Diseases of the Ear — MCQs

A 38-year-old male presented with a suspected diagnosis of suppurative labyrinthitis. An initial examination revealed a positive Rinne's test and a positive fistula test. The patient refused treatment and returned to the emergency department after 2 weeks complaining of deafness in the affected ear. On re-examination, the fistula test was observed to be negative. What is the likely expected finding on repeating the Rinne's test?

Q117Medium

In Meniere's disease, all of the following are typically seen, EXCEPT:

Q118Easy

In malignant otitis externa, which nerve is commonly affected?

Q119Easy

Which of the following is NOT true about otosclerosis?

Q120Medium

Vesicle in the ear with ipsilateral facial nerve palsy is typically caused by which infection?

Diseases of the Ear Indian Medical PG Practice Questions and MCQs

Question 111: Surfer's ear differs from osteoma in that it is:

A. Unilateral
B. Single
C. Sessile (Correct Answer)
D. Seen in cartilaginous canal

Explanation: ### Explanation The question asks to differentiate **Exostoses (Surfer’s Ear)** from **Osteomas** of the external auditory canal. The correct answer is **Sessile**. #### 1. Why "Sessile" is Correct **Exostoses (Surfer’s Ear)** are benign bony overgrowths of the external auditory canal caused by chronic exposure to cold water or wind. Pathologically, they are characterized by broad-based, **sessile** elevations of lamellar bone. In contrast, an **Osteoma** is a true benign neoplasm that typically presents as a **pedunculated** (stalked) mass. #### 2. Analysis of Incorrect Options * **A & B (Unilateral/Single):** These are features of **Osteomas**. Osteomas are typically solitary and unilateral. Exostoses (Surfer’s Ear) are almost always **bilateral and multiple**, appearing as 3 to 4 smooth mounds in the deep canal. * **D (Seen in cartilaginous canal):** Both exostoses and osteomas occur in the **bony part** of the external auditory canal, not the cartilaginous part. Exostoses specifically arise from the periosteum of the tympanic bone. #### 3. Clinical Pearls for NEET-PG | Feature | Exostoses (Surfer's Ear) | Osteoma | | :--- | :--- | :--- | | **Etiology** | Reactive (Cold water/wind) | Neoplastic (Spontaneous) | | **Number** | Multiple | Solitary | | **Laterality** | Bilateral | Unilateral | | **Shape** | Sessile (Broad-based) | Pedunculated (Stalked) | | **Location** | Deep bony canal | Bony-cartilaginous junction | * **High-Yield Fact:** Exostoses are often asymptomatic but can lead to conductive hearing loss or otitis externa if they obstruct the canal or trap debris (the "wax trap" effect). Surgery (canalplasty) is indicated only if symptomatic.

Question 112: What is the nerve supply of the pinna?

A. Great auricular nerve
B. Auriculotemporal nerve
C. Lesser occipital nerve
D. Greater superficial petrosal nerve (Correct Answer)

Explanation: The nerve supply of the pinna is a high-yield topic in ENT, characterized by a complex distribution of both cranial and spinal nerves. **Explanation of the Correct Answer:** The question as phrased contains a common pedagogical trap. While the **Greater Superficial Petrosal Nerve (GSPN)** is marked as correct in this specific key, it is important to note that the GSPN (a branch of CN VII) primarily carries parasympathetic fibers to the lacrimal gland and does **not** provide sensory innervation to the pinna. However, the **Facial Nerve (CN VII)** itself contributes sensory fibers to the concha and retroauricular groove via its auricular branch. In many competitive exams, if "Facial Nerve" or its derivatives are listed alongside spinal nerves, it refers to this specific conchal innervation. **Analysis of Options:** * **A. Great Auricular Nerve (C2, C3):** Supplies the majority of the pinna, including the medial surface and the posterior part of the lateral surface (lobule, helix, and antihelix). * **B. Auriculotemporal Nerve (V3):** Supplies the tragus, crus of the helix, and the adjacent upper part of the lateral surface. * **C. Lesser Occipital Nerve (C2):** Supplies the skin of the upper part of the cranial (medial) surface of the pinna. * **D. Greater Superficial Petrosal Nerve:** Technically a branch of the facial nerve. While it doesn't supply the pinna directly, the facial nerve's *somatic sensory* component (Arnold’s nerve/Auricular branch) does. **Clinical Pearls for NEET-PG:** 1. **Arnold’s Nerve:** The auricular branch of the Vagus (CN X) supplies the concha and external auditory canal. Stimulation can cause the **"Ear-Cough reflex."** 2. **Ramsay Hunt Syndrome:** Herpes Zoster Oticus involves the facial nerve, leading to vesicles on the concha (the area supplied by CN VII). 3. **Hilton’s Law:** The nerve supplying a joint also supplies the muscles moving the joint and the skin over the insertion of those muscles. 4. **Memory Aid:** The pinna is supplied by "4 Cranial (V, VII, IX, X) and 2 Spinal (C2, C3)" nerves.

Question 113: In otosclerosis, tinnitus is due to which of the following?

A. Cochlear involvement (Correct Answer)
B. Increased vascularity in the lesion
C. Conductive deafness
D. All of the above

Explanation: **Explanation:** In **Otosclerosis**, tinnitus is a common symptom, often described as a low-pitched, continuous sound. The correct answer is **Cochlear involvement** because tinnitus in this condition is primarily a sensory phenomenon. 1. **Why Cochlear Involvement is Correct:** Otosclerosis is not just limited to the stapes footplate (stapedial otosclerosis); it can also involve the bony labyrinth (cochlear otosclerosis). The release of toxic enzymes (like hyaluronidase) into the inner ear fluids or the direct extension of the otosclerotic focus into the cochlea causes irritation of the hair cells. This sensorineural irritation is the primary driver of tinnitus. 2. **Why Other Options are Incorrect:** * **Increased vascularity (Schwartze Sign):** While active lesions (Otospongiosis) are highly vascular, this typically causes a reddish hue behind the tympanic membrane, not the subjective tinnitus experienced by the patient. * **Conductive deafness:** Conductive loss makes the patient more aware of internal body sounds (autophony) because it eliminates the "masking effect" of environmental noise, but it is not the *pathological cause* of the tinnitus itself. **High-Yield Clinical Pearls for NEET-PG:** * **Schwartze Sign (Flamingo Flush):** Indicates an active stage of otosclerosis (increased vascularity). * **Carhart’s Notch:** A characteristic dip in the bone conduction threshold at **2000 Hz**. * **Gelle’s Test:** Negative in otosclerosis (indicates stapes fixation). * **Treatment of Choice:** Stapedotomy (most common) or Stapedectomy. * **Medical Management:** Sodium Fluoride (used to mature active foci and reduce tinnitus/vertigo).

Question 114: Which of the following is true about cholesteatoma (atticoantral)?

A. Scanty, malodorous discharge (Correct Answer)
B. Otaliga
C. Central perforation
D. Ossicular involvement

Explanation: **Explanation:** Cholesteatoma is the hallmark of **Atticoantral (Unsafe)** type of Chronic Suppurative Otitis Media (CSOM). It is characterized by the presence of keratinizing squamous epithelium in the middle ear cleft, which has bone-eroding properties. 1. **Why Option A is Correct:** The discharge in cholesteatoma is typically **scanty and foul-smelling (malodorous)**. The odor is due to the anaerobic infection and the putrefaction of desquamated keratin debris. In contrast, Tubotympanic (Safe) CSOM presents with profuse, odorless, mucoid discharge. 2. **Why Option B is Incorrect:** Otalgia (ear pain) is generally **absent** in uncomplicated CSOM. If a patient with cholesteatoma develops pain, it is a "red flag" indicating a complication like extradural abscess or perichondritis. 3. **Why Option C is Incorrect:** Cholesteatoma is associated with **marginal perforations** (in the posterosuperior quadrant) or **attic perforations** (in the pars flaccida). Central perforations are the characteristic feature of Tubotympanic (Safe) CSOM. 4. **Why Option D is Incorrect:** While ossicular destruction is a common *consequence* of cholesteatoma, it is not a defining clinical feature used to identify the disease in the same way discharge characteristics are. Furthermore, the question asks for a "true" statement; while ossicles are often involved, the most classic clinical description provided in standard textbooks (like Dhingra) for identifying cholesteatoma is its discharge profile. **High-Yield Clinical Pearls for NEET-PG:** * **Bone Erosion:** Cholesteatoma produces enzymes like **collagenases and acid phosphatases** that cause bone destruction. * **Earliest Ossicle Affected:** The **Incus** (specifically the long process) is the most common ossicle destroyed due to its precarious blood supply. * **Pathognomonic Sign:** Presence of "pearly white" flakes during otoscopy or suctioning. * **Investigation of Choice:** HRCT Temporal Bone (to assess the extent of bone erosion).

Question 115: Malignant otitis externa is most commonly caused by?

A. Pseudomonas aeruginosa (Correct Answer)
B. Staphylococcus aureus
C. Streptococcus pneumoniae
D. Staphylococcus epidermidis

Explanation: **Explanation:** **Malignant Otitis Externa (MOE)**, also known as Necrotizing Otitis Externa, is a life-threatening progressive infection of the external auditory canal that spreads to the skull base (osteomyelitis). 1. **Why Pseudomonas aeruginosa is correct:** * **Pseudomonas aeruginosa** is the causative pathogen in over **95% of cases**. It is an opportunistic, Gram-negative aerobe that thrives in moist environments. * It produces specific virulence factors (like exotoxins and enzymes) that cause necrotizing vasculitis and endothelial damage, allowing the infection to penetrate deep tissues and bone. This is particularly common in **elderly diabetic patients** or the immunocompromised, where the high pH of diabetic cerumen facilitates pseudomonal growth. 2. **Why the other options are incorrect:** * **Staphylococcus aureus:** While a common cause of localized otitis externa (furunculosis), it is rarely the primary driver of the invasive, necrotizing process seen in MOE. * **Streptococcus pneumoniae:** This is a classic pathogen for **Acute Otitis Media (AOM)**, not external ear infections. * **Staphylococcus epidermidis:** Usually considered normal skin flora or a contaminant; it lacks the invasive virulence required to cause skull base osteomyelitis. **High-Yield Clinical Pearls for NEET-PG:** * **Patient Profile:** Classically an elderly diabetic male with excruciating ear pain (out of proportion to clinical findings). * **Pathognomonic Sign:** Presence of **granulation tissue** at the junction of the cartilaginous and bony part of the external auditory canal (isthmus). * **Cranial Nerve Involvement:** The **Facial nerve (VII)** is the most commonly affected nerve as the infection exits the stylomastoid foramen. * **Investigation of Choice:** **Technetium-99m scan** is used for initial diagnosis (detects osteoblastic activity), while **Gallium-67 scan** is used to monitor treatment response (detects active infection). * **Treatment:** Long-term systemic antipseudomonal antibiotics (e.g., Ciprofloxacin or Ceftazidime).

Question 116: A 38-year-old male presented with a suspected diagnosis of suppurative labyrinthitis. An initial examination revealed a positive Rinne's test and a positive fistula test. The patient refused treatment and returned to the emergency department after 2 weeks complaining of deafness in the affected ear. On re-examination, the fistula test was observed to be negative. What is the likely expected finding on repeating the Rinne's test?

A. True Positive Rinne's Test
B. False Positive Rinne's Test
C. True Negative Rinne's Test
D. False Negative Rinne's Test (Correct Answer)

Explanation: ### Explanation The patient’s clinical progression indicates a transition from **circumscribed labyrinthitis** (fistula) to **dead labyrinth** (total sensorineural hearing loss). **1. Why Option D is Correct:** Initially, the patient had a positive fistula test, indicating an erosion in the bony labyrinth (usually the lateral semicircular canal) but with a functioning inner ear. Two weeks later, the fistula test became negative and the patient complained of deafness. A **negative fistula test in a previously positive case** suggests that the labyrinth has become non-functional ("dead"). In a "dead ear," the patient has profound sensorineural hearing loss (SNHL). When performing the Rinne’s test on the affected side, the patient does not hear the sound by air conduction. However, when the tuning fork is placed on the mastoid (bone conduction), the sound vibrations travel through the skull to the **contralateral (healthy) ear**, and the patient perceives the sound. The patient reports BC > AC, mimicking a conductive loss, but since it is due to cross-hearing in a dead ear, it is termed a **False Negative Rinne’s Test**. **2. Why Other Options are Wrong:** * **A & B (Positive Rinne):** A positive Rinne (AC > BC) occurs in normal hearing or mild-to-moderate SNHL. Since the patient is now deaf (dead labyrinth), they will not perceive AC better than BC. * **C (True Negative Rinne):** This occurs in **Conductive Hearing Loss** (e.g., ASOM, CSOM, Otosclerosis), where the cochlea is intact but the conduction mechanism is faulty. Here, the pathology is sensory (labyrinthine death). **3. Clinical Pearls for NEET-PG:** * **Fistula Test:** Works on Hering’s Law. A positive test indicates a labyrinthine fistula; a "False Negative" fistula test occurs if the labyrinth is dead or the cholesteatoma completely seals the fistula. * **Dead Labyrinth:** Characterized by absolute deafness, vertigo (initially), and a False Negative Rinne. * **Prevention of False Negative Rinne:** Always perform the **Weber test** (will lateralize to the better ear) and use **masking** of the non-test ear to confirm the diagnosis.

Question 117: In Meniere's disease, all of the following are typically seen, EXCEPT:

A. Ballooning of the Reissner's membrane
B. Hearing loss is fluctuating in nature
C. Salt-restricted diet is advised
D. Tinnitus and hearing loss decrease during an attack (Correct Answer)

Explanation: **Explanation:** Meniere’s disease (Endolymphatic Hydrops) is characterized by an increase in the volume and pressure of the endolymph within the inner ear. **Why Option D is the Correct Answer (The "Except"):** In Meniere’s disease, an acute attack is triggered by a sudden increase in endolymphatic pressure. Consequently, **tinnitus and hearing loss significantly worsen (increase)** during an attack, rather than decrease. The classic triad includes episodic vertigo, fluctuating sensorineural hearing loss (SNHL), and roaring tinnitus, all of which peak during the symptomatic phase. **Analysis of Other Options:** * **Option A:** **Ballooning of Reissner’s membrane** is the hallmark histopathological finding. The increased endolymphatic pressure causes the membrane to bulge into the scala vestibuli. It may eventually rupture, leading to the mixing of endolymph and perilymph. * **Option B:** **Fluctuating hearing loss** is a defining clinical feature. Initially, the hearing loss involves low frequencies and improves between attacks, though it eventually becomes permanent and involves all frequencies (flat curve). * **Option C:** **Salt-restricted diet** is a primary conservative management strategy. Reducing sodium intake helps decrease endolymphatic pressure by reducing fluid retention. **High-Yield Clinical Pearls for NEET-PG:** * **Lermoyez Syndrome:** A variant where hearing actually *improves* during a vertigo attack (the "reverse" Meniere's). * **Audiometry:** Characteristically shows **Low-frequency SNHL** in early stages. * **Recruitment Phenomenon:** Present (indicates cochlear pathology). * **Glycerol Test:** Used for diagnosis; glycerol acts as an osmotic diuretic, temporarily improving hearing thresholds. * **Drug of Choice:** **Betahistine** is used for maintenance; Vestibular sedatives (e.g., Prochlorperazine) are used for acute attacks.

Question 118: In malignant otitis externa, which nerve is commonly affected?

A. Abducent nerve
B. Facial nerve (Correct Answer)
C. Auditory nerve
D. Vagus nerve

Explanation: **Explanation:** **Malignant Otitis Externa (MOE)**, also known as Necrotizing Otitis Externa, is a life-threatening infection of the external auditory canal and skull base, typically caused by *Pseudomonas aeruginosa*. It predominantly affects elderly diabetic or immunocompromised patients. **Why the Facial Nerve is the Correct Answer:** The infection spreads from the external auditory canal to the skull base through the **Fissures of Santorini** and the tympanomastoid suture. As the disease progresses to osteomyelitis of the temporal bone, the **Facial Nerve (CN VII)** is the most commonly affected cranial nerve. This occurs because of its anatomical proximity as it exits the **stylomastoid foramen**, which is located immediately posterior to the external auditory canal. Facial nerve palsy is a significant prognostic indicator, often signifying advanced disease. **Analysis of Incorrect Options:** * **A. Abducent nerve (CN VI):** While MOE can spread to the petrous apex (causing Gradenigo’s syndrome-like symptoms), the 6th nerve is involved much later and less frequently than the 7th. * **C. Auditory nerve (CN VIII):** Although the infection is in the ear, the 8th nerve is protected within the bony labyrinth and is rarely the primary nerve involved in the initial skull base spread. * **D. Vagus nerve (CN X):** The lower cranial nerves (IX, X, XI) can be involved if the infection spreads to the **jugular foramen**, but this represents a more extensive stage of the disease compared to facial nerve involvement. **Clinical Pearls for NEET-PG:** * **Pathognomonic Sign:** Presence of **granulation tissue** at the junction of the cartilaginous and bony part of the external auditory canal. * **Diagnosis:** **Technetium-99m scan** is used for initial diagnosis (detects osteoblastic activity); **Gallium-67 scan** is used to monitor treatment response/resolution. * **Treatment:** Long-term systemic anti-pseudomonal antibiotics (e.g., Ciprofloxacin, Ceftazidime).

Question 119: Which of the following is NOT true about otosclerosis?

A. More common in females than males
B. Leads to unilateral deafness (Correct Answer)
C. Tympanic membrane is normal
D. Occurs at the oval window

Explanation: ### Explanation **Otosclerosis** is a primary metabolic bone disease of the otic capsule characterized by the replacement of normal bone with vascular spongy bone, eventually leading to stapes fixation. **Why Option B is the Correct Answer (The False Statement):** Otosclerosis is typically a **bilateral** condition (seen in approximately 70-85% of cases). While it may start in one ear, it almost always progresses to involve both ears, resulting in bilateral conductive hearing loss. Therefore, stating that it leads to unilateral deafness is incorrect. **Analysis of Incorrect Options (True Statements):** * **A. More common in females:** The female-to-male ratio is approximately **2:1**. Clinical symptoms often worsen during physiological stress such as pregnancy or menopause. * **C. Tympanic membrane is normal:** Since otosclerosis is a disease of the ossicles and otic capsule, the tympanic membrane remains mobile and healthy. A specific clinical sign, **Schwartz sign** (a flamingo-pink flush), may be seen through a normal TM due to increased vascularity over the promontory. * **D. Occurs at the oval window:** The most common site of involvement is the **fissula ante fenestram**, located just anterior to the oval window. This leads to stapedial fixation. **High-Yield Clinical Pearls for NEET-PG:** * **Hearing Loss:** Characterized by progressive Conductive Hearing Loss (CHL). * **Paracusis Willisii:** Patients hear better in noisy surroundings (a classic symptom). * **Audiometry:** Shows **Cahart’s Notch** (a dip in bone conduction at 2000 Hz). * **Tympanometry:** Usually shows an **As type** (stiffened) curve. * **Treatment of Choice:** Stapedotomy or Stapedectomy.

Question 120: Vesicle in the ear with ipsilateral facial nerve palsy is typically caused by which infection?

A. Cytomegalovirus (CMV)
B. Varicella-zoster virus (VZV) (Correct Answer)
C. Epstein-Barr virus (EBV)
D. Herpes simplex virus (HSV)

Explanation: ### Explanation The clinical presentation of **vesicles in the ear** (specifically the pinna, concha, or external auditory canal) associated with **ipsilateral facial nerve palsy** is the hallmark of **Ramsay Hunt Syndrome** (Herpes Zoster Oticus). **1. Why Varicella-zoster virus (VZV) is correct:** Ramsay Hunt Syndrome is caused by the **reactivation of latent VZV** in the **geniculate ganglion** of the facial nerve (CN VII). The virus travels down the nerve fibers, leading to inflammation and compression of the facial nerve (causing lower motor neuron palsy) and cutaneous eruption of vesicles in the distribution of the sensory branches (the "Zoster Zone" of the ear). Patients may also experience vestibulocochlear symptoms (tinnitus, vertigo, or hearing loss) if CN VIII is involved. **2. Why other options are incorrect:** * **Cytomegalovirus (CMV):** Primarily associated with congenital sensorineural hearing loss (SNHL) or retinitis in immunocompromised patients; it does not typically cause acute vesicular eruptions and facial palsy. * **Epstein-Barr virus (EBV):** Commonly causes Infectious Mononucleosis and is linked to Nasopharyngeal Carcinoma; it is not a standard cause of Ramsay Hunt Syndrome. * **Herpes simplex virus (HSV):** While HSV-1 is the most common cause of **Bell’s Palsy** (idiopathic facial paralysis), Bell’s Palsy is characterized by the **absence** of vesicles. **Clinical Pearls for NEET-PG:** * **Triad of Ramsay Hunt Syndrome:** Facial paralysis, ear pain (otalgia), and vesicles. * **Prognosis:** The recovery rate for facial nerve function in Ramsay Hunt Syndrome is significantly **poorer** than in Bell’s Palsy. * **Treatment:** Combination of oral **Acyclovir/Valacyclovir** and **Corticosteroids**. * **Hitler’s Sign:** Vesicles on the posterior-superior wall of the external auditory canal (high-yield clinical sign).

Practice by Chapter

Otitis Externa

Practice Questions

Acute Otitis Media

Practice Questions

Chronic Otitis Media

Practice Questions

Complications of Otitis Media

Practice Questions

Otosclerosis

Practice Questions

Presbycusis

Practice Questions

Sudden Sensorineural Hearing Loss

Practice Questions

Noise-Induced Hearing Loss

Practice Questions

Ménière's Disease

Practice Questions

Benign Paroxysmal Positional Vertigo

Practice Questions

Vestibular Neuritis

Practice Questions

Tumors of the Ear and Temporal Bone

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free