Diseases of the Ear — MCQs

Diseases of the Ear Indian Medical PG Practice Questions and MCQs

Question 131: A patient presents with hearing loss and a sensation of fullness in the left ear. What is the most likely diagnosis?

A. Cholesteatoma
B. Fracture of the temporal bone (Correct Answer)
C. Ochronosis
D. Otomycosis

Explanation: **Explanation:** The correct answer is **Fracture of the temporal bone**. Temporal bone fractures are a common cause of sudden hearing loss and ear fullness following head trauma. The hearing loss can be **conductive** (due to hemotympanum, tympanic membrane rupture, or ossicular disruption) or **sensorineural** (due to cochlear concussion or involvement of the otic capsule). The sensation of "fullness" is typically attributed to the accumulation of blood in the middle ear cleft (**hemotympanum**). **Analysis of Incorrect Options:** * **A. Cholesteatoma:** While it causes hearing loss, it is a chronic condition characterized by keratinizing squamous epithelium in the middle ear. It typically presents with foul-smelling ear discharge (otorrhea) rather than sudden fullness. * **C. Ochronosis:** This is a systemic manifestation of Alkaptonuria. While it can cause bluish-black pigmentation of the pinna and late-stage hearing loss due to ossicular stiffening, it is an extremely rare cause of acute ear fullness. * **D. Otomycosis:** This fungal infection of the external auditory canal presents with intense itching, pain, and debris. While it causes fullness, the hallmark is the presence of fungal hyphae (e.g., "wet newspaper" appearance for *Aspergillus niger*). **NEET-PG High-Yield Pearls:** * **Longitudinal Fractures (80%):** Most common; usually result in conductive hearing loss and bleeding from the ear. The facial nerve is involved in only 20% of cases. * **Transverse Fractures (20%):** More severe; often result in sensorineural hearing loss and vertigo due to otic capsule involvement. The facial nerve is involved in 50% of cases. * **Battle’s Sign:** Post-auricular ecchymosis indicating a posterior cranial fossa/temporal bone fracture. * **Hemotympanum:** A classic sign of temporal bone fracture where the tympanic membrane appears bright blue or dark red.

Question 132: Pinna calcification is seen in all except?

A. Gout (Correct Answer)
B. Ochronosis
C. Frost bite
D. Addison's disease

Explanation: **Explanation:** The correct answer is **Gout**. While gout is a systemic metabolic disorder, it typically presents in the pinna as **tophi**—deposits of monosodium urate crystals. These tophi are soft tissue swellings that may feel firm, but they represent **urate deposition**, not true calcification or ossification of the auricular cartilage. **Why the other options are causes of Pinna Calcification:** * **Ochronosis (Alkaptonuria):** This metabolic disorder leads to the deposition of homogentisic acid in connective tissues. This causes the cartilage to become brittle, dark-pigmented, and prone to secondary calcification. * **Frostbite:** Physical trauma from extreme cold leads to vascular compromise and perichondritis. During the healing process, the damaged auricular cartilage often undergoes dystrophic calcification. * **Addison’s Disease:** Chronic adrenocortical insufficiency is a classic systemic cause of "petrified ears." While the exact mechanism is debated, it is a high-yield association in medical literature. **Clinical Pearls for NEET-PG:** * **"Petrified Ear":** A clinical term used when the pinna becomes rigid and inflexible due to calcification or ossification. * **Other causes of Pinna Calcification:** Acromegaly, Diabetes Mellitus, Hyperthyroidism, and Relapsing Polychondritis. * **Most common cause:** Physical trauma (including frostbite and repeated hematomas, leading to "cauliflower ear"). * **Radiology:** On X-ray, the pinna will show increased radiodensity, confirming the diagnosis of calcification versus simple thickening.

Question 133: In Mastoiditis, tenderness is present at which anatomical landmark?

A. Tragus
B. Concha
C. Mastoid tip (Correct Answer)
D. All of the above

Explanation: ### Explanation **Correct Answer: C. Mastoid tip** **Medical Concept:** Mastoiditis is an inflammation of the mastoid air cells, usually occurring as a complication of Acute Otitis Media (AOM). The mastoid process is a bony prominence located behind the pinna. In acute mastoiditis, pus accumulates under pressure within the mastoid antrum and air cells, leading to hyperemia and osteitis of the overlying periosteum. This results in **exquisite tenderness** over the **mastoid tip** and the **Macewen’s triangle** (suprameatal triangle), which is the surgical landmark for the mastoid antrum. **Analysis of Incorrect Options:** * **A. Tragus:** Tenderness on pressing the tragus (**Tragus sign**) is a classic feature of **Otitis Externa** (inflammation of the external auditory canal) or furunculosis. It is absent in uncomplicated mastoiditis. * **B. Concha:** The concha is part of the external ear cartilage. While it may be displaced laterally or forward in mastoiditis (causing the "proptosis of the pinna"), direct tenderness of the concha itself is not a diagnostic sign of mastoiditis. * **D. All of the above:** Incorrect because tragal tenderness specifically differentiates external ear pathology from middle ear/mastoid pathology. **High-Yield Clinical Pearls for NEET-PG:** * **Reservoir Sign:** If the ear is mopped dry and pus reappears immediately in the meatus, it indicates a large reservoir of pus in the mastoid (highly suggestive of mastoiditis). * **Ironing out effect:** Due to periosteal thickening, the normal bony contours of the mastoid process feel smooth or "ironed out" on palpation. * **Radiology:** The investigation of choice is **HRCT Temporal Bone**, which shows clouding of air cells and loss of bony trabeculae (coalescent mastoiditis). * **Sagging of the posterosuperior meatal wall:** A pathognomonic sign caused by periosteitis adjacent to the mastoid antrum.

Question 134: On examination of the ear of a patient, you observe that the left ear tympanic membrane is reddish, immobile, and bulging, whilst the right ear tympanic membrane is white, mobile, and translucent. These findings suggest:

A. Right ear normal with left acute otitis media (Correct Answer)
B. Left ear normal with right acute otitis media
C. Bilateral ear normal
D. Bilateral acute otitis media

Explanation: ### Explanation **1. Why Option A is Correct:** The clinical description of the left ear—**reddish (hyperemic), immobile, and bulging**—is the classic triad for **Acute Otitis Media (AOM)** in the stage of suppuration. * **Redness:** Caused by intense vascular congestion of the tympanic membrane (TM). * **Bulging:** Occurs due to the accumulation of pus in the middle ear space, which increases pressure and pushes the TM outward (loss of landmarks). * **Immobility:** Pneumatic otoscopy would show no movement because the middle ear is filled with fluid/pus rather than air. Conversely, the right ear is described as **white (pearly gray), mobile, and translucent**. These are the hallmarks of a **normal tympanic membrane**. The translucency allows for the visualization of the long process of the incus and the cone of light, while mobility confirms a well-ventilated middle ear via the Eustachian tube. **2. Why Other Options are Incorrect:** * **Option B:** Reverses the findings; a white, mobile TM cannot be acutely infected. * **Option C:** The left ear findings (bulging and redness) are pathological and indicate an inflammatory process. * **Option D:** The right ear lacks any signs of inflammation (erythema) or effusion (immobility), ruling out bilateral involvement. **3. NEET-PG Clinical Pearls:** * **Stages of AOM:** 1. *Tubal Occlusion:* Retracted TM. 2. *Presuppuration:* Cartwheel appearance (vessels radiating from the handle of malleus). 3. *Suppuration:* Bulging TM (Lighthouse sign may be seen if a small perforation exists). 4. *Resolution/Coalescence.* * **Myringotomy Incision:** In AOM, it is performed in the **postero-inferior quadrant** to avoid injury to the ossicles (incus/stapes) and the chorda tympani nerve. * **Most Common Organism:** *Streptococcus pneumoniae* is the most common cause of AOM.

Question 135: What is the procedure for serous otitis media?

A. Tympanoplasty
B. Mastoidectomy
C. Myringotomy (Correct Answer)
D. Stapedotomy

Explanation: **Explanation:** **Serous Otitis Media (SOM)**, also known as Otitis Media with Effusion (OME) or "Glue Ear," is characterized by the accumulation of non-purulent fluid in the middle ear cleft, usually due to Eustachian tube dysfunction. **Why Myringotomy is the Correct Answer:** The primary goal of treatment in SOM is to evacuate the fluid and equalize middle ear pressure. **Myringotomy** (making a small incision in the tympanic membrane) is the surgical procedure of choice. It is typically performed in the **antero-inferior quadrant** to avoid injury to ossicular structures. In chronic or recurrent cases, a **Grommet (Ventilation Tube)** is inserted to provide long-term aeration of the middle ear. **Analysis of Incorrect Options:** * **Tympanoplasty:** This is a reconstructive procedure used to repair a perforated tympanic membrane and/or the ossicular chain (e.g., in Chronic Suppurative Otitis Media). In SOM, the drum is intact but retracted. * **Mastoidectomy:** This involves the removal of mastoid air cells, typically indicated for cholesteatoma or coalescent mastoiditis. It is too invasive for simple fluid drainage. * **Stapedotomy:** This is the surgery for Otosclerosis, involving the replacement of a fixed stapes footplate with a prosthesis. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Sign:** On otoscopy, look for a **dull/retracted tympanic membrane** with restricted mobility and the presence of **air bubbles or fluid levels**. * **Audiometry:** Typically shows **Conductive Hearing Loss**; Tympanometry reveals a **Type B (flat) curve**. * **Associated Condition:** In an adult with unilateral SOM, always rule out **Nasopharyngeal Carcinoma** (as it can block the Eustachian tube orifice). * **Medical Management:** Often tried first, including nasal decongestants and Valsalva maneuvers. Surgery is indicated if medical therapy fails for >3 months.

Question 136: What are the classical findings of tubercular otitis media?

A. Pain out of proportion to symptoms
B. Mastoiditis
C. Scanty discharge
D. Multiple perforations (Correct Answer)

Explanation: ### Explanation: Tubercular Otitis Media (TOM) Tubercular Otitis Media is a chronic granulomatous infection of the middle ear, typically occurring secondary to pulmonary tuberculosis (via the Eustachian tube or hematogenous spread). **Why "Multiple Perforations" is correct:** The hallmark of TOM is the formation of multiple tubercles on the tympanic membrane. these tubercles eventually caseate and necrose, leading to **multiple small perforations**. Over time, these small openings may coalesce into a single large, subtotal perforation. This finding is considered pathognomonic for the early stages of the disease. **Analysis of Incorrect Options:** * **A. Pain out of proportion to symptoms:** This is a classic feature of **Otitis Externa (specifically Furunculosis)** or **Malignant Otitis Externa**. In contrast, TOM is characteristically **painless** despite significant destruction. * **B. Mastoiditis:** While mastoid involvement can occur in advanced TOM, it is not a "classical" early finding. In TOM, there is often extensive bone necrosis (sequestrum formation) rather than the acute inflammatory mastoiditis seen in pyogenic infections. * **C. Scanty discharge:** TOM is typically associated with a **painless, odorless, and profuse (watery/creamy)** ear discharge. Scanty discharge is more common in the dry stage of CSOM or Otomycosis. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad of TOM:** Painless ear discharge + Multiple tympanic membrane perforations + Profound hearing loss (out of proportion to clinical findings). * **Facial Nerve Paralysis:** TOM is a common cause of facial nerve palsy in a patient with chronic ear discharge. * **Diagnosis:** Confirmed by identifying *Mycobacterium tuberculosis* on Ziehl-Neelsen (ZN) stain or culture of the discharge/granulation tissue. * **Treatment:** Standard Anti-Tubercular Therapy (ATT) for 6–9 months. Surgery is reserved for complications.

Question 137: Surfer's ear is defined as which of the following conditions?

A. Exostosis (Correct Answer)
B. Otosclerosis
C. Otitis externa
D. Squamous cell carcinoma

Explanation: **Explanation:** **Surfer’s Ear** refers to **External Auditory Canal Exostoses**. These are benign, broad-based bony outgrowths (hyperostoses) of the bony portion of the ear canal. 1. **Why Exostosis is correct:** The condition is triggered by prolonged and repeated exposure to **cold water and wind**. This thermal stimulus leads to reactive osteoblastic activity, resulting in the formation of multiple, bilateral, and symmetric bony swellings. It is classically seen in surfers, divers, and swimmers. 2. **Why other options are incorrect:** * **Otosclerosis:** This is a metabolic bone disease of the otic capsule (inner ear/stapes) leading to conductive hearing loss; it does not involve the external canal. * **Otitis externa:** This is an inflammation or infection of the external ear canal skin (e.g., Swimmer’s ear), not a bony growth. * **Squamous cell carcinoma:** This is a malignant neoplasm. While it can occur in the ear canal, it presents as an ulcerative or fungating mass, not as smooth bony outgrowths related to cold water. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Exostoses occur in the **medial (bony)** part of the external auditory canal. * **Appearance:** They are typically **multiple, bilateral, and sessile** (broad-based). * **Contrast with Osteoma:** Unlike exostoses, an **Osteoma** is usually **solitary, unilateral, and pedunculated**, occurring at the junction of the cartilaginous and bony canal. * **Management:** Usually conservative; surgical removal (canalplasty) is indicated only if they cause significant hearing loss or recurrent otitis externa due to trapped debris.

Question 138: Which of the following is NOT true about glue ear?

A. Myringotomy with curvilinear incision (Correct Answer)
B. Grommet insertion is the treatment
C. Also known as otitis media with effusion
D. Myringotomy performed in the anteroinferior quadrant

Explanation: **Explanation:** **Glue Ear**, clinically known as **Otitis Media with Effusion (OME)**, is characterized by the accumulation of non-purulent mucoid fluid in the middle ear cleft. **Why Option A is the correct answer (The False Statement):** In Glue Ear, the fluid is thick and tenacious. A **radial incision** (not curvilinear) is preferred for myringotomy. A radial incision is less traumatic to the circular fibers of the tympanic membrane, heals faster, and allows for better evacuation of the thick "glue." Curvilinear (circumferential) incisions are generally avoided as they can lead to wider scarring or permanent perforation. **Analysis of other options:** * **Option B:** **Grommet insertion** (ventilation tube) is the definitive surgical treatment. It bypasses the Eustachian tube to provide long-term ventilation and drainage. * **Option C:** **Otitis media with effusion** is the standard medical synonym for glue ear. * **Option D:** Myringotomy is performed in the **anteroinferior quadrant**. This is the safest site as it avoids injury to the ossicular chain (incudostapedial joint) and the chorda tympani nerve, which are located in the posterior quadrants. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of hearing loss in children:** Glue Ear. * **Audiometry:** Shows Conductive Hearing Loss (CHL) with a characteristic **B-type (flat) tympanogram**. * **Otoscopy:** Appearance of a dull, retracted tympanic membrane with restricted mobility; "air bubbles" or an amber-colored fluid level may be seen. * **Associated conditions:** Often linked to adenoid hypertrophy, cleft palate, or Eustachian tube dysfunction. In an adult with unilateral glue ear, always rule out **Nasopharyngeal Carcinoma**.

Question 139: How is Eustachian tube patency assessed?

A. Valsalva maneuver
B. Methylene blue test
C. Toynbee test
D. All of the above (Correct Answer)

Explanation: The Eustachian tube (ET) serves three primary functions: ventilation, protection, and clearance of the middle ear. Assessing its patency is crucial in diagnosing middle ear pathologies. **Explanation of Options:** * **Valsalva Maneuver:** This is an **active** test of ET patency. The patient forcibly exhales against a closed glottis, nose, and mouth. This increases nasopharyngeal pressure, forcing air into the ET. Success is confirmed by seeing the tympanic membrane (TM) move outward on otoscopy or hearing a "pop." * **Toynbee Test:** This is considered more physiological than Valsalva. The patient swallows while the nose is pinched shut. This creates negative pressure in the nasopharynx, drawing air out of the middle ear and causing inward movement of the TM. * **Methylene Blue Test:** This is a test of the **mucociliary clearance** function of the ET. A dye (like methylene blue or saccharin) is instilled into the middle ear through a perforation or grommet. If the ET is patent, the dye will appear in the nasopharynx (seen on posterior rhinoscopy) or the patient will report a metallic/sweet taste. **Clinical Pearls for NEET-PG:** 1. **Politzerization:** A method of inflating the middle ear using a Politzer bag; useful in children who cannot perform Valsalva. 2. **Tympanometry:** The most objective way to assess ET function. A **Type C tympanogram** (negative pressure) indicates ET dysfunction. 3. **Patulous Eustachian Tube:** A condition where the tube remains abnormally open. Patients complain of **autophony** (hearing their own voice/breath sounds). 4. **Siegle’s Speculum:** Can be used to observe TM mobility during Valsalva/Toynbee maneuvers.

Question 140: What is the most accepted theory for the formation of secondary cholesteatoma?

A. Congenital
B. Squamous metaplasia
C. Ingrowth of squamous epithelium
D. Retraction pocket (Correct Answer)

Explanation: **Explanation:** The pathogenesis of acquired cholesteatoma is a high-yield topic in ENT. The correct answer is **Retraction pocket**, specifically based on **Wittmaack’s Theory**. 1. **Why Retraction Pocket is Correct:** This is the most widely accepted theory for primary and secondary acquired cholesteatoma. It posits that negative middle ear pressure (due to Eustachian tube dysfunction) causes the tympanic membrane (usually the pars flaccida) to invaginate inwards. As the pocket deepens, desquamated keratin becomes trapped, leading to the formation of a cholesteatoma sac. 2. **Analysis of Incorrect Options:** * **A. Congenital:** This refers to epithelial rests trapped behind an intact tympanic membrane during embryogenesis (Levenson’s criteria). It is a distinct entity, not a theory for secondary formation. * **B. Squamous Metaplasia (Sade’s Theory):** This suggests that the middle ear mucosa transforms into squamous epithelium due to chronic infection. While a recognized theory, it is less commonly accepted than the retraction pocket theory. * **C. Ingrowth of Squamous Epithelium (Habermann’s Theory):** Also known as the **Migration Theory**, it suggests epithelium migrates from the external canal into the middle ear through a pre-existing marginal perforation. While it explains some cases of secondary cholesteatoma, the retraction pocket remains the "most accepted" mechanism in modern literature. **Clinical Pearls for NEET-PG:** * **Primary Acquired:** Occurs via a retraction pocket in an intact drum (Pars Flaccida/Shrapnell’s membrane). * **Secondary Acquired:** Occurs in the presence of a pre-existing perforation (Pars Tensa). * **Humas Theory:** Also known as the **Basal Cell Hyperplasia theory**, it suggests that epithelial cells in the Prussak’s space proliferate and invade the subepithelial tissue. * **Gold Standard Investigation:** HRCT Temporal Bone. * **Treatment of Choice:** Mastoidectomy (Canal Wall Down or Canal Wall Up).

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

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