steroids) has been proven largely ineffective in resolving the effusion. The definitive treatment is surgical: **Myringotomy with Grommet insertion**, which provides ventilation and equalizes pressure. **Analysis of Incorrect Options:** * **Tuberculous Otitis Media:** This is a chronic bacterial infection caused by *Mycobacterium tuberculosis*. It is treated medically with standard **Anti-Tubercular Therapy (ATT)**. * **Acute Suppurative Otitis Media (ASOM):** This is an acute bacterial infection (commonly *S. pneumoniae*). It responds excellently to **systemic antibiotics** (like Amoxicillin) and nasal decongestants. * **Chronic Suppurative Otitis Media (CSOM):** While the mucosal type (Tubotympanic) often requires surgery for permanent cure (Myringoplasty), the active infection is managed medically with **topical antibiotic ear drops** and aural toilet to achieve a "dry ear." **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis for SOM:** Impedance Audiometry (Tympanometry) showing a **Type B (Flat) curve**. * **Most common cause of SOM in children:** Adenoid hypertrophy. * **Unilateral SOM in an adult:** Must rule out **Nasopharyngeal Carcinoma** (biopsy of Fossa of Rosenmüller). * **Grommet placement:** Usually done in the **Antero-inferior quadrant** of the tympanic membrane to avoid injury to ossicles.

Q: A one-year-old child presents with bilateral hearing difficulty. Impedance audiometry shows a Type B curve and there is a bilateral conductive hearing deficit. There are no signs of infection. What is the next step?

Wait and watch. ### Explanation The clinical presentation describes **Otitis Media with Effusion (OME)**, also known as Serous Otitis Media or "Glue Ear." The presence of a **Type B (flat) tympanogram** indicates fluid in the middle ear, and the absence of fever or pain rules out acute infection. **1. Why "Wait and Watch" is correct:** In pediatric cases of OME, the standard of care is **watchful waiting for 3 months**. This is because approximately 75–90% of OME cases resolve spontaneously within this period. Since the child is only one year old and there are no signs of acute infection or structural damage, immediate surgical intervention is not indicated. **2. Why the other options are incorrect:** * **Grommet insertion (B):** This is indicated only if the effusion persists beyond 3 months (Chronic OME), if there is significant speech/language delay, or if there are structural changes to the tympanic membrane. * **Myringotomy and aspiration (C):** This provides temporary relief but has a high recurrence rate if done without a ventilation tube (grommet). It is not the first-line management for a fresh diagnosis. * **Canal wall down procedure (D):** This is a radical/modified radical mastoidectomy used for extensive Cholesteatoma or chronic suppurative otitis media (CSOM). It is entirely inappropriate for simple OME. **Clinical Pearls for NEET-PG:** * **Tympanometry Gold Standard:** Type B curve = Fluid (OME); Type C curve = Eustachian tube dysfunction (Negative pressure); Type As = Otosclerosis. * **First-line Medical Management:** There is no proven role for antibiotics, steroids, or antihistamines in OME; observation is the primary strategy. * **Hearing Loss:** OME is the most common cause of conductive hearing loss in children. * **Surgical Indications:** If OME persists >3 months AND is bilateral with hearing loss >20-30 dB, proceed to Myringotomy + Grommet insertion.

Q: Pulsatile otorrhoea is typically seen in which of the following conditions?

Acute suppurative otitis media (ASOM). **Explanation:** **Pulsatile otorrhoea** (also known as the **"Lighthouse effect"**) is a classic clinical sign of **Acute Suppurative Otitis Media (ASOM)** in the stage of suppuration/perforation. 1. **Why ASOM is correct:** During the acute phase of infection, the middle ear mucosa becomes intensely congested and hyperemic. When the tympanic membrane perforates due to pressure, the pus is extruded through a small perforation. Because the underlying mucosa is so vascular, the pulsations of the dilated capillaries are transmitted to the fluid (pus), causing it to "ebb and flow" or pulsate visibly through the perforation. 2. **Why other options are incorrect:** * **Glomus Tumor:** While this condition is famous for **pulsatile tinnitus** (the patient hears their heartbeat) and a "rising sun" appearance behind an intact drum, it does not typically cause pulsatile *otorrhoea* unless there is a secondary infection and perforation, which is rare. * **CSF Otorrhoea:** This presents as a clear, watery discharge (halo sign). While it may pulsate in sync with intracranial pressure changes, it is not the "typical" or classic association taught for this clinical sign in exams. * **Fistula:** A labyrinthine fistula typically presents with vertigo and nystagmus triggered by pressure changes (Hennebert’s sign), not pulsatile discharge. **High-Yield Clinical Pearls for NEET-PG:** * **Lighthouse Sign:** Always associate this term with ASOM. * **Pulsatile Tinnitus vs. Otorrhoea:** If the patient *hears* the pulse, think Glomus Jugulare or Carotid Body Tumor. If the doctor *sees* the discharge pulsing, think ASOM. * **Management of ASOM:** The treatment of choice is systemic antibiotics. If the drum is bulging and painful (pre-perforation), a **myringotomy** is performed in the postero-inferior quadrant.

Q: Which of the following conditions is characterized by a "rising sun" appearance?

Glomus tumor. **Explanation:** The **"Rising Sun" appearance** is a classic otoscopic finding pathognomonic for a **Glomus Tumor** (specifically Glomus Jugulare or Glomus Tympanicum). These are highly vascular, slow-growing, benign but locally invasive paragangliomas. The appearance is caused by a red, fleshy, vascular mass located behind an intact tympanic membrane, typically arising from the hypotympanum and resembling a sun rising over the horizon. **Why the other options are incorrect:** * **Acute Suppurative Otitis Media (ASOM):** Characterized by a **"Cartwheel appearance"** due to radiating congestion of the tympanic membrane or a bulging, hyperemic drum. * **Chronic Suppurative Otitis Media (CSOM):** Typically presents with a permanent perforation of the tympanic membrane (central or marginal) and otorrhea, not a vascular mass. * **Acoustic Neuroma:** This is a tumor of the 8th cranial nerve (vestibulocochlear). Since it is located in the internal auditory canal or cerebellopontine angle, the tympanic membrane appears **normal** on otoscopy. **High-Yield Clinical Pearls for NEET-PG:** * **Pulsatile Tinnitus:** The most common presenting symptom of Glomus tumors (synchronous with the pulse). * **Brown’s Sign:** Positive when the mass blanches on applying pressure with a Siegle’s speculum. * **Aquino’s Sign:** Pulsations of the mass decrease or stop upon carotid artery compression. * **Phelps’ Sign:** Loss of the bony plate between the jugular bulb and the middle ear (seen on CT). * **Treatment of Choice:** Surgical excision; preoperative embolization is often used to reduce vascularity.

Question 1

A boy with acute suppurative otitis media (ASOM) is undergoing treatment with penicillin therapy for 7 days. He now presents with subsidence of pain and persistence of deafness. What is the most likely diagnosis?

Accepted Answer

Secretory otitis media

Answer

Ototoxicity

Answer

Adhesive otitis media

Answer

Tympanosclerosis

Question 2

A 3-year-old girl ruptured her eardrum when she inserted a pencil into her ear. Her mother took her to the emergency department after noticing that the child was crying and complaining of pain in her ear with a few drops of blood in the external auditory meatus. The attending doctor examined the child for possible injury to a nerve that runs across the eardrum. Which is the MOST likely nerve to be injured?

Accepted Answer

Chorda tympani

Answer

Auricular branch of the vagus

Answer

Glossopharyngeal nerve (CN IX)

Answer

Lesser petrosal nerve

Question 3

What is the investigation of choice for cholesteatoma?

Accepted Answer

HRCT temporal bone

Answer

Schuller's view X-ray

Answer

Otoscopy

Answer

Skull X-ray, lateral view

Question 4

Medical treatment is not effective in which type of otitis media?

Accepted Answer

Secretory otitis media

Answer

Tuberculous otitis media

Answer

Acute suppurative otitis media

Answer

Chronic suppurative otitis media

Question 5

Cholesteatoma most commonly occurs in which of the following conditions?

Accepted Answer

Acute necrotizing otitis media

Answer

Chronic suppurative otitis media with central perforation

Answer

Masked mastoiditis

Answer

Coalescent mastoiditis

Question 6

A one-year-old child presents with bilateral hearing difficulty. Impedance audiometry shows a Type B curve and there is a bilateral conductive hearing deficit. There are no signs of infection. What is the next step?

Accepted Answer

Wait and watch

Answer

Grommet insertion

Answer

Myringotomy and aspiration

Answer

Canal wall down procedure

Question 7

A 7-year-old child with acute otitis media was treated with antibiotics for 10 days. His pain and fever subsided completely, but he still has conductive hearing loss. What is the next line of treatment?

Accepted Answer

Wait and observe for 3 months for spontaneous fluid drainage.

Answer

Give another course of a different antibiotic.

Answer

Perform a myringotomy and culture the middle ear fluid.

Answer

Perform a myringotomy and insert a grommet.

Question 8

What causes the maximum hearing loss?

Accepted Answer

Obliteration of the oval window

Answer

Ossicular chain damage

Answer

Tympanic membrane perforation

Answer

Blockage of the ear canal

Question 9

Pulsatile otorrhoea is typically seen in which of the following conditions?

Accepted Answer

Acute suppurative otitis media (ASOM)

Answer

Glomus tumor

Answer

CSF otorrhea

Answer

Fistula

Question 10

Which of the following conditions is characterized by a "rising sun" appearance?

Accepted Answer

Glomus tumor

Answer

Acute suppurative otitis media (ASOM)

Answer

Chronic suppurative otitis media (CSOM)

Answer

Acoustic neuroma

Diseases of the Ear — MCQs

Diseases of the Ear — MCQs

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