Diseases of the Ear — MCQs

A 18-month-old boy presents with a 2-day history of fever, irritability, and frequent tugging of his left ear. He was diagnosed with acute otitis media and treated with antibiotics. Two months later, otoscopic examination reveals air-fluid levels in the left ear, and medical management has failed to resolve the effusion. What is the treatment of choice for this child?

Q169Medium

Edema over the mastoid is seen in which condition?

Q170Easy

Herpes zoster infection of the geniculate ganglion is known to cause which of the following conditions?

Diseases of the Ear Indian Medical PG Practice Questions and MCQs

Question 161: A 7-year-old boy with severe otitis media and mastoiditis underwent surgery. Postoperatively, he developed right corner of the mouth drooping, inability to close his right eye, and food collection in his right oral vestibule. Which nerve was most likely injured during the surgery?

A. Glossopharyngeal nerve
B. Vagus nerve
C. Facial nerve (Correct Answer)
D. Maxillary division of the trigeminal nerve

Explanation: ### Explanation **Correct Option: C. Facial Nerve** The clinical presentation describes a classic case of **Lower Motor Neuron (LMN) Facial Nerve Palsy**. The facial nerve (CN VII) has a long and tortuous course through the temporal bone, specifically within the bony Fallopian canal. During mastoid surgery (like mastoidectomy for mastoiditis), the nerve is highly vulnerable to injury, particularly in its **tympanic (horizontal)** and **mastoid (vertical)** segments. * **Inability to close the eye:** Due to paralysis of the *Orbicularis oculi*. * **Drooping of the corner of the mouth:** Due to paralysis of the *Zygomaticus* and *Risorius* muscles. * **Food collection in the vestibule:** Due to paralysis of the *Buccinator* muscle, which normally maintains cheek tension to prevent food stasis. **Why Incorrect Options are Wrong:** * **A & B (Glossopharyngeal & Vagus):** These nerves exit the skull via the jugular foramen. Injury would result in dysphagia, loss of gag reflex, or vocal cord palsy, not facial asymmetry. * **D (Maxillary nerve):** This is a sensory branch of the Trigeminal nerve (CN V2). Injury would cause mid-face anesthesia but would not affect the muscles of facial expression. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of injury:** The **horizontal segment** (just above the oval window) is the most common site of surgical trauma, especially if the bone is dehiscent. * **Second Genu:** The nerve is also at risk at the "pyramidal bend" where it turns from horizontal to vertical. * **Landmark for identification:** The **Short process of the Incus** and the **Horizontal Semicircular Canal** are the most reliable surgical landmarks to locate the facial nerve during mastoidectomy. * **Bell’s Phenomenon:** The upward and outward rolling of the eyeball when the patient attempts to close the paralyzed eyelid.

Question 162: What is a characteristic feature of tuberculous otitis media?

A. Multiple perforations in the tympanic membrane (Correct Answer)
B. Mastoiditis
C. Middle ear effusion
D. Ear discharge

Explanation: **Explanation:** Tuberculous Otitis Media (TOM) is a chronic granulomatous infection of the middle ear, usually secondary to pulmonary tuberculosis. **Why Option A is correct:** The hallmark of TOM is the presence of **multiple "sieve-like" perforations** in the tympanic membrane. This occurs because multiple tubercles form on the drum, which then undergo caseous necrosis and break down. Over time, these small perforations may coalesce to form a single, large total perforation. **Analysis of Incorrect Options:** * **B. Mastoiditis:** While mastoid involvement occurs in TOM, it is usually characterized by extensive bone destruction and "painless" sequestration rather than the acute, painful mastoiditis seen in pyogenic infections. * **C. Middle ear effusion:** Effusion is typical of Serous Otitis Media (Eustachian tube dysfunction). TOM is characterized by pale granulation tissue and cheesy (caseous) discharge rather than simple sterile fluid. * **D. Ear discharge:** While ear discharge is present in TOM, it is not a *characteristic* feature because it is common to almost all forms of Otitis Media. In TOM, the discharge is specifically described as **painless, odorless, and watery/scanty.** **High-Yield Clinical Pearls for NEET-PG:** 1. **Classic Triad:** Painless ear discharge + Multiple perforations + Profound hearing loss (out of proportion to clinical findings). 2. **Facial Nerve Paralysis:** TOM is a common cause of facial nerve palsy in chronic ear infections. 3. **Diagnosis:** Confirmed by identifying *Mycobacterium tuberculosis* on Ziehl-Neelsen (ZN) stain or culture of the discharge/granulation tissue. 4. **Appearance:** The tympanic membrane and middle ear mucosa often appear pale and "cadaveric."

Question 163: Which of the following conditions is associated with the Phelps sign?

A. Acoustic neuroma
B. Glomus tumor (Correct Answer)
C. Meniere disease
D. Otosclerosis

Explanation: **Explanation:** **Phelps sign** is a classic radiological finding associated with **Glomus Jugulare** (a type of Paraganglioma). It refers to the **erosion of the bony septum** (the "jugular spur") that normally separates the jugular bulb from the carotid canal. In Glomus jugulare tumors, the expansive growth of the vascular mass destroys this thin plate of bone, which is visible on a high-resolution CT scan of the temporal bone. **Why other options are incorrect:** * **Acoustic Neuroma:** This is a tumor of the 8th cranial nerve. The characteristic radiological sign is the widening or "flaring" of the **Internal Auditory Meatus (IAM)**, not the jugular bulb area. * **Meniere Disease:** This is a clinical diagnosis characterized by endolymphatic hydrops. Imaging is typically normal; there are no specific bony erosion signs like Phelps sign. * **Otosclerosis:** This involves bony remodeling of the otic capsule. The classic radiological sign is the **"Halo sign"** (double ring sign) in cochlear otosclerosis, or a lucent focus at the *fissula ante fenestram*. **High-Yield Clinical Pearls for Glomus Tumors:** * **Brown’s Sign:** Pulsatile blanching of the tympanic membrane when pressure is applied via a Siegel’s speculum. * **Aquino’s Sign:** Pulsations of the tumor cease upon carotid artery compression. * **Clinical Presentation:** Pulsatile tinnitus (most common symptom) and a "rising sun" appearance behind the eardrum. * **Classification:** Fisch Classification is used to grade the extent of the tumor.

Question 164: What is Boxer's ear?

A. Aural hematoma (Correct Answer)
B. Malformed ear
C. Ear with absent tragus
D. Lacerated ear

Explanation: **Explanation:** **Boxer’s Ear**, also known as **Auricular Hematoma**, is a condition caused by blunt trauma to the pinna, commonly seen in contact sports like boxing, wrestling, and rugby. **Why Option A is correct:** The underlying medical concept involves the shearing forces of trauma causing the perichondrium to separate from the underlying cartilage. This creates a space that fills with blood (hematoma). Since the auricular cartilage relies on the perichondrium for its blood supply, an untreated hematoma leads to avascular necrosis. If not drained promptly, the hematoma organizes into fibrocartilage, resulting in the characteristic shriveled, thickened deformity known as **"Cauliflower Ear."** **Why the other options are incorrect:** * **B. Malformed ear:** This is a generic term for congenital anomalies (like Microtia) rather than an acquired traumatic condition. * **C. Ear with absent tragus:** This is typically a feature of congenital syndromes (e.g., Treacher Collins) or surgical excision, not trauma-induced hematoma. * **D. Lacerated ear:** While a boxer may suffer a laceration (a cut), "Boxer's Ear" specifically refers to the subperichondrial collection of blood and its subsequent deformity. **High-Yield Clinical Pearls for NEET-PG:** * **Treatment of Choice:** Immediate **Incision and Drainage (I&D)** under aseptic conditions, followed by a **pressure dressing** to prevent re-accumulation of blood. * **Site of Collection:** The hematoma typically forms on the **anterior/lateral surface** of the pinna where the skin is tightly adherent. * **Complication:** If infected, it can lead to **Perichondritis**, often caused by *Pseudomonas aeruginosa*.

Question 165: Brown's sign, characterized by blanching of redness, is typically observed in which of the following conditions?

A. Glomus tumor (Correct Answer)
B. Meniere's disease
C. Acoustic neuroma
D. Otosclerosis

Explanation: **Explanation:** **Brown’s Sign** is a classic clinical finding associated with **Glomus tumors** (specifically Glomus Jugulare and Glomus Tympanicum). These are highly vascular, benign but locally invasive paragangliomas. * **Mechanism:** When positive pressure is applied to the external auditory canal using a Siegle’s speculum, the pressure is transmitted to the middle ear. This compresses the capillaries within the vascular tumor mass, causing it to **blanch (turn pale)** and stop pulsating. Once the pressure is released, the redness and pulsations return. **Analysis of Incorrect Options:** * **Meniere’s Disease:** Characterized by the triad of vertigo, tinnitus, and sensorineural hearing loss due to endolymphatic hydrops. The tympanic membrane appears normal. * **Acoustic Neuroma:** A retrocochlear lesion (Vestibular Schwannoma) involving the 8th cranial nerve. It presents with unilateral hearing loss and equilibrium issues, but no middle ear vascular signs. * **Otosclerosis:** Presents with conductive hearing loss due to stapes fixation. While it may show **Schwartz’s sign** (a flamingo-pink flush on the promontory due to increased vascularity), it does not exhibit blanching upon pneumatic pressure. **High-Yield Clinical Pearls for NEET-PG:** * **Pulsatile Tinnitus:** The most common presenting symptom of Glomus tumors. * **Rising Sun Appearance:** The red/blue fleshy mass seen behind an intact tympanic membrane in Glomus tumors. * **Aquino’s Sign:** Blanching of the tumor and cessation of pulsations upon carotid artery compression (also seen in Glomus tumors). * **Phelps’ Sign:** Loss of the bony plate between the jugular bulb and the middle ear (seen on CT).

Question 166: Which of the following statements about the tympanic membrane is false?

A. The cone of light is located anteroinferiorly.
B. Shrapnell's membrane is also known as the pars flaccida.
C. A healed perforation of the tympanic membrane has three layers. (Correct Answer)
D. The anterior malleolar fold is longer than the posterior malleolar fold.

Explanation: ### Explanation **1. Why Option C is the Correct (False) Statement:** A normal tympanic membrane (TM) consists of three layers: the outer epithelial layer (ectoderm), the middle fibrous layer (mesoderm), and the inner mucosal layer (endoderm). When a perforation heals spontaneously, the **middle fibrous layer fails to regenerate** properly. Consequently, a healed perforation (neomembrane) consists of only **two layers** (epithelial and mucosal), making it thinner, more translucent, and prone to retraction or atrophy. **2. Analysis of Other Options:** * **Option A (True):** The cone of light is a triangular reflection of light seen in the **anteroinferior quadrant**. It radiates from the umbo to the periphery due to the concavity of the TM. * **Option B (True):** **Shrapnell’s membrane** is the synonym for the **pars flaccida**. It is the small, triangular, non-tense portion of the TM situated above the lateral process of the malleus, lacking a well-organized fibrous layer. * **Option C (True):** This is a high-yield anatomical fact. The **anterior malleolar fold is longer** than the posterior malleolar fold. These folds, along with the lateral process of the malleus, form the boundaries of the pars flaccida. **3. NEET-PG High-Yield Pearls:** * **Layers:** The fibrous layer (lamina propria) contains outer radial and inner circular fibers. These are absent in the pars flaccida. * **Nerve Supply:** The TM is supplied by the Auriculotemporal nerve (CN V3), Arnold’s nerve (CN X), and Jacobson’s nerve (CN IX). * **Position:** The TM is tilted at an angle of 55° to the floor of the external auditory canal. * **Clinical Sign:** A "monomeric" membrane refers to a healed perforation that looks like a thin, transparent patch, often mistaken for an actual hole.

Question 167: The 'Cart Wheel' sign is seen in which of the following conditions?

A. Acute suppurative otitis media (ASOM) (Correct Answer)
B. Acute otitis media (AOM)
C. Otitis media with effusion (OME)
D. Chronic suppurative otitis media (CSOM)

Explanation: **Explanation:** The **'Cart Wheel' sign** (also known as the 'Spoke-like' appearance) is a classic otoscopic finding in the **Stage of Hyperemia** of **Acute Suppurative Otitis Media (ASOM)**. **1. Why ASOM is correct:** During the initial stage of ASOM, the mucoperiosteum of the middle ear becomes congested. This leads to the dilation of blood vessels along the handle of the malleus and the periphery of the tympanic membrane. These engorged vessels radiate from the center (umbo) toward the periphery, resembling the spokes of a wheel, hence the term "Cart Wheel" sign. **2. Why other options are incorrect:** * **Acute Otitis Media (AOM):** While ASOM is a type of AOM, the question specifically targets the pathological stages of the suppurative process where this specific vascular pattern is described. * **Otitis Media with Effusion (OME):** This is characterized by a dull, retracted tympanic membrane with an altered light reflex, air-fluid levels, or bubbles. It lacks the acute inflammatory hyperemia seen in ASOM. * **Chronic Suppurative Otitis Media (CSOM):** This involves a permanent perforation of the tympanic membrane. The membrane is usually thickened or scarred (tympanosclerosis) rather than acutely hyperemic. **3. Clinical Pearls for NEET-PG:** * **Stages of ASOM:** 1. **Stage of Hyperemia:** Cart wheel sign. 2. **Stage of Exudation:** Bulging TM (**'Donut' sign** or 'Nipple' sign if a small perforation is imminent). 3. **Stage of Suppuration:** Perforation occurs; pulsatile discharge (**'Lighthouse' sign**). 4. **Stage of Resolution:** Healing. 5. **Stage of Complication:** Spread beyond the middle ear. * **Most common organism in ASOM:** *Streptococcus pneumoniae* (followed by *H. influenzae*). * **Treatment of choice:** Amoxicillin is the first-line antibiotic.

Question 168: A 18-month-old boy presents with a 2-day history of fever, irritability, and frequent tugging of his left ear. He was diagnosed with acute otitis media and treated with antibiotics. Two months later, otoscopic examination reveals air-fluid levels in the left ear, and medical management has failed to resolve the effusion. What is the treatment of choice for this child?

A. Conservative management
B. Tympanoplasty
C. Myringotomy with ventilation tube insertion (Correct Answer)
D. Myringotomy with diode laser

Explanation: ### Explanation The child is presenting with **Otitis Media with Effusion (OME)**, also known as "Glue Ear." This condition is characterized by the presence of non-purulent fluid in the middle ear without signs of acute infection. In this case, the effusion has persisted for two months following an episode of Acute Otitis Media (AOM) and has failed medical management. **1. Why Option C is Correct:** The standard indication for **Myringotomy with Ventilation Tube (Grommet) insertion** is persistent OME (usually >3 months) or OME that is symptomatic and refractory to medical treatment. In a child, persistent fluid can lead to conductive hearing loss, which may interfere with speech and language development. The ventilation tube bypasses the dysfunctional Eustachian tube, providing continuous aeration to the middle ear and allowing the mucosa to return to normal. **2. Why Incorrect Options are Wrong:** * **Option A (Conservative management):** While OME often resolves spontaneously, this child has already failed medical management, and the persistence of air-fluid levels warrants surgical intervention to prevent complications like retraction pockets or hearing delay. * **Option B (Tympanoplasty):** This is a reconstructive procedure for a perforated tympanic membrane or ossicular chain issues. It is not indicated for simple middle ear effusion. * **Option D (Myringotomy with diode laser):** While laser myringotomy exists, it often results in rapid healing of the incision (within weeks), which is insufficient for chronic OME. A ventilation tube is required for long-term aeration. **Clinical Pearls for NEET-PG:** * **Most common cause of hearing loss in children:** Otitis Media with Effusion. * **Otoscopic finding:** Dull/opaque tympanic membrane, retracted drum, or **air-fluid levels/bubbles**. * **Tuning Fork Test:** Rinne negative (Conductive Hearing Loss). * **Tympanometry:** **Type B curve** (flat curve) is characteristic of middle ear effusion. * **Common site for Grommet insertion:** Antero-inferior quadrant of the tympanic membrane (to avoid injury to the ossicles and chorda tympani).

Question 169: Edema over the mastoid is seen in which condition?

A. Bell's Palsy
B. Lateral sinus thrombophlebitis (Correct Answer)
C. Chronic suppurative otitis media (CSOM)
D. Acute suppurative otitis media (ASOM)

Explanation: **Explanation:** The correct answer is **Lateral sinus thrombophlebitis**. Edema over the mastoid process in this condition is known as **Griesinger's sign**. **1. Why Lateral Sinus Thrombophlebitis is correct:** Lateral (Sigmoid) sinus thrombophlebitis is a serious intracranial complication of middle ear infections. The sigmoid sinus drains into the internal jugular vein. When a thrombus forms, it can lead to retrograde congestion of the **mastoid emissary vein**, which connects the sigmoid sinus to the extracranial venous system. This congestion results in edema and tenderness over the posterior part of the mastoid bone (Griesinger's sign). **2. Why the other options are incorrect:** * **Bell’s Palsy:** This is an idiopathic lower motor neuron facial nerve palsy. It presents with facial drooping but does not involve venous congestion or mastoid edema. * **CSOM/ASOM:** While these are the underlying infections that *lead* to complications, uncomplicated CSOM or ASOM typically presents with ear discharge or pain. Mastoid edema only occurs if they progress to **Mastoiditis** (edema in the post-auricular sulcus) or **Lateral Sinus Thrombophlebitis** (edema over the mastoid bone). **3. High-Yield Clinical Pearls for NEET-PG:** * **Griesinger’s Sign:** Edema over the mastoid due to mastoid emissary vein thrombosis. * **Picket-fence Fever:** The characteristic hectic, spiking fever seen in lateral sinus thrombophlebitis. * **Tobey-Ayer Test / Queckenstedt’s Test:** Used to detect lateral sinus obstruction by measuring CSF pressure during jugular vein compression. * **Delta Sign:** Seen on contrast-enhanced CT, representing a thrombus in the sigmoid sinus. * **Greisinger's vs. Mastoiditis:** In Mastoiditis, the edema is usually more anterior, causing the pinna to be displaced "downwards and forwards."

Question 170: Herpes zoster infection of the geniculate ganglion is known to cause which of the following conditions?

A. Bell's palsy
B. Ramsay Hunt syndrome (Correct Answer)
C. Mérkelson-Rosenthal syndrome
D. Frey's syndrome

Explanation: **Explanation:** **Ramsay Hunt Syndrome (Herpes Zoster Oticus)** is caused by the reactivation of the **Varicella-Zoster Virus (VZV)** dormant in the **Geniculate Ganglion** of the Facial Nerve (CN VII). The classic clinical triad includes: 1. **Facial Nerve Palsy:** Lower motor neuron type. 2. **Otalgia:** Severe ear pain. 3. **Vesicular Eruptions:** Located on the pinna, external auditory canal, or soft palate (the sensory distribution of the facial nerve). *Note: It may also involve CN VIII, leading to vertigo and sensorineural hearing loss.* **Analysis of Incorrect Options:** * **A. Bell’s Palsy:** This is an **idiopathic**, acute lower motor neuron facial palsy. While some theories suggest Herpes Simplex Virus (HSV) involvement, it is by definition a diagnosis of exclusion and lacks the vesicular eruptions seen in Ramsay Hunt. * **C. Melkersson-Rosenthal Syndrome:** A rare neurological disorder characterized by a triad of **recurrent facial paralysis**, **fissured tongue (lingua plicata)**, and **granulomatous orofacial edema**. * **D. Frey’s Syndrome (Gustatory Sweating):** This is a complication of **parotid surgery** (parotidectomy). It occurs due to aberrant regeneration of auriculotemporal nerve fibers, where parasympathetic fibers meant for the parotid gland instead supply the sweat glands of the overlying skin. **High-Yield NEET-PG Pearls:** * **Prognosis:** Ramsay Hunt syndrome has a poorer prognosis for facial nerve recovery compared to Bell’s palsy. * **Treatment:** Combination of **Oral Acyclovir/Valacyclovir** and **Corticosteroids**. * **Sensory Supply:** The "Hitler’s area" (concha and external meatus) is the specific site where VZV vesicles appear due to the sensory distribution of the facial nerve.

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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