Diseases of the Ear Practice Questions

Q: Schirmer test is done for?

Facial nerve. Explanation: The **Schirmer test** is a clinical diagnostic tool used to measure tear production (lacrimation). It is primarily used to evaluate dry eye syndrome or conditions like Sjögren’s syndrome. **Why Facial Nerve is the Correct Answer:** The **Facial nerve (CN VII)** provides parasympathetic innervation to the **lacrimal gland** via the Greater Petrosal Nerve. In cases of proximal facial nerve palsy (e.g., Bell’s palsy or lesions at the geniculate ganglion), tear production is significantly reduced. The Schirmer test is used topographically to determine the level of the facial nerve lesion; if lacrimation is absent, the lesion is at or proximal to the geniculate ganglion. **Why Other Options are Incorrect:** * **Oculomotor Nerve (CN III):** This nerve controls most extraocular muscles, the levator palpebrae superioris (eyelid elevation), and pupillary constriction. It does not control lacrimation. * **Optic Nerve (CN II):** This is a purely sensory nerve responsible for vision and the afferent limb of the pupillary light reflex. It has no motor or secretomotor function. **High-Yield Clinical Pearls for NEET-PG:** * **Procedure:** A filter paper (Whatman No. 41) is placed in the lower conjunctival fornix for 5 minutes. * **Interpretation:** Normal wetting is >15 mm. Wetting <5 mm is diagnostic of **Keratoconjunctivitis Sicca (Dry Eye)**. * **Topographic Diagnosis:** In Facial Nerve palsy, the Schirmer test helps differentiate a lesion in the Internal Auditory Meatus/Geniculate ganglion (abnormal test) from a lesion in the Stylomastoid foramen (normal test). * **Sjögren’s Syndrome:** Often presents with a positive Schirmer test along with xerostomia (dry mouth).

Q: Unilateral sensorineural hearing loss may occur in which of the following viral infections?

Mumps. **Explanation:** **Mumps** is the most common viral cause of **unilateral sudden sensorineural hearing loss (SNHL)**. The virus causes endolymphatic labyrinthitis, leading to the destruction of the hair cells in the Organ of Corti and atrophy of the stria vascularis. While the hearing loss is typically sudden and profound, it is characteristically unilateral in about 80% of cases, though bilateral involvement can occur. **Analysis of Options:** * **Coronavirus:** While COVID-19 has been associated with rare cases of SNHL and tinnitus, it is not a classic or frequently tested cause of unilateral SNHL in the context of standard ENT textbooks. * **Pertussis:** Caused by *Bordetella pertussis*, this is a respiratory bacterial infection (Whooping cough) and is not associated with direct viral labyrinthitis or SNHL. * **Rotavirus:** This is a primary cause of viral gastroenteritis in children and does not have neurotropic or ototropic properties. **Clinical Pearls for NEET-PG:** * **Mumps:** Most common cause of unilateral SNHL in children. * **Measles:** Often causes **bilateral** and symmetrical SNHL. * **Congenital Rubella:** Classically associated with "cookie-bite" SNHL and the "Salt and Pepper" retinopathy. * **Herpes Zoster Oticus (Ramsay Hunt Syndrome):** Presents with SNHL, facial palsy, and vesicles on the auricle (caused by VZV). * **Cytomegalovirus (CMV):** The most common **non-genetic** cause of congenital SNHL.

Q: A child underwent adenoidectomy and subsequently developed middle ear effusion. What is the ideal surgical management step?

Grommet insertion. **Explanation:** The middle ear is ventilated via the **Eustachian tube (ET)**. In children, adenoid hypertrophy is a common cause of ET dysfunction, leading to negative middle ear pressure and **Otitis Media with Effusion (OME)**. When a child develops persistent middle ear effusion despite an adenoidectomy, it indicates that the ET function has not fully recovered or that the effusion is thick ("glue ear") and unlikely to resolve spontaneously. **Why Option A is correct:** **Grommet insertion (Myringotomy with ventilation tube)** is the gold standard for persistent OME. The grommet bypasses the dysfunctional Eustachian tube, providing continuous ventilation to the middle ear, equalizing pressure, and allowing the drainage of fluid. This restores hearing and prevents complications like ossicular necrosis or cholesteatoma. **Why other options are incorrect:** * **B. Mastoidectomy:** This is indicated for chronic suppurative otitis media (CSOM) with cholesteatoma or mastoiditis. It is too invasive for simple middle ear effusion. * **C. Tympanoplasty:** This is a reconstructive surgery to repair a perforated tympanic membrane or ossicular chain. In OME, the drum is intact but retracted; creating a permanent graft is not indicated. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site for Grommet:** Antero-inferior quadrant of the tympanic membrane (to avoid injury to the incudostapedial joint). * **Indications for Adenoidectomy in OME:** Recurrent OME, nasal obstruction, or if the effusion persists after a previous myringotomy. * **Hearing Loss type:** OME typically causes a **Conductive Hearing Loss** of 25–40 dB. * **Bilateral OME in an adult:** Always rule out **Nasopharyngeal Carcinoma** (NPC) obstructing the ET opening.

Q: What is the commonest cause for grommet insertion?

Secretory otitis media. **Explanation:** **1. Why Secretory Otitis Media (SOM) is correct:** Secretory Otitis Media (also known as Otitis Media with Effusion - OME) is characterized by the accumulation of non-purulent fluid in the middle ear cleft. The primary pathophysiology involves **Eustachian tube dysfunction**, leading to negative middle ear pressure. A **Grommet (Myringotomy with Ventilation Tube)** is the surgical treatment of choice when medical management fails. It serves two purposes: it provides an alternative route for ventilation of the middle ear and allows for the continuous drainage of fluid, thereby restoring hearing and preventing complications like retraction pockets. **2. Why other options are incorrect:** * **Otosclerosis:** This is a disease of the bony labyrinth causing stapes fixation. The treatment is primarily medical (Sodium Fluoride), surgical (**Stapedotomy/Stapedectomy**), or hearing aids. Grommets have no role here as there is no fluid or pressure issue. * **CSOM:** Chronic Suppurative Otitis Media involves a permanent perforation of the TM. Since the drum is already open, a grommet is redundant. Treatment involves **Tympanoplasty** or **Mastoidectomy**. * **Cholesteatoma:** This is a destructive keratinizing squamous epithelium in the middle ear. It requires surgical excision via **Mastoidectomy** to prevent intracranial complications. **Clinical Pearls for NEET-PG:** * **Most common site for Myringotomy:** Postero-inferior quadrant (to avoid injury to the ossicles and chorda tympani). * **Indications for Grommet:** Recurrent SOM (>3 months), Reversion of retraction pockets, and Barotrauma. * **Commonest complication of Grommet:** Otorrhoea; long-term complication includes Tympanosclerosis. * **Hearing loss in SOM:** Usually a Conductive Hearing Loss of 20-40 dB; the audiogram shows a **Type B (Flat) Tympanogram**.

Q: In Ramsay Hunt syndrome, which cranial nerve is involved?

Facial. **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)**. 1. **Why Facial Nerve is Correct:** The virus travels along the sensory fibers of the facial nerve, leading to the classic clinical triad: **ipsilateral facial nerve palsy** (Lower Motor Neuron type), **otalgia** (ear pain), and **vesicular eruptions** in the external auditory canal, concha, or pinna. It may also involve the vestibulocochlear nerve (CN VIII), causing vertigo or hearing loss. 2. **Why Incorrect Options are Wrong:** * **Trigeminal (CN V):** While VZV can affect the Gasserian ganglion (causing Herpes Zoster Ophthalmicus), it is not the primary nerve involved in Ramsay Hunt Syndrome. * **Glossopharyngeal (CN IX):** This nerve provides sensation to the posterior third of the tongue and oropharynx; its involvement is rare and does not define this syndrome. * **Oculomotor (CN III):** This is a motor nerve for eye movements; it is not associated with the cutaneous vesicular patterns of VZV reactivation in the ear. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Primarily clinical; Tzanck smear shows multinucleated giant cells. * **Prognosis:** The facial palsy in Ramsay Hunt is generally **more severe** and has a **poorer recovery rate** compared to Bell’s Palsy. * **Treatment:** Combination of oral **Acyclovir/Valacyclovir** and **Corticosteroids**. * **Hitches’ Rule:** Vesicles may also appear on the anterior 2/3rd of the tongue or soft palate (via the chorda tympani and greater petrosal branches).

Q: A 30-year-old woman with a family history of hearing loss from her mother's side developed a hearing problem during pregnancy. The hearing loss is bilateral, slowly progressive, with bilateral tinnitus that bothers her at night. Pure tone audiometry shows conductive hearing loss with an apparent bone conduction hearing loss at 2000 Hz. What is the most likely diagnosis?

Otosclerosis. ### Explanation **Otosclerosis** is the most likely diagnosis based on the classic clinical triad presented: **bilateral progressive conductive hearing loss (CHL)**, a positive **family history** (autosomal dominant with incomplete penetrance), and **aggravation during pregnancy** (due to hormonal changes accelerating the remodeling of the otic capsule). The "apparent bone conduction hearing loss at 2000 Hz" is the pathognomonic **Carhart’s Notch**. This is not a true sensorineural loss but a mechanical artifact caused by the stapes fixation, which disrupts the natural resonance of the ossicular chain. #### Why the other options are incorrect: * **Acoustic Neuroma:** Presents with unilateral sensorineural hearing loss (SNHL) and balance issues, not bilateral CHL. It is not influenced by pregnancy. * **Otitis Media with Effusion (OME):** While it causes CHL, it is usually preceded by upper respiratory infections and does not typically present with a family history or a specific 2000 Hz notch. * **Sigmoid Sinus Thrombosis:** A serious complication of chronic suppurative otitis media (CSOM). It presents with "picket-fence" fever, headache, and signs of raised intracranial pressure, not isolated progressive hearing loss. #### High-Yield Clinical Pearls for NEET-PG: * **Schwartz Sign:** A flamingo-pink blush seen on the promontory through the TM, indicating active otosclerosis (Otospongiosis). * **Gelle’s Test:** Negative in otosclerosis (indicates fixed ossicles). * **Bezold’s Triad:** 1. Negative Rinne test, 2. Raised bone conduction threshold (Carhart’s notch), 3. Low-frequency hearing loss. * **Treatment of Choice:** Stapedotomy (using a Teflon piston). Sodium fluoride can be used to medically stabilize active disease.

Q: Which of the following is NOT a typical feature of malignant otitis externa?

Mitotic figures are high. **Malignant Otitis Externa (MOE)**, also known as Necrotizing Otitis Externa, is a severe, life-threatening infection of the external auditory canal that spreads to the skull base (osteomyelitis). ### **Explanation of the Correct Answer** **Option C (Mitotic figures are high)** is the correct answer because it is **NOT** a feature of MOE. High mitotic figures are a hallmark of **malignancy (cancer)**. Despite its name, "Malignant" Otitis Externa is an **infectious/inflammatory process**, not a neoplastic one. While it behaves "malignantly" by invading bone and surrounding tissues, a biopsy would show inflammatory cells and granulation tissue, not cancerous cells or increased mitosis. ### **Analysis of Incorrect Options** * **Option A:** **Pseudomonas aeruginosa** is the causative organism in more than 95% of cases. It produces exotoxins that cause tissue necrosis and vasculitis. * **Option B & D:** MOE characteristically affects **elderly patients** (usually >60 years) who are **immunocompromised**, most commonly due to poorly controlled **Diabetes Mellitus**. The microangiopathy of diabetes impairs perfusion, facilitating the spread of infection. ### **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. * **Earliest Cranial Nerve Involved:** Facial nerve (VII), followed by IX, X, and XI as it spreads to the jugular foramen. * **Diagnosis:** **Technetium-99m scan** is the most sensitive for initial diagnosis (detects osteoblastic activity). * **Monitoring:** **Gallium-67 scan** or **Indium-111 labeled WBC scan** is used to monitor response to treatment and confirm resolution (as Technetium remains positive for months). * **Treatment:** Long-term IV antipseudomonal antibiotics (e.g., Ciprofloxacin, Ceftazidime) and strict glycemic control.

Q: In which syndrome is sensorineural hearing loss associated with abnormality of thyroxin synthesis?

Pendred syndrome. **Explanation:** **Pendred Syndrome** is an autosomal recessive disorder caused by a mutation in the **SLC26A4 gene**, which encodes the protein **pendrin**. Pendrin is an ion exchanger found in the inner ear and the thyroid gland. 1. **In the Thyroid:** It is responsible for iodide transport. A defect leads to impaired organification of iodine, resulting in a multinodular goiter (euthyroid or mildly hypothyroid). 2. **In the Inner Ear:** It leads to **bilateral sensorineural hearing loss (SNHL)**, typically associated with structural malformations like an **enlarged vestibular aqueduct (EVA)** or Mondini dysplasia. **Analysis of Incorrect Options:** * **Alport Syndrome:** Characterized by SNHL associated with **progressive renal failure** and ocular abnormalities (lenticonus) due to a defect in Type IV collagen. * **Klippel-Feil Syndrome:** Defined by the clinical triad of a short neck, low posterior hairline, and restricted neck motion due to **fused cervical vertebrae**. It may be associated with hearing loss (Wildervanck syndrome) but not thyroid issues. * **Usher Syndrome:** The most common cause of combined deafness and blindness. It involves SNHL associated with **Retinitis Pigmentosa**. **High-Yield Clinical Pearls for NEET-PG:** * **Perchlorate Discharge Test:** Historically used to diagnose Pendred syndrome; it shows an abnormal washout of iodine from the thyroid. * **Radiology:** The most common radiological finding in Pendred syndrome is a **dilated/enlarged vestibular aqueduct**. * **Mnemonic:** Remember **P**endred = **P**erchlorate test, **P**endrin protein, and **P**artial thyroid defect.

Q: Which of the following is NOT an extracranial complication of chronic suppurative otitis media?

Perisinus abscess. **Explanation:** Complications of Chronic Suppurative Otitis Media (CSOM) are broadly classified into two categories: **Intracranial** (within the cranial cavity) and **Extracranial** (outside the cranial cavity). **Why Perisinus Abscess is the correct answer:** A **Perisinus abscess** is an **intracranial complication**. It occurs when pus collects between the dural wall of the lateral sinus (sigmoid sinus) and the overlying mastoid bone. Since it involves the space within the skull and is often a precursor to lateral sinus thrombophlebitis, it is categorized as intracranial. **Analysis of Incorrect Options (Extracranial Complications):** * **Bezold’s Abscess:** A neck abscess formed when pus breaks through the thin inner table of the mastoid tip, tracking down into the **sternocleidomastoid muscle** sheath. * **Citelli’s Abscess:** Occurs when pus tracks through the mastoid tip or digastric fossa, following the posterior belly of the **digastric muscle** to the digastric triangle. * **Luc’s Abscess:** A subperiosteal abscess of the **external auditory canal** wall, resulting from pus tracking through the notch of Rivinus or a defect in the meatal bone. **High-Yield Clinical Pearls for NEET-PG:** * **Most common intracranial complication:** Meningitis (though some texts cite Extradural abscess). * **Most common extracranial complication:** Mastoiditis. * **Griesinger’s Sign:** Edema over the mastoid bone due to thrombosis of the mastoid emissary vein (seen in lateral sinus thrombosis). * **Zygomatic Abscess:** Pus tracks into the root of the zygoma, causing swelling in front of and above the pinna.

Question 1

Schirmer test is done for?

Accepted Answer

Facial nerve

Answer

Oculomotor nerve

Answer

Optic nerve

Answer

All

Question 2

Unilateral sensorineural hearing loss may occur in which of the following viral infections?

Accepted Answer

Mumps

Answer

Coronavirus

Answer

Pertussis

Answer

Rotavirus

Question 3

A child underwent adenoidectomy and subsequently developed middle ear effusion. What is the ideal surgical management step?

Accepted Answer

Grommet insertion

Answer

Mastoidectomy

Answer

Tympanoplasty

Answer

None of the above

Question 4

What is the commonest cause for grommet insertion?

Accepted Answer

Secretory otitis media

Answer

Otosclerosis

Answer

Chronic suppurative otitis media (CSOM)

Answer

Cholesteatoma

Question 5

In Ramsay Hunt syndrome, which cranial nerve is involved?

Accepted Answer

Facial

Answer

Trigeminal

Answer

Glossopharyngeal

Answer

Occulomotor

Question 6

A 30-year-old woman with a family history of hearing loss from her mother's side developed a hearing problem during pregnancy. The hearing loss is bilateral, slowly progressive, with bilateral tinnitus that bothers her at night. Pure tone audiometry shows conductive hearing loss with an apparent bone conduction hearing loss at 2000 Hz. What is the most likely diagnosis?

Accepted Answer

Otosclerosis

Answer

Acoustic neuroma

Answer

Otitis media with effusion

Answer

Sigmoid sinus thrombosis

Question 7

Which of the following is NOT a typical feature of malignant otitis externa?

Accepted Answer

Mitotic figures are high

Answer

Caused by Pseudomonas aeruginosa

Answer

Patients are usually elderly

Answer

Patient is immunocompromised

Question 8

In which syndrome is sensorineural hearing loss associated with abnormality of thyroxin synthesis?

Accepted Answer

Pendred syndrome

Answer

Alport syndrome

Answer

Klippel-Feil syndrome

Answer

Usher syndrome

Question 9

Which of the following is NOT an extracranial complication of chronic suppurative otitis media?

Accepted Answer

Perisinus abscess

Answer

Citelli abscess

Answer

Bezold abscess

Answer

Lüch-type abscess

Question 10

All of the following are true about Ramsay Hunt syndrome except?

Accepted Answer

Paralysis of facial muscles occurs on the contralateral side of the face.

Answer

Geniculate ganglion of the facial nerve is involved.

Answer

Vesicles are present on the tympanic membrane, external auditory canal, and tongue.

Answer

It is caused by herpes zoster.

Diseases of the Ear — MCQs

Diseases of the Ear — MCQs

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